WBC CASTS

• Clinical significance: Infection and

inflammation
• Hallmark of PYELONEPHRITIS and ACUTE
INTERSTITIAL NEPHRITIS and may accompany
RBC casts in cases of glomerulonephritis
• Primary marker for distinguishing
pyelonephritis (upper UTI) from cystitis (lower
UTI)
 WBC CASTS
• Appearance: mostly composed of neutrophils, appear
granular, cast matrix containing WBC
• Reporting: average number/lpf
• Clinical correlation: (+) protein, leucocyte esterase in
the strip and observation of adjacent free WBC’s
• Supravital stains can also be used to demonstrate the
nuclei. It is helpful in differentiating RTE from WBC
• Clinical correlations:
– WBC, protein, and LE strip
– Bacteria (pyelonephritis)
– Eosinophil casts in stained specimens (AIN)
 BACTERIAL CASTS
• Appearance: bacilli bound in the protein
matrix
• Clinical significance: Pyelonephritis (may be
pure bacterial casts or mixed with WBC)
• Sources be correlated with the presence of
WBC casts, many free WBCs and bacteria in
the urine sediment
• Confirmation: Gram stain
 EPITHELIAL CELL CASTS
• RTE Cells attached to a protein matrix
• Clinical significance: Advanced Tubular Destruction. Also
associated with heavy metal/chemical or drug-induced
toxicity, viral infections and allograft rejection
• If pyelonephritis is suspected, it should be accompanied by
WBC casts
• Since they are formed in the DCT, cells visible on the cast
matrix are the smaller, round and oval cells
• May be difficult to differentiate from WBCs particularly if
degeneration has occurred.
• Staining and phase microscopy can be helpful to enhance
the nuclear detail needed for identification
• Bilirubin stained RTE cells: Hepatitis
 FATTY CASTS
• Appearance: Fat droplets and Oval Fat bodies
attached to a protein matrix. Highly refractile
(due to lipids)
• Seen in cases of LIPIDURIA and are also
associated with nephrotic syndrome, toxic
tubular necrosis, diabetes mellitus and crush
injuries
• Confirmation is done by staining Sudan III and
Oil Red O or the use of polarized microscope
 Mixed Cellular Casts
• Most commonly encountered are:
– RBC and WBC casts in cases of glomerulonephritis
– WBC and RTE cell casts or WBC and bacterial casts
in cases of pyelonephritis
 GRANULAR CASTS
• Two types
• Coarse granular casts
• Fine granular casts
• Could be pathologic or non pathologic
• Non pathologic origin of the granules are from the
lysosomes of RTE during normal metabolism (Strenous
exercise)
• Pathologic causes represent disintegration of cellular casts
and tubular cells or protein agreggates filtered by
glomerulus
– Pyelonephritis
– glomerulonephritis
 WAXY CASTS
• Representative of extreme stasis indicating
Chronic Renal Failure
• Appearance: brittle, highly refractive cast
matrix with JAGGED ENDS OR NOTCHES
• Supravital stains- they appear pink
 BROAD CASTS
• Often referred to as Renal Failure Casts (also
represent extreme urine statis)
• Indicates destruction (widening) of the tubular
walls
• Reflection of highly compromised kidneys
• Bile stained broad casts are indicative of
tubular necrosis caused by viral hepatitis
 Cast formation
• Hyaline casts- beginning; PROTOTYPE OF ALL
CASTS at first made up of entirely Tamm-Horsfall
protein
• Cellular casts- (WBC, RBC, Epithelial cell cast)
which will undergo degeneration and dissolution
• Coarse granular casts- will be formed and later
on will disintegrate
• Fine granular casts- will be formed and will
degenerate to form:
• Waxy casts- FINAL DEGENERATIVE FORM OF ALL
CAST
URINARY CRYSTALS
 Urinary Crystals
• Usual crystals are rarely of clinical significance
• Primary reason for identification:
– Detect abnormal crystals indicative of liver
disease, inborn errors of metabolism and renal
damage caused by crystallization of iatrogenic
compounds
Normal Crystals in Acid Urine
 Amorphous Urates
• Seen in acid urine and appear as yellow brown
