4

Urinalysis
Giovanni B. Fogazzi, Giuseppe Garigali

For a urine sediment sample, after the washing of hands, women

DEFINITION
should spread the labia of the vagina and men withdraw the foreskin
Urinalysis is one of the key tests to evaluate kidney and urinary tract of the glans. The external genitalia are washed and wiped dry with a
disease. When a patient is first seen by a nephrologist, urinalysis must paper towel, and the midstream urine is collected after the first portion
always be performed. Reagent strips are still the most widely used method is discarded. The same procedures can be used for children. For small
for urinalysis to supply physicochemical information. However, the infants, bags for urine are often used, even though these carry a high
nephrologist should be aware of their limitations and ask for more probability of contamination. A suprapubic bladder puncture may
sensitive and specific measurements by other methods in the case of occasionally be necessary. In special situations, urine can also be col-
reagent strip abnormalities (e.g., the accurate measurement of protein- lected through a bladder catheter, although this procedure may cause
uria in case of reagent strip positivity for albumin).1 hematuria. Permanent indwelling catheters are almost invariably associ-
As well as physiochemical findings, urine sediment examination is ated with bacteriuria, leukocyturia, hematuria, and candiduria.
an integral part of urinalysis2,3 and ideally should be performed by The container for urine should be clean, have a capacity of at least
nephrologists, who may be able to identify particles of clinical relevance 50 ml, and have a diameter opening of at least 4 cm to allow easy col-
that escape laboratory personnel.4 lection. It should have a wide base to avoid accidental spillage and
should be capped. The label should identify the patient and the hour
of urine collection.5
THE URINE SAMPLE Several elements (but especially leukocytes) can lyse rapidly after
The use of an early morning urine sample is suggested by the Kidney collection; thus ideally the sample should be handled and examined as
Disease: Improving Global Outcomes (KDIGO) guideline,1 especially soon as possible. We recommend analysis within 3 hours from collec-
for the measurement of albumin (see later discussion). tion. If this is not possible, refrigeration of specimens at +4° to +8° C
However, the 24-hour urine collection is still widely used for the assists preservation but may cause precipitation of phosphates or urates,
measurement of multiple parameters, even though errors caused by which can hamper examination. Alternatively, chemical preservatives
improper timing and missed samples can lead to overcollection or such as formaldehyde or glutaraldehyde can be used.
undercollection of urine. Errors can be minimized by giving the patient
clear written instructions (e.g., at 7:00 am discard the first urine of the PHYSICAL CHARACTERISTICS
morning; then collect in a capacious—of at least 2.5 L—and graduated
container all the urine produced, including that passed at 7:00 am of Color
the day after; measure the volume of urine carefully and record it). The color of normal urine ranges from pale yellow to amber, depending
Written instructions should also be provided for other types of urine on the concentration of the urochrome. Abnormal changes in color
samples—for example, when testing for orthostatic proteinuria, one can be caused by pathologic conditions, drugs, or foods.
sample produced while the patient has been recumbent for some hours, The most frequent color changes are caused by hematuria, hemoglo-
and another sample produced while the patient has been standing. binuria, or myoglobinuria (pink, red, brown, or black urine); bilirubi-
Strenuous physical exercise (e.g., running, soccer) should be avoided nuria (dark-yellow to brown urine); and massive uric acid crystalluria
for at least 24 hours before the urine sample delivery to avoid exercise- (pink urine). Less frequent causes are urinary infection, mainly from
induced proteinuria and hematuria or urinary casts. In women, urinalysis Klebsiella spp., Proteus mirabilis, Escherichia coli, Providencia stuartii, or
must be avoided during menstruation because of the high probability Enterococcus spp. in patients with a permanent bladder catheter (purple
of blood contamination. urine, known as “purple urine bag syndrome”)7; chyluria (white milky
For urine microscopy, a midstream sample of the first morning urine); porphyrinuria (associated with the excretion in the urine of por-
urine is recommended by some international guidelines because this phobilinogen); and alkaptonuria (red urine turning black on standing).
urine is the most concentrated and acidic and theoretically the best The main drugs responsible for abnormal urine color are rifampin;
for the preservation of particles.5 On the other hand, the prolonged phenazopyridine (yellow-orange to red urine); desferrioxamine
persistence in the bladder may favor the lysis of cells and casts, which (pinkish urine); phenytoin (red urine); chloroquine and nitrofurantoin
may lead to false-negative urine sediment examination. For this reason, (brown urine); triamterene, propofol, and blue dyes of enteral feeds
we use a combined dipstick and urine microscopy on the second (green urine); methylene blue (blue urine); and metronidazole, meth-
morning urine.6 yldopa, and imipenem-cilastatin (darkening on standing).

39
40 SECTION II Investigation of Renal Disease

Among foods are beetroot (red urine), senna and rhubarb (yellow SG, pH, glucose, hemoglobin, albumin, leukocyte esterase, nitrites, bile
to brown or red urine), and carotene (brown urine). pigments, and ketones), each pad being impregnated with chemical
reagents meant to detect a specific urine feature. In wealthy countries,
Turbidity the reagent strip reading is performed by automated reader devices,
Normal urine is transparent. Urine can be turbid because of a high using reflectance spectrometry. Alternatively, the reading is performed
concentration of any urine particle, especially cells, crystals, and bacteria. manually, which is simple and quick; however, it must be performed
The most frequent causes of turbidity are urinary tract infection (UTI), correctly, that is, rapid plunging of the strip in the urine; removal of
heavy hematuria, and genital secretions. The absence of turbidity is not the urine in excess on the pads to avoid color carryover from one pad
a reliable criterion by which to judge a urine sample because pathologic to the close ones; adherence to the time interval between removal of
urine can be transparent. the strip from urine and the reading of results as indicated by the
manufacturer; matching the color developed in the pad with the color
Odor scale reported on the strip box in adequate light conditions.
A change in urine odor may be caused by the ingestion of some foods, Reagent strips have the advantages of simplicity and low cost and
such as asparagus. A pungent odor, caused by the production of ammonia, supply a full urinary profile within 2 to 3 minutes. Disadvantages include
is typical of most bacterial UTIs, whereas there is often a sweet or fruity semiquantitative results only, susceptibility to interference by substances
odor with ketones in the urine. Some rare conditions confer a character- and urine discoloration. Sensitivity and specificity of reagent strips
istic odor to the urine. These include maple syrup urine disease (maple greatly differ across studies and partly depend on the brand used (there
syrup odor), phenylketonuria (musty odor), isovaleric acidemia (sweaty is no standardization across manufacturers). Table 4.1 summarizes the
feet odor), and hypermethioninemia (rancid butter or fishy odor).

