1. KAU-Faculty of Science- Biochemistry department Clinical biochemistry lab (Bioc 416) 2012 Lecturer: Nouf Alshareef nf.shareef@hotmail.com

2. RBCs WBCs Epithelial cells Bacteria Yeast Microscopic Analysis of Urine CrystalsCells Casts

3. Microscopic analysis. In this test, urine is spun in a special machine (centrifuge) so the solid materials (sediment) settle at the bottom. The sediment is spread on a slide and looked at under a microscope. Things that may be seen on the slide include: Red or white blood cells. Blood cells are not found in urine normally. Inflammation, disease, or injury to the kidneys, ureters, bladder, or urethra can cause blood in urine. Strenuous exercise, such as running a marathon, can also cause blood in the urine. White blood cells may be a sign of infection or kidney disease. Casts. Some types of kidney disease can cause plugs of material (called casts) to form in tiny tubes in the kidneys. The casts then get flushed out in the urine. Casts can be made of red or white blood cells, waxy or fatty substances, or protein. The type of cast in the urine can help show what type of kidney disease may be present. Crystals. Healthy people often have only a few crystals in their urine. A large number of crystals, or certain types of crystals, may mean kidney stones are present or there is a problem with how the body is using food (metabolism). Bacteria, yeast cells, or parasites. There are no bacteria, yeast cells, or parasites in urine normally. If these are present, it can mean you have an infection. Squamous cells. The presence of squamous cells may mean that the sample is not as pure as it needs to be. These cells do not mean there is a medical problem, but your doctor may ask that you give another urine sample.

4. 1- Crystals Not usually present in fresh urine Appear if urine is left for several hours before examination. Type of crystal depends on: pH and constituents of urine (conc.) Diagnostically significant crystals:  if present in high conc. for long time May indicate the presence of:  metabolic disorder (congenital disorder or sever liver disease)  renal calculi formation (stones)  provide information that can be used to regulate medications

5. Identification of urine crystals Can identified by morphology alone but … Knowing urine pH is important (provide supporting information)

6. Urinary Crystals Found in healthy individual Include:  Uric acid,  Calcium oxalate  Amorphous urates or phosphates  Triple phosphate  Ammonium biurate  Calcium carbonate. Abnormally found in urine Due to certain disorders Include:  Amino acid crystals  Bilirubin crystals  Cholesterol

8. occur in urine at any pH. Calcium oxalate crystals are square shape with a characteristic “X” mark 1- Oxalate crystals crystals Crystals in Normal Acid Urine

9. 2- Uric acid crystals uric acid crystals: lemon or star needle shaped Note: Gout Presence of high conc. Of Uric acid crystal may indicates Gout Crystals in Normal Acid Urine

10. 3- Amorphous urates crystals aggregates of finely granular material without any defining shape. (Na, K, Mg, or Ca salts) urate Has a pink precipitate of urate salts Crystals in Normal Acid Urine

11. 1- Phosphate crystals found if urine pH > 6.5 Its formation depends on ammonia conc. usually associated with bacterial growth. can indicate urinary tract infection. Crystals in Normal Alkaline Urine

12. aggregates of finely granular material without any defining shape. Has a white precipitate of calcium phosphate Alkaline pH of urine may be due to: 1- Caused by diet (vegetarian, rich in phosphates) 2- Pathology 2- Amorphous phosphates Crystals in Normal Alkaline Urine

13. cystine crystals are hexagon in shape 1- Cystine crystals 3- Bilirubin Crystals 2- Tyrosine Crystals:

14. Differentiation between amorphous urates and amorphous phosphates : Urine pH Centrifugation

15. 3- Urinary Casts

16. Urinary Casts They are cylindrical structures found in urine and composed mainly of mucoprotein (Tamm-Horsefall mucoprotein) which is secreted by epithelial cells of kidney tubules Why these proteins are precipitated? factors responsible are not fully understood but may relate to the concentration and pH of urine in these areas. Some casts may contain cells (epithelial cells, RBC, WBC) so, Casts can be made up of Protein, lipid, cells or mixed.Casts can be made up of Protein, lipid, cells or mixed.