granules
• If seen in clumps- resemble granular casts
• Frequently encountered in specimens that had
been preserved after refrigeration and may
appear as pink sediment due to uroerythrin
• Usually seen in higher pH higher that 5.5 but
lower than 7.0
• Soluble in heat and alkali
 URIC ACID (Monosodium Urates)
• Are seen in variety of shapes: rhombic, four sided
flat plates (whet stones), wedges and rosettes,
barrel-shaped/lemon shaped crystals
• Soluble in alkali; appear yellow brown in color but
may also be colorless and have a six sided
hexagonal shape similar to cystine
• Increased amounts are seen in cases of:
– Increased nuclei acid and purine metabolism
– Leukemic patients receiving chemotherapy
– Lesch-nyhan syndrome (orange sand in diapers)
– gout
 Acid Urates and Sodium Urates
• Rarely encountered
• Seen in less acidic rine
• Have little or no clinical significance
• Acid urates appear as large granules with spicules
• Sodium urates appear as needle shaped and are
seen in synovial fluid during episodes of gout
• If seen in urine, they appear slender prisms in
fan-like manner and are called peacock-tail
crystals
 Calcium Oxalate
• Frequently seen in acidic urine but can also be seen in
neutral or alkaline urine
• Occur in two forms:
– Monohydrate calcium oxalate (whewellite crystals)
– Appear oval or dumbbell shaped
– Birefringent under polarized light
– Clinically significant in cases of ethylene glycol poisoning
– Dihydrate calcium oxalate (weddelite crystals)
– Appear colorless, octahedral envelope
– Two pyramids joined at their bases
– Enveloped-shaped crystals
– More commonly observed than the monohydrate and are also
birefringent under polarized light
Normal Crystals in Alkaline Urine
 Amorphous Urates
• Seen in alkaline urine and appear as white or
colorless granules
• Frequently encountered in specimens that had
been preserved after refrigeration and may
appear as white sediment
• An be differentiated from a urates by the color
of the sediment and the pH of urine
• Soluble in dilute acetic acid
 Triple Phosphate
• Also known as ammonium magnesium
phosphate or struvite crystals
• Colorless, prism that resembles “coffin-lid’’
• Birefringent under polarized light
• No clinical significance but are often seen in
alkaline urine associated with urea-splitting
bacteria
• Soluble in dilute acetic acid
 Calcium Phosphate
• Appear colorless, flat rectangular plates or
thin prisms often in rosette formation
• The rosette form may be confused with
sulfonamide crystals
• Calcium phosphate will be dissolved in dilute
acetic acid but sulfonamides will not
• No clinical significance although it is a
common constituent of renal calculi
 Calcium Carbonate
• Appear as small, colorless dumbbell or
spherical shape crystals
• Some may appear in clumps that resemble
amorphous material but produce gas after the
addition of acetic acid
• They are also birefringent and have no clinical
significance
 Ammonium Biurate
• Appear as yellow brown crystal with a
characteristic “thorny apples” appearance
(spicule-covered spheres)
• Commonly encountered in old specimens and
may be associated with the presence of
ammonia produced by urea splitting enzymes
• The only urate found in alkaline urine
Abnormal Urine Crystals
 Abnormal Urine Crystals
• Usually found in acid urine, but rarely in
neutral urine
• Most have very characteristic shapes but
should be confirmed using chemical tests
• Manner of reporting of abnormal crystals:
• Average and reported/lpf
 CYSTINE
• Appear in cases of cystinuria (defective tubular
reabsorption of four amino acids)
• Lysine
• Ornithine
• Cystine- least soluble that is why prone to
crystallization
• May appear as colorless hexagonal plates and
may be thick or thin
• They may be difficult to distinguish from uric acid
 CYSTINE VS. URIC ACID
Substance CYSTINE URIC ACID