Relative Density
Relative density can be measured by specific gravity or osmolality. Specific
TABLE 4.1 Urine Reagent Strip Testing
gravity (SG) refers to the weight of a volume of urine compared with
the weight of the same volume of distilled water and depends on the False-Positive
mass and number of the dissolved particles. SG is most frequently Constituent False-Negative Results Results
evaluated by reagent strip (see discussion of chemical characteristics), Specific Urine pH >6.5 Urine protein >7.0 g/l
which measures the ionic concentration of urine. In the presence of gravity (SG)
ions, protons are released by a complexing agent and produce a color pH Reduced values in presence —
change in the indicator bromothymol blue from blue to blue-green to of formaldehyde
yellow. Underestimation occurs with urine of pH above 6.5, whereas
Hemoglobin High urine SG Myoglobin
overestimation is found with urine protein concentration above 7.0 g/l.
Ascorbic acid Microbial peroxidases
Because nonionized molecules, such as glucose and urea, are not detected
Formaldehyde (0.5 g/l) used
by dipstick, this method does not strictly correlate with the results
to preserve samples
obtained by refractometry and osmolality.
Refractometry measures SG through the refraction of light while it Glucose Ascorbic acid Oxidizing detergents
passes through a drop of urine on a glass plate. This measures the number Bacteria Very acid urine pH
of solutes per unit volume and measures all solutes rather than just ionic Albumin Albumin <0.25-0.30 g/l Urine SG ≥1.030
substances. Therefore refractometry is more accurate than reagent strip, Low urine SG Urine pH >8.0
despite being influenced by urine temperature, although temperature- Tubular proteins Quaternary ammonium
compensated refractometers are available. We suggest refractometry for Monoclonal heavy/light detergents
everyday practice, because refractometers are inexpensive, simple to use, chains Chlorhexidine
and require only one drop of urine. SG of 1.000 to 1.003 is seen with Polyvinylpyrrolidone
marked urinary dilution, as observed in patients with diabetes insipidus Leukocyte Ascorbic acid Formaldehyde (0.4 g/l)
or water intoxication. SG of 1.010 is often called isosthenuric urine because esterase Glucose ≥20 g/l Imipenem
it is of similar SG (and osmolality) to plasma, so it is often observed in Protein >5.0 g/l Meropenem
conditions in which urinary concentration is impaired, such as acute Cephalothin (+++) Clavulanate
tubular necrosis (ATN) and chronic kidney disease (CKD) with renal Tetracycline (+++) Abnormally colored
dysfunction. SG above 1.040 almost always indicates the presence of Cephalexin (++) urine
some extrinsic osmotic agent, such as radiocontrast. Tobramycin (+)
Osmolality is measured by an osmometer, which evaluates the High urine SG
freezing-point depression of a solution and supplies results as millios- Nitrites Bacteria that do not reduce Abnormally colored
moles per kilogram (mOsm/kg) of water. Osmolality depends only on nitrates to nitrites urine
the number of particles present and is not influenced by urine tempera- No vegetables in diet
ture or protein concentrations. However, high glucose concentrations Short bladder incubation time
significantly increase osmolality (10 g/l of glucose = 55.5 mOsm/l).
Ketones Improper storage Free sulfhydryl groups
Measurement of osmolality is more reliable than SG by either reagent
(e.g., captopril)
strip or refractometry.
Levodopa
Abnormally colored
CHEMICAL CHARACTERISTICS urine
Chemical characteristics of urine are most frequently evaluated by (Main false-negative and false-positive results of urine reagent strips.
reagent strips. These plastic strips bear several pads (the most used are False results also may occur when time-expired strips are used.)
 CHAPTER 4 Urinalysis 41

main false-negative and false-positive results that can occur with strip do vary by age.1 Three different approaches can be used for the evalu-
reagent testing. ation of proteinuria, as described next.

