NP6 Nephrology

Assessment of Renal Function

Essential Med Notes 2015

5. Leukocyte Esterase
enzyme found in WBC and detected by dipstick
presence of WBCs indicates infection (e.g. UTI) or inflammation (e.g. AIN)
6. Nitrites
nitrates in urine are converted by some bacteria to nitrites
high specificity, low sensitivity for UTI

Nitrite Negative Bacteria

Enterococci
Staphylococci

7. Ketones
positive in alcoholic/diabetic ketoacidosis, prolonged starvation, fasting
8. Hemoglobin
positive in hemoglobinuria (hemolysis), myoglobinuria (rhabdomyolysis), and true hematuria
(RBCs seen on microscopy)

Urine Microscopy
centrifuge urine specimen for 3-5 min, discard supernatant, resuspend sediment and plate on slide
shaking tube vigorously may disrupt casts
Table 2. Comparison of Urinary Sediment Findings

Any one or more of the

following seen on microscopy

Active Sediment = Suggestive of

Parenchymal Kidney Disease

Bland Sediment = Less Likely

Parenchymal Kidney Disease

Red cell casts

White cell casts
Muddy-brown granular or epithelial cell casts
>2 red cells per HPF
>4 white cells per HPF

Only hyaline casts

<2 red cells per HPF
<4 white cells per HPF
Small quantities of crystals
Small amount of bacteria

1. CELLS
Erythrocytes
normal range = up to 2-3 RBCs per HPF
hematuria = greater than 2-3 RBCs per HPF
dysmorphic RBCs and/or RBC casts suggest glomerular bleeding (e.g. proliferative GN)
isomorphic RBCs, no casts suggest extraglomerular bleeding (e.g. bladder Ca)
Leukocytes
normal range = up to 3 WBCs per HPF
pyuria = greater than 3 WBCs per HPF
indicates inflammation or infection
if persistent sterile pyuria present (i.e. negative culture), consider: chronic urethritis, prostatitis,
interstitial nephritis, calculi, papillary necrosis, renal TB, viral infections
Eosinophils
detected using Wrights or Hansels stain (not affected by urine pH)
consider AIN, atheroembolic disease
Oval Fat Bodies
renal tubular cells filled with lipid droplets
seen in heavy proteinuria (e.g. nephrotic syndrome)
2. CASTS
cylindrical structures formed by intratubular precipitation of Tamm-Horsfall mucoprotein; cells
may be trapped within the matrix of protein
Table 3. Interpretation of Casts
Hyaline casts

Physiologic (concentrated urine, fever, exercise)

RBC casts

Glomerular bleeding (GN, vasculitis)

WBC casts

Infection (pyelonephritis)
Inflammation (interstitial nephritis)

Pigmented granular casts

(heme granular casts, muddy brown)

ATN
Acute GN

Fatty casts

Heavy proteinuria (>3.5 g/d)

Positive dipstick for leukocyte esterase

and nitrites is 94% specific for
diagnosing a UTI