17. If casts are present in large numbers, the urine is almost sure to be positive for albumin.

18. Types of Urinary cast Hyaline Cellular Granular Waxy casts They represent different stages of degeneration of cells in a cast. Clinical indications Casts in the urine always indicate some form of kidney disorder.

19. Is the most common type of cast They are solidified Tamm-Horsfall mucoprotein secreted from the tubular epithelial cells of each nephron Causes: Most commonly seen in normal individuals due to: – Dehydration, low urine flow, concentrated urine, or acidic urine – or vigorous exercise. Morphology: Hyaline casts are cylindrical and clear, colorless, homogeneous, transparent, and usually have rounded ends.

20. Hyaline casts

21. Red blood cell casts Aggregation of RBCs Always pathological. Found in urine due to: Glomerular damage, or urinary tract injury (bleeding) (Glomerular damage allows RBCs to pass through glomerular membrane) Red blood cell cast in urine

22. White blood cell casts Indicate inflammation or infection of the kidnies This renal tubular cell cast suggests injury to the tubular epithelium. White blood cell cast in urine http://library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html#6

23. Epithelial cell casts Is rarely seen in urine because renal disease that affects the tubules is infrequent. Found in urine due to: Degeneration of nephron tubule due to acute tubular necrosis and toxic ingestion distinguished from WBCs by its large size, round nuclei

24. 3- Granular casts The second-most common type of cast result either from the breakdown of cellular casts or the inclusion of aggregates of coagulated proteins Causes: Indicates significant chronic renal disease can also be seen for a short time following exercise Morphology: contain fine granules may appear grey or pale yellow in color or appear black because of the density of the granules.

25. Casts which persist may break down, so that the cells forming it are degenerated into granular debris, as has occurred in this granular cast.

26. represent the end product (final step) of cast degeneration result from the degeneration of granular casts. Causes: usually indicate renal failure. malignant hypertension and diabetic Morphology: larger than hyaline casts, more rigid, sharp edges, fractures, and broken-off ends. appear yellow, grey, or colorless.

27. This is a broad, waxy cast. Note that the edges are sharp and there are "cracks" in this cast.

29. granular cast (A) Hyaline cast B) erythrocyte cast (C) leukocyte cast

30. Microscopic analysis RBCs: RBCsWBCs 3- Cells

31. 1- Epithelial cells Little amount normally appear in female due to reproductive period.

32. 2- RBCs: RBCs up to 5/HPF are commonly accepted as normal. High RBCs in urine is called hematuria, may be due to: - hemorrhage, - inflammation, nephratitis - necrosis, - trauma, or neoplasia in urinary tract.

33. 3- WBCs presence of WBCs suggests infection. WBC up to 5/HPF are commonly accepted as normal. Higher numbers (pyuria) indicate presence of inflammation somewhere in urinary tract.

34. 4- Bacteria and yeast Bacteria are the commonest organism seen commonly due to contaminants. Bacteriayeast

35. Others Sperm Schistosoma & Hematobium Tricochomonas vaginal

36. Exercises:

37. Oxalate

38. Phosphate

39. Phosphate crystals

41. Microscopic Examination: Urine sedimentation may contain cells, casts and crystals and is examined microscopically after centrifugation of a urine sample. A very small amount of all of the above sediments is normal. Concern begins when any of these components is significantly elevated.

42. Procedure: 1.centrifuged well-mixed urine 10 ml at 3000 r.p.m for 10 min until precipitate. 2.supernatant is decanted and 0.2 -0.5 ml is left inside the tube. 3.The sediment is resuspended in the remaining supernatant. 4.drop of sediment is poured in slide and cover-slipped. 5.The sediment is first examined under low power to identify most crystals, casts, cells and other large objects. 6.Next, examination is carried out at high power to identify crystals, cells, and bacteria.