pH Albumin Reagent Strip

The pH is determined by a strip that covers the pH range of 5.0 to 8.5 The albumin reagent strip test is based on the effect of albumin on a
or to 9.0, with intervals of only 0.5, which limits precision. Moreover, buffer (tetrabromophenol blue), which causes a change in pH propor-
significant deviations from true pH are observed for values below 5.5 tional to the concentration of the albumin itself. The pad changes color,
and above 7.5. In the presence of formaldehyde, the strip supplies reduced from pale green to green and blue, according to the pH changes induced
pH values; no causes of increased pH values are known. When an by the albumin. The strip is sensitive to albumin but has a very low
accurate measurement of pH is necessary, a pH meter with a glass sensitivity to other proteins, such as tubular proteins and light-chain
electrode is mandatory. immunoglobulins; thus it will not detect tubular proteinuria or overflow
Urine pH reflects the presence of hydrogen ions (H+), but this proteinuria, which can occur in monoclonal gammopathies. Moreover,
does not necessarily reflect the overall acid load in the urine because the detection limit is 0.25 to 0.3 g/l, so does not identify microalbu-
most of the acid is excreted as ammonia. Low pH is often observed minuria and is influenced by hydration status (false-negative results
with metabolic acidosis (in which acid is secreted), high-protein meals may occur at low urine SG, and vice versa) and urine pH (false-positive
(which generate more acid and ammonia), and volume depletion (in results at strongly alkaline pH). The reagent strip supplies only a semi-
which aldosterone is stimulated, resulting in an acid urine). In addi- quantitative measurement of urine albumin, which is expressed on a
tion, low urine pH may help distinguish pre-renal acute kidney injury scale from 0 to +++ or ++++. Some manufacturers also supply numerical
(AKI) from ATN, which is typically associated with a higher pH. High results, although these represent only approximate quantitative mea-
pH is often observed with renal tubular acidosis, vegetarian diets surements. Some reagent strips also include a creatinine pad, which
(caused by minimal nitrogen and acid generation), and infection due supplies an albumin-to-creatinine ratio (ACR) and reduces the vari-
to urease-positive organisms (e.g., Proteus) that generate ammonia ability caused by changing diuresis and urine dilution.11 Nevertheless,
from urea. for accurate quantification other methods are needed.
Measurement of urine pH is also needed for a correct interpretation
of other urine parameters (e.g., specific gravity, albumin) and several 24-Hour Protein Excretion
urine sediment findings. The 24-hour protein excretion averages the variation of proteinuria
caused by the circadian rhythm and is still considered the reference
Hemoglobin method,1 especially for monitoring proteinuria during treatment.12-14
Hemoglobin is detected by a dipstick based on the pseudoperoxidase The measurement of proteinuria can be done by chemical assays (e.g.,
activity of the heme moiety of hemoglobin, which catalyzes the reaction biuret or Folin-Lowry reaction), turbidimetric techniques (e.g., trichlo-
of a peroxide and a chromogen to form a colored product. The presence roacetic acid, benzethonium chloride, ammonium chloride), or dye-
of hemoglobin is shown as green spots, which result from intact erythro- binding techniques (e.g., Ponceau S, Coomassie brilliant blue G-250,
cytes, or as a homogeneous, diffuse green pattern. The latter can result pyrogallol red molybdate), which quantify total proteins rather than
from marked hematuria because of the high number of erythrocytes only albumin. However, the 24-hour urine collection can be impractical
that cover the whole pad surface; from lysis of erythrocytes favored by in some settings (e.g., children, outpatients, elderly patients) and is
delayed examination, alkaline urine pH, or low SG; or from hemoglo- subject to error from overcollection or undercollection.
binuria secondary to intravascular hemolysis.
False-negative results are most frequently caused by high SG or by Protein-to-Creatinine Ratio and Albumin-to-Creatinine Ratio
ascorbic acid, a strong reducing agent, which can result in low-grade on Random Urine Sample
microhematuria being completely missed. Some reagent strips also The protein-to-creatinine ratio (PCR) measured on an early morning
include a vitamin C pad to reduce these false-negative results.8 urine sample represents a practical alternative to the 24-hour urine
The most important causes of false-positive results are myoglobin- collection because the sample is easy to supply and is not influenced
uria, resulting from rhabdomyolysis, and a high concentration of bacteria by variation in water intake or rate of diuresis.1 The PCR is obtained
with pseudoperoxidase activity (Enterobacteriaceae, staphylococci, and by the ratio between urine protein excretion and creatinine excretion,
streptococci).9 expressed as milligrams per milligrams or milligrams per millimole. A
close correlation between the PCR in a random urine sample and the
Glucose 24-hour protein excretion has been demonstrated in a wide range of
The reagent strip uses glucose oxidase as catalyst: glucose is first oxidized patients,10,15 including those with different types of glomerulonephritis
to gluconic acid and hydrogen peroxide. Through the catalyzing activity (GN) evaluated longitudinally during treatment.16 However, the results
of a peroxidase, hydrogen peroxide then reacts with a reduced colorless may be influenced by a reduced creatinine excretion because of low
chromogen to form a colored product. This test detects concentrations muscle mass. Thus, in elderly and female patients, PCR values can be
of 0.5 to 20 g/l. When more precise quantification of urine glucose is higher than in young men. Some investigators consider a normal PCR
needed, enzymatic methods such as hexokinase must be used. sufficient to rule out pathologic proteinuria, but an elevated PCR should
False-negative results for glucose occur in the presence of ascorbic be confirmed and quantified with a 24-hour collection.12 Others have
acid and bacteria. False-positive findings may be observed in the pres- found poor correlation between PCR and 24-hour proteinuria at high
ence of oxidizing detergents and very acid urine pH. levels of protein excretion16 or that PCR is an unreliable method to
monitor some patients with lupus nephritis.17
Protein The KDIGO guideline suggests ACR rather than PCR as first mea-
Although there has been no consistent definition of proteinuria,10 the surement of proteinuria in adults because albuminuria is a reliable
definitions in the KDIGO guideline are increasingly used.1 It is accepted marker of the outcome of CKD, it provides a specific and sensitive
that physiologic proteinuria does not exceed 150 mg/24 h for adults1 measure of changes in glomerular permeability in several renal diseases,
and 140 mg/m2 for children,10 in whom, however, the normal values and the measurement of total proteins is problematic in several respects.1
42 SECTION II Investigation of Renal Disease