Solubility Ammonia-soluble Ammonia-soluble

Soluble to dilute HCl Insoluble to dilute HCl

Birefringence NEGATIVE POSITIVE

(thick cystine are the only
positive)
CYANIDE NITROPRUSSIDE POSITIVE NEGATIVE
TEST Formation of Red-purple
color
 Cholesterol crystals
• Rarely seen unless specimens have been
refrigerated because lipids remain in droplet form
• They appear as rectangular plates with a notch in
one or more corners
• Also described as “staircase pattern” or “stair
step crystals” or “notched crystals”
• Associated with lipiduria such as nephrotic
syndrome and can be seen together with an oval
fat body or fatty casts
• Highly birefringent in polarized light
 Radiographic Dye Crystals
• Similar to cholesterol crystals and are also
highly birefringent
• Seen in patients who had undergone xrays
using contrast media
• Usually manifests high specific gravity; higher
than 1.040; measured via refractometer
 Tyrosine
• Appear as fine colorless to yellow needles that
form clumps or rosettes
• Clinically significant in cases of liver disease in
conjunction with leucine crystals
• Can also be encountered in some cases of
defective amino acid metabolism
 Leucine
• Appear as yellow brown spheres that demonstate
concentric circles with radial striations
• Usually described as “scallop-lily” crystals
• Often mistaken as fat globules
• Add ether to differentiate leucine and fat globules
• Fat globules are dissolved; leucine remains
• Tyrosine+leucine= chronic liver disease
 Bilirubin crystals
• Present in hepatic disorders that produced large
amounts of bilirubin in urine
• They appear as clumped needles or granules with
characteristic yellow color of bilirubin
• Should be accompanied with positive chemical test for
bilirubin
• In disorders that produce renal tubular damage; such
as viral hepatitis, bilirubin crystals may be seen
incorporated into the matrix of casts
• Bilirubin stained RTE cell cast seen in cases of hepatitis
• Bile stained broad cast caused by severe hepatitis
 Miscellaneous/Iatrogenic Crystals
• Sulfonamide crystals
• Seen in patients with UTI and inadequate fluid
hydration
• Appear as rhombic; needles; whetstones, sheaves
of wheat, rosettes ranging from colorless to
yellow brown (may resemble calcium phosphate)
• Check patient’s medication history
• May resemble bilirubin crystals; check for reagent
strip reaction (diazo) to confirm identity of crystal
• Ampicillin crystals
– Encountered when the patient had taken massive
doses of penicillin w/out adequate hydration
– Appear as colorless needles that appear in
bundles after refrigeration
– Check patient’s medication history to aid in the
identification of the crystal
URINARY SEDIMENT ARTIFACTS
 Artifacts/Contaminants
• Are commonly observed in specimens
collected under improper conditions usually
from contaminated specimen bottles
• commonly encountered artifacts include:
starch, oil droplets, air bubbles, pollen grains,
fibers and fecal contamination
• They may resemble cells and casts and should
be properly observed when necessary
• Artifacts are never reported in the result form
 Starch granules
• Frequent contaminant from gloves
• Appear as highly refractile spheres usually
with a dimpled cente
• Resemble RBC and FAT DROPLETS
• Fat droplets manifest maltese cross and RBC’s
(should be correlated with chemical tests)
 Oil Droplets
• Highly refractile
• Usually from contamination by immersion oils;
lotions and cream
• They resemble RBC
 Air bubbles
• Occur when specimen is placed under a cover
slip
• They also resemble RBC
 Pollen grains
• Seasonal contaminants
• Appear as spheres with a cell wall and
occasional concentric circles
 Hair and fibers
• Usually diaper fibers that resemble casts
(much longer and more refractile)
• Under polarized light; fibers will polarize; casts
will not
• Fecal contamination such as plant and meat
fibers may also be seen as artifacts in the
urine sediment