APPROACH TO A PATIENT

WITH ACTIVE URINARY

SEDIMENTS

Dr. Sayan Chakraborty

First Year PGT-MD Tropical Medicine
School of Tropical Medicine, Kolkata
 Urine Microscopy
The Liquid Renal Biopsy!
INDICATIONS:
Suspected urinary tract infection
Suspected acute glomerulonephritis.
Suspected acute interstitial nephritis
(requires staining for eosinophils).
Unexplained acute or chronic renal failure.
Haematuria (with or without proteinuria) on
urine dipstick test.
Suspected urinary tract malignancy.
 Classification of Urinary
Sediments
Cells
Renal casts
Crystals
Microorganisms
Mucus
Miscellaneous
 Cells- Erythrocytes
Description Associated Conditions
Size: 7-8 m in diameter Glomerulonephritis
Pale or yellowish, smooth Calculi
biconcave disk BHP/ Prostatitis
No nucleus or cytoplasmic Carcinoma of
granules bladder/kidney
Normal: Less than 2 Trauma
RBC/HPF IgA nephropathy
Can originate from any part Urinary Schistosomiasis
of the urinary tract
etc.
Hematuria
 Leucocytes
Description Associated Conditions

Typically neutrophils Can originate from any part

(PMN) of the urinary tract
Larger than RBC, 10-12 m (glomerulus to urethra)
in diameter Increased In inflammatory
Contain nucleus and processes of the urinary
cytoplasmic granules tract (pyuria)
Brownian
movement (glitter cells)
Normal: no more than 2
WBC/HPF
PYURIA BACTERIURIA
 EPITHELIA
Squamous epithelia
Large flat cell with central oval nucleus
Transitional (bladder) epithelia
Spindle shaped with large oval nucleus
Maybe in sheet
Renal tubular epithelia
Small cell with large oval nucleus
Most clinically significant
Squamous
Epithelial Cells

Large, flat,
irregular-shaped
cells
Principally from
the urethra and
vagina
Transistional
Epithelial Cells

2-4 times larger

than leukocytes
Round, pear-
shaped, tail-like
projections
Large round
nucleus
 Renal Tubular Epithelial Cells

Description Associated conditions

Slightly larger than WBC Tubular damage

Flat, cuboidal or columnar Pyelonephritis
One large round nucleus ATN
Salicylate intoxication
Transplant rejection
Renal Tubular Cells
 Urinary Casts
First described by Henry Bence
Jones (1813-1873)
Cylindrical structures
Formed in the distal convoluted
tubule and collecting ducts of nephrons
Form via precipitation of Tamm-
Horsfall mucoprotein which is secreted
by renal tubule cells, and sometimes also
by albumin in conditions of proteinuria
 Classification of Casts
Acellular casts Cellular casts
Hyaline casts Red blood cell casts
Granular casts White blood cell casts
Waxy casts Bacterial casts
Fatty casts Epithelial cell casts
Pigment casts
Crystal casts
 Hyaline Cast
Most common type of cast
Solidified Tamm-Horsfall
mucoprotein secreted from the tubular
epithelial cells.
CAUSES: Low urine flow, concentrated
urine, acidic environment, dehydration or
vigorous exercise.
Phase contrast microscopy leads to easier
identification.
HYALINE CASTS
 Granular Casts
Second-most common type of cast
Result from the breakdown of cellular casts
or the inclusion of aggregates of plasma
proteins (e.g. albumin) or Ig light chains
Classified as fine or coarse depending on
the size of inclusions
Most often indicative of chronic renal
disease
The "muddy brown cast" seen in acute
tubular necrosis is a type of granular cast.
Fine Granular Cast Coarse Granular Cast
 Waxy Casts
End product of cast evolution
Waxy casts fall under the umbrella of
broad casts
Suggest very low urine flow associated with
severe, longstanding kidney disease such as
chronic renal failure.
Formed in diseased, dilated ducts
 Waxy Cast

Broad Cast
 Hyaline casts with fat
Fatty Cast globule inclusions
Formed by the breakdown
of lipid-rich epithelial cells
If cholesterol or cholesterol
esters are present -
Maltese cross sign under
polarized light
Pathognomonic for high
urinary protein nephrotic
syndrome
 Pigment Cast
So named due to discolouration
Formed by the adhesion of metabolic
breakdown products or drug pigments
Caused by:
Hemoglobin in hemolytic anemia
Myoglobin in rhabdomyolysis
Bilirubin in liver disease.
Drug pigments, such as phenazopyridine
 RBC Cast
Always pathological, and is strongly
indicative of glomerular damage
Causes:
Glomerulonephritis from various causes
Wegener's granulomatosus
Systemic lupus erythematosus
Goodpastures syndrome
Renal infarction
Subacute bacterial endocarditis
RBC Cast
 WBC Cast
Indicative of inflammation or infection
Causes:
Pyelonephritis (strong suggestion)
Acute allergic interstitial nephritis
Nephrotic syndrome
Post-streptococcal acute
glomerulonephritis
WBC Cast
 Bacterial Cast