However, false-negative results may occur with ACR,18 especially in

tubulointerstitial diseases and monoclonal gammopathies, in which URINE MICROSCOPY
urine proteins are mostly composed of tubular proteins and monoclonal
light chains, respectively. In children, KDIGO guidelines1 recommend Methods
the measurement of PCR rather than ACR because the latter can miss We instruct the patient to deliver the second urine specimen of the
the identification of congenital disorders associated with nonalbumin morning because it avoids the lysis of particles that can occur in the
proteinuria.1 bladder overnight (Box 4.1). We centrifuge an aliquot of urine within
3 hours from collection and concentrate it by removal of a fixed aliquot
Specific Proteins of supernatant urine. After this, the sediment is resuspended with a
Albuminuria. Albuminuria is the term that should be used now, Pasteur pipette, and a fixed aliquot is transferred to the slide and pre-
according to the KDIGO guideline, instead of microalbuminuria,1 defined pared using a coverslip with a fixed surface. Some suggest the use of
as urine albumin in the range of 30 to 299 mg/24 h. In persons with noncentrifuged urine, because centrifugation may cause the damage
diabetes it identifies increased risk for developing overt diabetic nephropa- and/or lysis of particles during the procedure. On the other hand, with
thy and, in the general population, subjects at increased risk of CKD, this approach, clinically important particles (e.g., erythrocyte casts),
cardiovascular morbidity, and overall mortality. Semiquantitative reagent when in small numbers, can easily be missed.
strips are available to screen for urine albumin in this range.19 Once Phase contrast microscopy is recommended because it improves the
the reagent strip is positive, a quantitative method on early morning identification of almost all particles, especially cells and casts, whereas
urine must be used for confirmation.1 Because of its great simplicity, polarized light is mandatory for the correct identification of lipids and
immunoturbidometry is most frequently used. crystals, especially when they have uncommon morphologies.6
Tubular proteins. When an isolated tubular lesion is suspected, At least 20 microscopic fields, in different areas of the sample, should
specific tubular proteins such as α1-microglobulin, retinol-binding be examined at both low magnification (e.g., ×100 or ×200) and high
protein, or β2-microglobulin should be measured.1 This can be done magnification (e.g., ×400). More extensive examination may be required
by qualitative analysis of urine proteins, using electrophoresis on cel- in certain clinical settings, such as isolated microhematuria of unknown
lulose acetate or agarose after protein concentration or using very sensi- origin, for which we suggest examination of 50 low-power fields (lpfs)
tive stains such as silver and gold, or sodium dodecyl sulfate–polyacrylamide to look for erythrocyte casts.23
gel electrophoresis (SDS-PAGE). For correct examination, both pH and SG of the sample must be
Bence Jones proteinuria. Bence Jones proteinuria indicates the known. Both alkaline pH (≥7.0) and low SG (especially ≤1.010) favor
presence of free monoclonal immunoglobulin (heavy or light chains) the lysis of erythrocytes and leukocytes, which can cause discrepancies
as occurs with monoclonal gammopathies. Bence Jones proteinuria is between dipstick readings and the microscopic examination (see earlier
revealed by urine electrophoresis, whereas light-chain identification discussion). Alkaline pH also impairs the formation of casts and favors
requires urine immunofixation.20 the precipitation of amorphous phosphates. On the contrary, high SG
(≥1.030) may reduce the sensitivity of reagent strips for hemoglobin
Leukocyte Esterase and leukocyte esterase.
The leukocyte esterase dipstick test evaluates the presence of leukocytes We quantify the particles seen as number per microscopic field,
based on the activity of an indoxyl esterase released from lysed neu- whereas if counting chambers are used, the elements are quantified as
trophil granulocytes. Leukocyte esterase may be positive but microscopy number per volume. Counting chambers allow a precise quantitation
negative when leukocytes are lysed because of low SG, alkaline pH, or but are not frequently used in everyday practice.
a delay in sample handling and examination.
False-negative results derive from vitamin C,8 high glucose (≥20 g/l)
or high protein (≥5 g/l) concentration or from the presence of antibiot-
ics such as cephalothin and tetracycline (strong inhibition), cephalexin BOX 4.1 Procedures for Preparation and
(moderate inhibition), or tobramycin (mild inhibition). The sensitivity Examination of Urine Sediment*
is also reduced by high SG, because this prevents leukocyte lysis. False-
• Written instructions for the patient to deliver a correct urine sample (i.e.,
positive results may occur when formaldehyde is used as a urine pre-
the second urine of the morning after discarding the first few milliliters of
servative, from the presence in the urine of imipenem, meropenem, or
urine [midstream urine] collected in a proper container).
clavulanate,21 and with all discolored urine.
• Sample handling and examination within 3 hours of collection.
Nitrites • Centrifugation of a 10-ml aliquot of urine at 400 g for 10 minutes.
• Removal by suction of 9.5 ml of supernatant urine.
The dipstick nitrites test detects bacteria that reduce nitrates to nitrites
• Gentle but thorough resuspension with a Pasteur pipette of sediment in
by nitrate reductase activity. This includes most gram-negative uro-
remaining 0.5 ml of urine.
pathogenic bacteria, but not Pseudomonas, Staphylococcus albus, or
• Transfer by a precision pipette of 50 µl of resuspended urine to a slide.
Enterococcus. False-negative results also may occur on a diet with low
• Covering of sample with a 24- × 32-mm coverslip.
content of nitrate (vegetables), which form the substrate for nitrite
• Examination of the urine sediment with a phase contrast microscope at
production and short bladder incubation time. Thus the sensitivity of
×160 and ×400.
the dipstick nitrites test is low, whereas specificity is high.22 False-positive
• Use of polarized light to identify doubtful lipids and crystals.
results may occur in the presence of abnormally colored urine.
• Matching of the microscopic findings with reagent strip for pH, specific
Ketones gravity, hemoglobin, leukocyte esterase, nitrites, and albumin.
• Cells expressed as lowest/highest number seen per high-power field (hpf),
The ketone dipstick tests for acetoacetate and acetone (but not
casts as number per low-power field (lpf), and all other elements (e.g.,
β-hydroxybutyrate), which are excreted into urine during diabetic aci-
bacteria, crystals) on scale from 0 to ++++.
dosis or during fasting, vomiting, or strenuous exercise. It is based on
the reaction of the ketones with nitroprusside. *Procedures used in the authors’ laboratory.
 CHAPTER 4 Urinalysis 43

system; and dysmorphic, with irregular shapes and contours, which

Cells are of glomerular origin (see Fig. 4.1A and B).24 Erythrocyte dysmor-
Erythrocytes phism is thought to result from deformation of the erythrocytes as they
Urinary erythrocytes have a mean diameter of approximately 6 µm. pass through gaps in the glomerular basement membrane, followed by
In the urine, there are two main types of erythrocytes: isomorphic, physicochemical insults while the erythrocytes pass through the tubular
with regular shapes and contours, derived from the urinary excretory system.25

A B

E G H
Fig. 4.1 Urinary sediment cells. (A) Isomorphic nonglomerular erythrocytes (diameter ~6 µm). The arrows
indicate the so-called crenated erythrocytes, which are a finding in nonglomerular hematuria. (B) Dysmorphic
glomerular erythrocytes (diameter ~6 µm). The dysmorphism consists mainly of irregularities of the cell
membrane. Inset, Acanthocytes, with their typical ring-formed cell bodies with one or more blebs of different
sizes and shapes. (C) Neutrophils (diameter ~10 µm). Note their typical lobulated nucleus and granular cyto-
plasm. (D) Granular phagocytic macrophage (diameter ~60 µm). (E) Different types of renal tubular epithelial
cells (diameter ~14 µm). (F) Two cells from deep layers of uroepithelium (diameter ~18 µm). (G) Three cells
from superficial layers of uroepithelium (diameter ~25 µm). Note the difference in shape, size, and ratio of
nucleus to cytoplasm between the two types of uroepithelial cells. (H) Squamous epithelial cells (diameter
~50 µm). (All images by phase contrast microscopy; original magnification ×400.)
44 SECTION II Investigation of Renal Disease

