1. Urinalysis and Body Fluids CRg
Unit 2; Session 2
RBCs in the Urine Microscopic

2. Microscopic Sediment – Red Blood Cells
Pathological finding - cannot appear in filtrate if nephron is intact.
result of damage / injury to glomerular membrane, or urinary tract (inc. renal calculi)
Isomorphic / fresh looking RBCs usually come from lower tract
Dysmorphic / oddly shaped RBCs been subjected to effects of urine environment longer.
Many RBCs and a squamous epithelial cell, low power magnification / lpf
The picture in this slide comes from Lippincott Williams & Wilkings, the publishers of the Graff Textbook of Urinalysis and Body Fluids. This is how the RBCs would look under low power magnification - abbreviated lpf.

3. Microscopic Sediment – Red Blood Cells
differentiate:
Hemoglobinuria – free hemoglobin in urine
Hematuria – presence of increased numbers of intact RBCs in urine
Hemosiderin – orange/ brown pigment found as intracellular granules

4. Microscopic Sediment – Red Blood Cells
Although NV = 0-2 hpf, an occasional RBC is more significant than occasional WBC.
American Urological Association
defines clinical significant microscopic hematuria as: three or more RBC / hpf in 2 of 3 properly collected urine samples.

5. Microscopic Sediment – Red Blood Cells
NV = 0-2 / hpf

6. Microscopic Sediment – Red Blood Cells
Detection
High power magnification
Reduced light
yellow - red sheen (sometimes blue-green)
Usually highly retractile,
Use fine adjustment knob
In dilute or alkaline urine appear as ghost or shadow cells
Can be any shape
Normal disc
Dysmorphic
swollen or
crenated .

7. Microscopic Sediment – Red Blood Cells
RBCs of various shapes & different levels of magnification

8. Microscopic Sediment – Red Blood Cells
RBC can even get small ‘blebs’ on them, making them appear similar to budding yeast.

9. Microscopic Sediment – Red Blood Cells
Urine RBCs can be easily confused with:
WBCs
Generally larger
Contain nucleus
Do not lyse in 2 % acetic acid

10. Microscopic Sediment – Red Blood Cells
Urine RBCs can be easily confused with:
Yeast
Generally refract light differently
Usually have buds / and often are more egg shaped
Sometimes demonstrate branching
Do not dissolve in 2% acetic acid
Do not stain with eosin

11. Microscopic Sediment – Red Blood Cells
Urine RBCs can be easily confused with:
Bubbles or oil droplets
Large variation in size. Even more refractive / and have ‘hard’ appearing edges.
Confirmation?– test for hemoglobin - by dipstick, which is most sensitive to free hemoglobin, rather than intact RBCs

12. Microscopic Sediment – Red Blood Cells
RBC or yeast cell?
So here is a quiz slide.
Look at all the cells and other sediment in this slide.
Now look at the cells at the end of the pointers – are they RBCs, Yeast cells, or one of each?
Take a moment to study this slide – how would you want to call this?

13. Microscopic Sediment – Red Blood Cells
RBC or yeast cell?
What did you decide ?
When I look at this slide, I see some wbcs near the center and at the bottom of the slide… there may be a couple of squamous epithelial cells also at the bottom 6 oclock) There are 5-7 RBCs throughout , Then there those cells in question.
First a disclaimer:
We are at a disadvantage when evaluating microscopic slides in a powerpoint or a kodochrome slide – we cannot adjust the fine focus knob – something I would want to do - so I could see the depth of these cells and compare them to others in the sediment.
My answer?
With just this slide frame and without ability to change the focus, I would call both of these RBCs – and here is my reasoning:
Both of these cells have the same coloring and are refracting or bouncing the light the same, Yes the cell at the bottom is oval and it appears to have some yeast-like characteristics
But – it is the only one in the field that looks this way – a patient with a yeast infection would usually have a larger number of cells to look at. And that little blob at the bottom of that cell can be a bleb – or artifact caused from the urine environment.
If in doubt, you must lean to the normal – that is to say – don’t jump to pathology, unless you have sound proof to back you up.

14. Microscopic Sediment – Red Blood Cells
yeast
Here is another view of yeast cells, and a WBC at the bottom. This slide came from one of your reference textbooks – Urinalysis and Body Fluids, 5th edition -authored by Susan Strasinger and Marjorie Di Lorenzo.

15. RBCs (cont’d)
Air Bubble
Oil Droplets

16. Microscopic Sediment – Red Blood Cells
Viewed on high dry ; 0-2 /hpf
Damage anywhere in the urinary tract
No nuclei; Yellow-greenish & biconcave / hourglass - if on edge
Swollen or Ghosts if in hypotonic or alkaline urine
Crenated if in hypertonic urine
Can be confused with
WBCs
Yeast
Oil dropplets
Air bubbles