1. The urinary sediment

2. The urinary sediment

3. The urinary sediment

4. The urinary sediment

5. The urinary sediment

6. The urinary sediment
the document published by the European Urinalysis Group as a supplement of the Scandinavian Journal of Clinical and Laboratory Investigation (2000; Vol 60, Suppl 231)
as well as a book (Fogazzi GB, Ponticelli C, Ritz E. The Urinary Sediment. An Integrated View 2nd Edition. Oxford , Oxford University Press, 1999)

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8. A correct urine collection The patient has to:
The urinary sediment
A correct urine collection
The patient has to:
supply the first and/or the second urine of the morning
the second urine could be better – the overnight urine, due to its prolonged permanence in the bladder can favour the lysis of particles
avoid of strenuous physical effort in the hours preceding the test - may influence in various ways the findings (for instance by causing haematuria and/or cylindruria)

9. clean the external genitalia in an ordinary way
The urinary sediment
The patient has to:
avoid contamination
clean the external genitalia in an ordinary way
do not suggest  special procedures - the more the procedures suggested are complicated, the less the patient is compliant
the male has to uncover the glans and female to spread the labia of the vagina
collect the midstream urine
avoid urine collection during menstruation - high probability of blood contamination
use a proper urine container

10. A proper urine container a capacity of at least 50 to 100 mL
The urinary sediment
A proper urine container
a capacity of at least 50 to 100 mL
an opening of at least of 5 cm to allow easy collection of urine for both men and women
a wide base to avoid accidental spillage
a cap to avoid leakage
a label for patient identification
it is no more time for the patient to collect the urine into jugs, bottles, cans, etc

11. The urinary sediment

12. Why is standardization of the handling of the urine important?
The urinary sediment
Why is standardization of the handling of the urine important?
Because only with a standardized method we can obtain:
quantitative reproducible results
correlated significantly with the number of particles found by the counting chamber
Centrifugation G = 2,000rpm
The expression of particles
as lowest/highest number seen by microscopic field
for scientific results - number of the cells found over 20 high power field

13. The urinary sediment

14. The urinary sediment Why phase contrast?
on the right - bright-field, and on the left - phase contrast
with phase contrast  the particles are much better seen against the background
than with bright-field
and this without the use of stains!
the European Guidelines strongly recommends the use of phase contrast microscopy

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16. The urinary sediment
Why polarized light?
Polarized light is extremely useful to correctly recognize the crystals

17. The urinary sediment
uric acid crystals as seen by phase contrast microscopy and  by polarized light
Under polarized light, uric acid crystals assume a typical polychromatic appearance, which is useful to identify them

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Polarized light is also important to correctly identify lipid particles
under polarized light appear as “Maltese crosses” -“shining” particles containing a “black cross” whose arms are regular and symmetrical
this feature allows the identification of lipid particles, especially when they come with an atypical appearance

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20. The urinary sediment
The urinary sediment report
the patient details
pH, density (or specific gravity)
haemoglobin and leukocyte esterase as detected by dipstick
the particles: erythrocytes (with their morphological classification),
leukocytes, tubular cells, transitional cells (from the deep and superficial layers of the uroepithelium), squamous cells, casts, lipids, crystals, bacteria, and yeasts
a space for a brief conclusive comment
high importance - to have in the report  the findings obtained by dipstick

21. Why this? to have in the report the findings obtained by dipstick
The urinary sediment
Why this?
to have in the report  the findings obtained by dipstick

22. The urinary sediment an example
by microscopy - a low number of erythrocytes and leukocytes
which is in contrast with +++ haemoglobin and +++ leukocytes esterase
explanation for this discrepancy: low density the lysis of erythrocytes and
leukocytes which therefore cannot be seen by microscopy

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In contrast, in other instances we may have negative haemoglobin and many erythrocytes by microscopy
This may be due, for example, to the presence of large concentrations of Vitamin C in the urine, which reduces the sensitivity of dipstick for haemoglobin

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Therefore, it is always important to match the findings obtained by dipstick with those obtained with microscopy and to try to explain them

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Thus, the comment for the sample above is: ” Mild erythrocyturia and leucocyturia. Please note the discrepancy between dipstick for haemoglobin and leukocyte esterase and microscopy. This is probably due to cell lysis caused by low density.” 

26. examining the urine only by dipsticks or only by microscopy
The urinary sediment
An important message !
examining the urine only by dipsticks or only by microscopy
exposes to the risk of false results
This risk is reduced when both methods are used on the same sample

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28. The urinary sediment

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30. The urinary sediment

31. The urinary sediment
Since the early 1980s we know that in the urine we can find two main types of erythrocytes:
so-called glomerular - or dysmorphic
so-called non-glomerular - or isomorphic

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Dysmorphic erythrocyte
cells with irregular shape, size, and cell membrane

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34. The urinary sediment
Dysmorphic erythrocyte
differ remarkably from the image of erythrocytes we have stored in our mind

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36. The urinary sediment
Non glomerular  or isomorphic erythrocyte
with a spherical shape and regular contours
containing (green-bluish cells) or not  (colourless cells) haemoglobin

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38. The urinary sediment
Conclusion - the evaluation of urinary erythrocyte morphology could be used to identify the source of hematuria
glomerular or dysmorphic erythrocytes were found in patients with haematuria caused by a glomerular disease
non glomerular or isomorphic erythrocytes were found only in patients with hematuria of urological origin

39. The urinary sediment
haematuria is of glomerular origin when it contains >80% dysmporhic erythrocytes
haematuria is of non glomerular origin when >80% of erythrocytes are isomorphic

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41. The urinary sediment
“Acanthocyte” - marker of glomerular bleeding
a subtype of dysmorphic erythrocyte
easily (and less subjectively) identified
shape of a ring from which one or more blebs protrude

42. an acanthocyte as seen by scanning electron microscopy
The urinary sediment
an acanthocyte as seen by scanning electron microscopy

43. acanthocytes can be identified by phase contrast
The urinary sediment
acanthocytes can be identified by phase contrast

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What is the main indication for  the evaluation of urinary erythrocyte morphology in clinical practice?
Persistent isolated microscopic haematuria of unknown origin

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Persistent isolated microscopic haematuria of unknown origin
the evaluation of red cell morphology helps in deciding whether the patient  has to be submitted to a nephrological work-up rather than to a urological one
this  saves to the patient inappropriate investigation such as cystoscopy for a patient with haematuria due to a glomerular disease

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49. The urinary sediment
Urinary lipids
a marker of GBM damage
a consequence of lipid ultrafiltration due to an impairment of glomerular basement membrane (GBM) permeability
it occurs in glomerular diseases
rarely- due to  lipid storage diseases (Fabry disease)  

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51. The urinary sediment
lipid particles within the cytoplasm of a proximal renal tubular cell after they have been ultrafiltered at glomerular level and reabsorbed by the tubular cells and organised into lysosomes

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A typical “oval fat body” = macrophages or renal tubular cells gorged with lipid particles

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A typical fatty cast - under polarized light lipid particles show the typical appearance of “Maltese crosses”.

54. A typical cholesterol crystal
The urinary sediment
A typical cholesterol crystal

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58. Low sensitivity for diagnosis
The urinary sediment
Low sensitivity for diagnosis

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