Unfortunately, there is no agreement on the criteria to classify hema- Transitional Epithelial Cells
turia as glomerular or nonglomerular. Some define glomerular hematuria The transitional epithelial cells derive from the exfoliation of the uro-
as more than 80% of erythrocytes being dysmorphic; others define the epithelium, which lines the urinary tract from the calyces to the bladder
discriminating cut-off as low as 10% or 15%.6 Still, others define hema- in women and to the proximal urethra in men. This multilayered epi-
turia as glomerular when at least 5% of erythrocytes examined are thelium has small cells in the deep layers and larger cells in the superficial
acanthocytes,26 a subtype of dysmorphic erythrocytes with a distinguish- layers. When cells of the deep epithelial layers (average diameter 18 µm,
ing appearance easily identifiable by the presence of one or more blebs see Fig. 4.1F) are present in large numbers (e.g., ≥1/high-power field
of different size and shape protruding from a ring-shaped body (see [hpf]), this suggests severe uroepithelial damage, such as caused by
Fig. 4.1B, inset). neoplasia, stones, obstruction, or long-standing bladder catheters or
In our laboratory, glomerular hematuria is diagnosed when there ureteral stents.6 Transitional cells of the superficial layers (average diam-
are 40% or more dysmorphic erythrocytes and/or 5% or more acan- eter ~25 µm; see Fig. 4.1G) are a common finding associated with mild
thocytes and/or one or more red blood cell casts/50 lpf (×160). With uroepithelial damage, as may occur in cystitis.
this criterion, a good correlation was found between urinary sediment
and renal biopsy findings in 16 patients with long-standing isolated Squamous Epithelial Cells
microhematuria.23 Squamous epithelial cells (SECs) (average diameter 50 µm; see Fig.
The distinction between glomerular and nonglomerular hematuria 4.1H) derive from the urethra or from the external genitalia. In small
is of special value in the evaluation of patients with isolated microhe- numbers, SECs are a normal finding, but in large numbers, they indicate
maturia, in whom it is important to decide whether nephrologic or urine contamination from genital secretions.
urologic investigation is needed.
Rare types of erythrocytes found in the urine include sickle cells, Lipids
elliptocytes, spherocytes, dacryocytes, etc. The finding in the urine of Lipids are found in the urine as drops, which are spherical, translucent,
such cells reflects their presence in the circulation.27 yellowish particles of different size that can be isolated or in clusters (see
Fig. 4.2A); as oval fat bodies, which are RTECs or macrophages gorged
Leukocytes with lipid droplets; as fatty casts, cylindrical structures containing variable
Urinary neutrophils have an average diameter of approximately10 µm amounts of fatty droplets or even oval fat bodies; and cholesterol crystals
and are the most frequently found leukocytes in the urine. Neutrophils (see Crystals). All these particles contain mainly cholesterol esters and
are identified by their granular cytoplasm and lobulated nucleus (see free cholesterol. Under polarized light, drops, oval fat bodies, and casts
Fig. 4.1C). In most patients, neutrophils indicate UTI, but they may give the appearance of Maltese crosses with symmetric arms (see Fig.
also result from urine contamination caused by genital secretions, espe- 4.2B), whereas cholesterol crystals are nonbirefringent.
cially in fertile women. Variable numbers of neutrophils are often, but These lipids are typical of glomerular diseases associated with marked
not always, found in acute interstitial nephritis. Neutrophils can be proteinuria, usually but not invariably in the nephrotic range.
found in low numbers in chronic interstitial nephritis and in prolifera- In Fabry disease, urine sediment may contain fatty particles even
tive GN, intermingled with high numbers of erythrocytes.28 in the absence of proteinuria. These particles contain glycosphingolipids
Eosinophils, which can be identified only by the use of stains (e.g., (especially globotriaosylceramide-3) and have irregular shape and size,
Hansel), were once considered a marker of acute allergic interstitial variable protrusions or an internal lamellar structure, and irregular or
nephritis. However this is not specific,29 because eosinophils may be truncated Maltese crosses under polarized light (see Fig. 4.2C).31
present in various types of GN, prostatitis, chronic pyelonephritis,
urinary schistosomiasis, and cholesterol embolism. Casts
Lymphocytes, whose identification also requires staining, may indicate Casts are cylindrical structures that form in the lumen of distal renal
acute cellular rejection in renal allograft recipients, although this is not tubules and collecting ducts. Their matrix is made of Tamm-Horsfall
sufficiently reliable to avoid renal biopsy. Lymphocytes are also a typical glycoprotein, today known as uromodulin, which is secreted by the
finding in patients with chyluria. cells of the thick ascending limb of Henle loop. Trapping of particles
Macrophages are mononucleated or multinucleated cells of variable within the cast matrix results in casts with different appearances, each
size (13 to 95 µm in diameter) and variable appearance: some are granular of which may have specific clinical significance (Table 4.2). Because
(see Fig. 4.1D). In patients with nephrotic syndrome, macrophages may be casts form in the renal tubules, whatever particle is contained in a cast
engorged with lipid droplets, appearing as “oval fat bodies.” Macrophages derives from the kidneys. Specific casts include the following:
have been found in the urine of patients with active GN. In our experi- • Hyaline casts are colorless with a low refractive index (see Fig. 4.3A).
ence, macrophages are frequently seen in the urine of kidney transplant They are easily seen with phase contrast microscopy but can be
recipients with BK virus infection (see later discussion). However, urinary overlooked when bright-field microscopy is used. Hyaline casts may
macrophages are not yet diagnostic of any specific condition. occur in normal urine, especially when it is concentrated and acidic
(both conditions favor precipitation of uromodulin). In patients
Renal Tubular Epithelial Cells with renal disease, hyaline casts are usually associated with other
The renal tubular epithelial cells (RTECs) derive from the exfoliation types of casts.
of the tubular epithelium. In the urine, RTECs can differ in size (diam- • Hyaline-granular casts contain variable amounts of granules within
eter ~9 to 25 µm, average 14 µm) and shape, from roundish to rect- the hyaline matrix (see Fig. 4.3B) and are the most common mixed
angular or columnar, with a central or peripheral large nucleus (see casts (see later discussion). Hyaline-granular casts are rare in normal
Fig. 4.1E). RTECs are not found in the normal individual but can be individuals but are common in patients with renal diseases such as
found when there is acute tubular damage, including ATN,30 acute GN28 and acute interstitial nephritis.32
interstitial nephritis, and acute cellular rejection. In smaller numbers, • Granular casts can be finely granular (see Fig. 4.3C) or coarsely
RTECs also can be found in glomerular diseases.28 In ATN, these cells granular. Both types indicate renal disease. In patients with AKI,
are frequently damaged and necrotic and may be present in casts granular casts together with RTECs30 or with epithelial casts33 are a
(so-called epithelial casts). sensitive marker of ATN.
 CHAPTER 4 Urinalysis 45

A B C
Fig. 4.2 Fatty particles. (A) Lipid droplets, both aggregated and isolated (arrows), and filaments also made
up of cholesterol by phase contrast microscopy. (B) Same lipid droplets in A under polarized light, showing
typical Maltese crosses with symmetric arms. (C) Fatty particle with protrusions, as found in Fabry disease
(phase contrast microscopy). Inset, Same particle under polarized light. Note the truncated and asymmetric
Maltese cross. (Original magnification ×400.)