Found in pyelonephritis
Seen in association with loose bacteria,
white blood cells, and white blood cell casts
Discovery is rare, due to the infection-
fighting efficiency of neutrophils, and the
possibility of misidentification as a fine
granular cast.
Epithelial
Cell Cast
Stasis and
desquamation of
renal tubular
epithelial cells
following
tubular damage
and necrosis.
 Crystals
In Acidic Urine In Alkaline Urine

Uric Acid Triple phosphate

Calcium Oxalate Ammonium biurate
Cystine Calcium phosphate
Leucine
Cholesterol
Tyrosine
Sulfonamide
CRYSTALS IN ACIDIC URINE
 Uric Acid Crystal
Description Associated conditions

Many different Very common

shapes, diamond, Can be normal
rhombic prism or occurence
rosette Associated with
Yellow or brown in increased purine
colour metabolism
Uric Acid Crystals
 Calcium oxalate crystal
Description Associated Conditions

Colorless, octahedral or Ingestion of oxalate-rich

envelope foods: spinach, rhubarb,
tomatoes, garlic,
oranges, asparagus
High intake of ascorbic
acid
Ethylene glycol
poisoning
Calcium Oxalate
Crystal
 Cystine Crystal

Colorless, refractile, hexagonal plates

Found in Congenital cystinosis or cystinuria
 Leucine Crystal
Description Associated Conditions
Oily, highly Clinically significant
refractile, yellow or Maple syrup urine
brown spheroids and disease, Oasthouse
concentric striations urine disease, severe
liver disease
Seen with tyrosine in
liver disease
 Cholesterol Crystal
Description Associated Conditions
Large, flat, Excessive tissue
transparent breakdown
Notched corners Obstructed lymphatic
flow
Nephritis and
nephrotic conditions
 Tyrosine Crystal
Description Associated Conditions
Very fine, highly Severe liver disease
refractile needles Tyrosinosis
Black, yellow
In sheaves or clusters
CRYSTALS IN ALKALINE
URINE
 Triple Phosphate Crystal
Description Associated Condition

Colorless prisms Can be found in

3-6 sides, oblique normal urines
ends Chronic urinary
Coffin lids inflammation
Triple Phosphate Crystals
 Ammonium Biurate Crystal
Yellow brown
spherical bodies with
long irregular spicules
 Calcium Phosphate Crystal
Long thin, colorless
needles
One pointed end
Arranged as
rosettes or star
Can be found
normally
 Active Urinary Sediments
Indicates inflammation
in the glomerular
capillary wall
The sediments are:
Red blood cells/casts
White cells/casts
Approach to a patient with RBCs
or RBC casts in urine
HEMATURIA
 Microscopic hematuria D/D
Glomerular
Primary nephritis (post streptococcal
glomerulonephritis, Ig A nephropathy, Anti-GBM
disease)
2nd nephritis (SLE, Goodpastures syndrome,
ANCA related vasculitis)
Alports syndrome (hereditary nephritis)
Thin basement membrane nephropathy
(benign familial hematuria)
 Microscopic hematuria D/D
contd..
Extra-glomerular:

Renal
Malignancy
Vascular disease (malignant hypertension, AVM,
nutcracker syndrome, renal vein thrombosis, sickle cell
trait/disease, papillary necrosis)
Infection (pyelonephritis, TB, CMV, EBV)
Hypercalciuria
Hereditary disease (polycystic kidney disease,
medullary sponge kidney)
 Microscopic hematuria D/D
contd..
Extra-renal
malignancy (prostate, ureter, bladder)
BPH
Nephrolithiasis
Coagulopathy
Trauma
 Extraglomerular vs Glomerular
Hematuria in Urine Analysis
Extraglomerular Glomerular
Color (if Red, smoky brown,
Red or pink
macroscopic) or "Coca-Cola"
Clots May be present Absent
May be >500
Proteinuria <500 mg/day
mg/day
RBC morphology Normal Dysmorphic
RBC casts Absent May be present
Major causes of hematuria by age
and duration
 Glomerular Hematuria with
active sediments
HISTORY:
Early morning periorbital puffiness,
oliguria, dark colored urine, edema or
hypertension
Recent throat or skin infection may suggest
postinfectious glomerulonephritis
Joint pains, skin rashes, and prolonged fever
in adolescents suggest a collagen vascular
disorder
 Skin rashes and arthritis can occur in
Henoch-Schnlein purpura and systemic
lupus erythematosus
A family history that is suggestive of Alport
syndrome, collagen vascular diseases,
urolithiasis, or polycystic kidney disease is
important
Passage of clots in urine suggests an extra-
glomerular cause
 Physical Examination
Measurement of the blood pressure (with an
appropriately sized cuff)
Evaluation for the presence of periorbital
puffiness or peripheral edema
Detailed skin examination to look for
purpura.
Abdominal examination to look for palpable
kidneys
 Initial Work up
CBC, PT, INR, electrolytes, kidney
function
UA and microscopy to determine the
number and morphology of RBC, crystal
and casts
Consider urine C/S
Repeat UA in a few days
 Further Work up

Throat swab C/S, ASO titre, complement

levels for PSGN
ANA, dsDNA for SLE
Skin biopsy showing IgA deposition s/o
HSP
ANCA for systemic vasculitis
Imaging: USG, CT, Radionuclide studies
 Renal Biopsy
Indications:
Significant proteinuria
Abnormal renal function
Recurrent persistent hematuria
Serologic abnormalities (abnormal complement,
ANA, or dsDNA levels)
Recurrent gross hematuria
A family history of end stage renal disease
Approach to a patient with pyuria
or WBC cast
Differential Diagnosis:
Asymptomatic Bacteriuria
Cystitis
Pyelonephritis
Prostatitis
Complicated UTI
 CASE 1
A 40 year old female patient presented with
Dysuria
Frequency
Urgency

What is the approach for management?

 Diagnostic Approach
Patient profile Management
1. Otherwise healthy woman, not Uncomplicated cystitis:
pregnant, clear history No Urine c/s needed
OPD management
2. Woman with unclear history or risk Uncomplicated cystitis or STD:
factors for STD Dipstick, Urinalysis
STD evaluation, pelvic examination
3. Male with pelvic, perineal or Acute prostatitis:
prostatic pain Urinalysis and C/S
Urologic evaluation
4. Indwelling urinary catheter CAUTI:
Change or remove catheter
Urinalysis, C/S
Blood C/S if fever
5. All other patients Complicated UTI;
Urinalysis, C/S
Modify functional or anatomic
abnormality
 Case 2

A patient presented with acute onset of:

Back pain
Nausea/vomiting
Fever
Possible cystitis symptoms

Approach?
 Diagnostic Approach
Patient profile Management
Otherwise healthy woman, not pregnant Uncomplicated pyelonephritis:
Urine Culture
OPD management
All other patients Pyelonephritis:
Urine Culture
Blood Culture

Patients with non-localizing systemic symptoms like fever,

altered mental status along with leucocytosis:
Consider Complicated UTI or Pyelonephritis :-
Look for other potential etiologies
Urine Culture
Blood Culture
 Case 3
30 year old second gravida lady in her third
trimester presented with a positive urine
culture in the absence of any symptom.

What should be her ideal management?

 Diagnostic Approach
Patient profile Management

Pregnant or renal transplant Asymptomatic Bacteriuria (ABU)

recipient or planned to undergo an Screening and treatment
invasive urologic procedure warranted
All other patients Consider ABU
No additional treatment and
workup needed
Patient with urinary catheter Consider CA-ABU
No additional treatment and
workup needed
Remove unnecessary catheters
 Case 4
68 year old gentleman presented with
recurrent acute urinary symptoms.

Approach to management?
 Diagnostic Approach
Patient Profile Management

Male Consider chronic bacterial prostatitis:

Meares-Stamey 4-glass test
Urology consultation

Otherwise healthy female not pregnant Consider reucurrent cystitis:

Urine Culture
Consider prophylaxis or patient
initiated management
QUIZ BUGS
 Carrot no. 1
A 10 year old male child presented with
hearing loss, dimness in vision and
persistent hematuria. Gene study showed
COL4A4 mutation.

What is your diagnosis?

 Carrot no. 2
21 Year old female visited ophthalmology
clinic with complaints of pain in eyes and
difficulty in adjusting to dark. She was
found to have iliac horns and gave history
of passage of reddish urine.

What is your diagnosis?

 Carrot no. 3
30 year old lady
presented with pain in
left lower quadrant
along with hematuria.
The figure beside
shows the etiology.

What is your diagnosis?