TABLE 4.2 Types of Casts and Their Main • Waxy casts derive their name from their appearance, which is similar
to that of melted wax (see Fig. 4.3D). They are typically found in
Clinical Associations
patients with renal disease associated with impaired renal function,
Cast Main Clinical Associations whether acute, rapidly progressive, or chronic.34
Hyaline Normal individual; renal disease • Fatty casts contain variable amounts of lipid droplets, isolated, in
clumps, or packed or even oval fat bodies or cholesterol crystals.
Hyaline-granular Normal individual; renal disease
Fatty casts are typical of glomerular diseases associated with marked
Granular Renal disease; acute tubular necrosis proteinuria or the nephrotic syndrome.
Waxy Renal disease with possible functional • Erythrocyte casts may contain a few erythrocytes (see Fig. 4.3E) or
impairment so many that the matrix of the cast cannot be identified. Erythrocyte
Fatty Proteinuria; nephrotic syndrome casts are usually considered a marker of glomerular bleeding, although
Erythrocyte Glomerular hematuria; proliferative/ a recent report found them in 28% of patients with acute interstitial
necrotizing GN; acute interstitial nephritis nephritis.32
• Hemoglobin casts generally have a brownish hue and a coarsely
Leukocyte Acute interstitial nephritis; acute
granular appearance, which derives from the degradation of erythro-
pyelonephritis; proliferative GN
cytes entrapped within the cast matrix (see Fig. 4.3F). In such cases,
Renal tubular epithelial Acute tubular necrosis; acute interstitial hemoglobin casts have the same clinical significance as erythrocyte
cell (so-called nephritis; proliferative GN; nephrotic casts. However, hemoglobin casts also may derive from hemoglo-
epithelial casts) syndrome binuria, as may occur in intravascular hemolysis. In these patients,
Hemoglobin Same as for erythrocyte cast; hemoglobinuria hemoglobin casts have a smooth surface.
caused by intravascular hemolysis • Leukocyte casts contain variable amounts of polymorphonuclear
Myoglobin Rhabdomyolysis leukocytes (see Fig. 4.3G). They can be found in patients with acute
Bilirubin Jaundice caused by increased direct bilirubin pyelonephritis and acute interstitial nephritis, as well as in active
proliferative GN.28
Bacterial, fungal Bacterial or fungal infection in the kidney
• Renal tubular epithelial cell casts (so-called epithelial casts) contain
Containing crystals Renal stone disease; crystalline
variable numbers of RTECs, which can be identified by their promi-
nephropathies
nent nucleus (see Fig. 4.3H). Epithelial casts indicate damage of the
Mixed According to components present in the cast renal tubular epithelium and can therefore be found in the urine
AKI, Acute kidney injury; GN, glomerulonephritis. of patients with ATN,30 acute interstitial nephritis, and glomerular
disease.28
• Myoglobin casts are pigmented cylinders, with the myoglobin
providing their color. They may be similar to hemoglobin casts
46 SECTION II Investigation of Renal Disease

A B C D

E F G

Fig. 4.3 Casts. (A) Hyaline cast. (B)

Hyaline-granular cast. (C) Finely granular
cast. (D) Waxy cast. (E) Erythrocyte cast,
with erythrocytes (arrows) plunged into
the cast matrix. (F) Hemoglobin cast with
a coarsely granular appearance and typical
brownish hue. (G) Leukocyte cast. Note
the lobulated nucleus of polymorphonu-
clear leukocytes (arrows). (H) Epithelial
cell cast. Note, in its lower extremity, the
large nucleus of the renal tubular epithelial
cells. (I) Bilirubin cast with a coarsely
granular appearance and typical yellow
I color. (All images by phase contrast
H microscopy; original magnification ×400.)
 CHAPTER 4 Urinalysis 47

(see Fig. 4.3F), from which they can be distinguished by the clinical
setting. Myoglobin casts are observed in the urine of patients with Pathologic Crystals
AKI associated with rhabdomyolysis. Cholesterol crystals. Cholesterol crystals are thin, transparent plates,
• Bilirubin casts are cylinders pigmented with bilirubin, which can often clumped together, with sharp edges (see Fig. 4.4F), which do not
stain any particle contained in the cast (see Fig. 4.3I). They are polarize light. They can be found in a wide spectrum of urine pH.
observed in the urine of patients with jaundice associated with Cystine crystals. Cystine crystals occur in cystinuria and are
increased direct (conjugated) bilirubin. hexagonal plates with irregular sides that are often heaped on one
• Casts containing microorganisms (bacteria and yeasts) indicate renal another (see Fig. 4.4G). They either do not polarize light or show a
infection. whitish biferingence. They are insoluble in a urine pH up to 7.4. Their
• Casts containing crystals indicate that crystals derive from the persistence in urine and their number is significantly associated with
renal tubules. Crystal casts are an important diagnostic element the formation of cystine stones.37
in crystalline-induced nephropathies, such as acute urate 2,8-dihydroxyadenine(2,8-DHA) crystals. 2,8-DHA crystal are
nephropathy.35 spherical, brownish structures with a central umbilicus and a birefringent
• Mixed casts contain components of different nature, such as granules, cross-like appearance under polarized light (see Fig. 4.4H). They are a
cells, and lipids. This causes the appearance of pleomorphic cylinders, marker of homozygous deficiency of the enzyme adenine phosphori-
whose clinical significance is the same as that for the pure types of bosyltransferase. Crystalluria is absent in heterozygotes and so allows
casts, of which mixed casts contain some components. specific identification of homozygotes in 100% of cases. The search for
crystalluria is best performed on the first voided morning urine samples,
Crystals which are the most concentrated.38
Correct identification of urine crystals requires knowledge of crystal Other rare pathologic crystals are tyrosine, found in patients with
morphology, their appearance under polarized light, and urine pH. acute liver disease and the rare hereditary disease tyrosinemia, and
However, for unusual crystals, additional investigation may be needed, leucine, found in acute liver disease.
such as infrared spectroscopy, which is available only in specialized
laboratories.36 Examination of the urine for crystals is a key test in the Crystals Caused by Drugs
assessment of patients with stone disease, with some rare inherited Many drugs can cause crystalluria, especially in a setting of drug over-
metabolic disorders (e.g., cystinuria, hyperoxaluria, phosphoribosyl- dose, dehydration, or hypoalbuminemia in the presence of a urinary
transferase deficiency), and with suspected drug nephrotoxicity.6 Crystals pH favoring drug crystallization. Examples include the antibiotics
can be classified in four categories: common, pathologic, caused by sulfadiazine, amoxicillin (see Fig. 4.4I), ciprofloxacin6 (see Fig. 4.4J),
drugs, and other crystals. and sulfamethoxazole39; the antiviral agents acyclovir, indinavir (see
Fig. 4.4K),6 atazanavir, and darunavir40; the vasodilators pyridoxylate
Common Crystals and naftidrofuryl oxalate; the barbiturate primidone; the antiepileptic
Uric acid crystals and amorphous urates. Uric acid crystals have felbamate; the inhibitor of gastroenteric lipase orlistat; and intravenous
an amber color and a wide spectrum of appearances, most frequently vitamin C.6 Most of these drugs cause crystals made of the drug, with
rhomboids or barrels (see Fig. 4.4A) and, rarely, needle-like structures. unusual morphologies that differ from those of the crystals previously
Under polarized light they are strongly birefringent and polychromatic. described. However, naftidrofuryl oxalate, orlistat, and vitamin C cause
They are found in acidic urine (pH 5.0 to 5.8). calcium oxalate crystals, which are indistinguishable from calcium oxalate
Amorphous urates are tiny granules of irregular shape that polarize crystals resulting from other causes.6
light and precipitate in acidic urine. They are identical to amorphous
phosphates, which, however, precipitate in alkaline urine and do not Other Crystals
polarize light. Hippuric acid crystals, calcium carbonate crystals, and ammonium
Calcium oxalate crystals. There are two types of calcium oxalate biurate crystals are rare and devoid of clinical significance.
crystals: bihydrated (or weddellite) crystals, which most often have a
bipyramidal appearance (see Fig. 4.4B), and monohydrated (or whewel- Clinical Significance of Crystals
lite) crystals, which are ovoid, dumbbell-shaped, or biconcave disks Uric acid, calcium oxalate, and calcium phosphate crystals may have
(see Fig. 4.4C). Monohydrated crystals always polarize light, whereas no clinical significance because they can reflect transient supersatura-
bihydrated crystals usually do not. Both types of calcium oxalate crystals tion of the urine caused by ingestion of some foods (e.g., meat for uric
precipitate at pH 5.4 to 6.7. acid, spinach or chocolate for calcium oxalate, milk or cheese for calcium
Calcium phosphate crystals (brushite) and amorphous phos- phosphate) or mild dehydration. However, the persistence of calcium
phates. Calcium phosphate crystals are pleomorphic, appearing as oxalate or uric acid crystalluria may reflect hypercalciuria, hyperoxaluria,
prisms, star-like particles, or needles of various sizes and shapes (see or hyperuricosuria. In calcium stone formers, the evaluation of crystal-
Fig. 4.4D) that polarize light intensely. They also can appear as plates luria is an important tool to assess calcium stone disease activity.41
with a granular surface and do not polarize light. Both types of crystals Large numbers of uric acid crystals may be associated with AKI
precipitate in alkaline urine (pH ≥7.0). caused by acute urate nephropathy, whereas large numbers of mono-
Amorphous phosphates are tiny particles identical to amorphous hydrated calcium oxalate crystals, especially with a spindle shape, may
urates, but they do not polarize light and precipitate at a pH of 7.0 or be associated with AKI from ethylene glycol intoxication. Triple phos-
higher. phate crystals are usually associated with UTI caused by urea-splitting
Triple phosphate (struvite) crystals. Triple phosphate crystals microorganisms such as Proteus sp., Ureaplasma urealyticum, and Cory-
contain magnesium ammonium phosphate, and most frequently nebacterium urealyticum.
have the appearance of “coffin lids” (see Fig. 4.4E), although variants Cholesterol crystals are found in association with other fatty particles
such as “flower-like, scissors-like” structures, etc., can be found. These in patients with marked proteinuria. Cystine crystals are a marker of
crystals usually polarize light strongly and are found in alkaline urine cystinuria, and 2,8-dihydroxyadenine crystals are associated with phos-
(pH ≥7.0). phoribosyltransferase enzyme deficiency. Crystalluria resulting from
48 SECTION II Investigation of Renal Disease

A B C

D E F

G H I
Fig. 4.4 Crystals. (A) Uric acid crystals. This rhomboid shape is the most common. (B) Bihydrated calcium
oxalate crystals with typical “letter envelope” appearance. (C) Different types of monohydrated calcium
oxalate crystals. (D) Star-like brushite (calcium phosphate) crystal. (E) Struvite (triple phosphate) crystal, on
the background of a massive amount of amorphous phosphate particles. (F) Cholesterol crystal. (G) Cystine
crystals heaped one on the other. (H) 2,8-Dihydroxyadenine crystal by bright-field microscopy; inset, by
polarized light. (I) Amoxicillin crystal resembling a branch of a broom or bush.
 CHAPTER 4 Urinalysis 49

J K
Fig. 4.4, cont’d (J) Star-like ciprofloxacin crystals. (K) Large crystal of indinavir. (All images by phase contrast
microscopy; original magnification ×400.) (H, Courtesy Professor Michel Daudon, Paris.)

Contaminants
A large number of particles can contaminate urine. These particles may
come from the patient (e.g., spermatozoa; erythrocytes from menstrua-
tion; leukocytes from vaginitis, cloth or synthetic fibers, creams, or
talcum), the laboratory (e.g., starch particles, glass fragments from
coverslips), or the environment (e.g., pollens, plant cells, fungal spores).6

INTERPRETATION OF URINE SEDIMENT FINDINGS

Examination of the urine sediment, coupled with the quantity of pro-
teinuria and other urine and blood findings, results in urine sediment
profiles that aid in diagnosis of urinary tract diseases (Table 4.3).

Nephrotic Syndrome
Fig. 4.5 Egg of Schistosoma haematobium (Diameter µm, ~100 µm). The typical nephrotic sediment contains lipids, casts, and RTECs. Fatty,
Note the thick shell, which contains the miracidium, and the typical epithelial, granular, hyaline, and hyaline-granular casts are frequent,
terminal spike (arrow). (Phase contrast microscopy; original magnification
whereas erythrocyte or hemoglobin casts, leukocyte casts, and waxy
×400.)
casts are few or absent. Erythrocytes may be totally absent, especially
in minimal change disease or may be in low to moderate numbers (e.g.,
3-5/hpf to 20-30/hpf), which is seen especially in membranous nephropa-
drugs must be suspected whenever crystals with unusual morphology thy and focal segmental glomerulosclerosis. Leukocytes are usually not
are seen. In this setting, crystalluria may be isolated and asymptomatic found.
or associated with hematuria, obstructive uropathy, or AKI caused by
the precipitation of crystals within the renal tubules.6,35 Nephritic Syndrome
Erythrocytes with erythrocyte and hemoglobin casts are the hallmark
Organisms of the nephritic sediment. Usually, the number of erythrocytes ranges
Bacteria are a frequent finding because urine is usually collected and from 30 to 40 cells/hpf to more than 100 cells/hpf, with the higher
handled under nonsterile conditions and examination is often delayed. figure found especially in patients with extracapillary or necrotizing
UTI should be suspected if bacteria are found in freshly voided mid- glomerular lesions. Leukocyturia is also common and is mild (e.g., 3-5/
stream urine in association with leukocytes (in the absence of large hpf) in most patients, but in those with acute postinfectious GN or active
amounts of SECs, which indicate likely contamination from genital proliferative lupus nephritis, we have seen samples with up to 30 to 40
secretions). Candida (yeasts), Trichomonas vaginalis (protozoon), and leukocytes/hpf. Leukocyte casts and waxy casts34 also may be observed.
Enterobius vermicularis (parasite) are usually present as contaminants
derived from genital secretions. Acute Kidney Injury
Examination of the urinary sediment is the most widely used, sim- In patients with AKI, the finding in the urine sediment of RTECs in
plest, and fastest method for diagnosis of schistosomiasis because it association with granular casts and/or epithelial casts is the hallmark
shows the eggs of the Schistosoma haematobium parasite, with their of ATN,30,33 whereas these elements are rarely found in functional pre-
typical terminal spike (see Fig. 4.5). The eggs are especially found in renal AKI.30 A score based on the number of RTECs and granular casts
the urine collected between 10 am and 2 pm, when the parasite female significantly correlates with the severity of AKI, with new AKI urine
lays the eggs, and after physical exercise such as running, which favors biomarkers (NGAL, KIM-1, IL 18), with the progression of AKI, and
the detachment of the eggs from the bladder mucosa. with the need for dialysis and death.30 Depending on the cause of the
50 SECTION II Investigation of Renal Disease

tubular damage, other elements can be seen. These include myoglobin-

TABLE 4.3 Main Urinary Profiles
pigmented casts in rhabdomyolysis, uric acid crystals (usually in massive
Renal Disease Hallmark Associated Findings amounts) in acute uric acid nephropathy (tumor lysis syndrome), and
Nephrotic Fatty particles Renal tubular epithelial erythrocytes (high numbers) and erythrocyte casts in proliferative glo-
syndrome cells (RTECs) merular diseases.
(proteinuria: RTEC casts
++++) Erythrocytes (absent to Urinary Tract Infection
moderate number) Bacteria and leukocytes are the hallmarks of UTI, with or without
Nephritic Erythrocytes Leukocytes (low to
superficial transitional epithelial cells and/or isomorphic erythrocytes.
syndrome (moderate to moderate number)
Struvite crystals also can be present when the infection is caused by
(proteinuria: high number) RTECs (low number)
urease-producing bacteria, such as Proteus sp., U. urealyticum, and C.
+ → ++++) Erythrocyte/ RTEC casts
urealyticum. In patients with renal infection, leukocyte casts and casts
hemoglobin casts Waxy casts
containing microorganisms may be found.
The correlation between the urine sediment findings and the urine
AKI with ATN RTECs Variable according to cause
culture is usually good. False-positive results may be caused by urine
(proteinuria: RTEC casts of ATN (e.g., myoglobin
contamination from genital secretions (in which case large amounts
absent to +) Granular casts casts in rhabdomyolysis,
of SECs are usually found, especially in women) or bacterial overgrowth
uric acid crystals in acute
on standing. False-negative results may be caused by the lysis of leu-
urate nephropathy,
kocytes or misinterpretation of cocci with other tiny particles, such as
erythrocytes in
amorphous urates or phosphates.
proliferative/active
glomerulonephritis) BK Virus Infection
Urinary tract Bacteria Isomorphic erythrocytes The KDIGO clinical practice guideline in kidney transplant recipients
infection Leukocytes Superficial transitional recommends that the monitoring of BK polyomavirus (BKV) reactivation,
(proteinuria: epithelial cells which may lead to BKV nephropathy (BKVN) and graft loss, is carried
absent) Struvite crystals (for out by the periodical measurement of viral nucleic acid in the blood
infections caused by (i.e., viremia).42 This approach, however, is expensive and not always avail-
urease-producing able.43 As an alternative, the search of “decoy cells” on either smeared or
bacteria) cytocentrifuged alcohol-fixed and Papanicolaou-stained urine specimens,
Leukocyte casts (in renal also provides satisfactory diagnostic accuracy.43,44 However, decoy cells
infection) can be easily seen by phase contrast microscopy in routine unstained
Polyomavirus BK Decoy cells Decoy cell casts (in BK samples.45 Four decoy cell phenotypes are recognized: (1) nuclear ground-
infection virus nephropathy) glass or gelatinous appearance (see Fig. 4.6A), (2) intranuclear inclu-
(proteinuria: sion surrounded by a clear halo (cytomegalovirus-like) (see Fig. 4.6B),
absent) (3) multinucleated cells (see Fig. 4.6C), and (4) vesicular nuclei with
Urologic diseases Isomorphic Transitional cells (deep, clumped chromatin and nucleoli (see Fig. 4.6D). In addition, hybrid
(proteinuria: erythrocytes (low superficial, atypical) forms, which represent transitions between the different phenotypes
absent) to high number) cells are frequently seen, as well as cells with eccentric nucleus and
Leukocytes comet-like appearance. The presence of decoy cells may just indicate the
reactivation of BKV infection; however, when they persist over time, are

A B C D
Fig. 4.6 Decoy cells. (A) Cell with nuclear ground-glass or gelatinous appearance (phenotype 1). (B) Cyto-
megalovirus-like cell with a large intranuclear inclusion surrounded by a clear halo (phenotype 2). (C) a binucle-
ated cell (bottom, phenotype 3) and a cell with an enlarged ground glass nucleus (phenotype 1). (D) Cell with
clumped chromatin (phenotype 4). (Phase contrast microscopy; original magnification ×400.)
 CHAPTER 4 Urinalysis 51

in high numbers, or are found within urinary casts, they are a reliable Management of Chronic Kidney Disease. Kidney Int Suppl. 2013;
marker of likely BKVN, which should be confirmed by measurement 3:1–150.
of BK viremia.43,44,46 2. Perazella MA. The urine sediment as a biomarker of kidney disease. Am J
Kidney Dis. 2015;66:748–755.
Urologic Diseases 3. Becker GJ, Garigali G, Fogazzi GB. Advances in urine microscopy. Am J
Kidney Dis. 2016;67:954–964.
Urinary tract disorders such as cancer, urolithiasis, and hydronephrosis 4. Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of
are associated with variable numbers of isomorphic urinary erythrocytes, urinalysis performed by a nephrologist versus a hospital-based clinical
which are often associated with leukocytes or transitional epithelial laboratory. Am J Kidney Dis. 2005;46:820–829.
cells (from deep or superficial layers of uroepithelium). In addition, in 5. Clinical and Laboratory Standard Institute. GP-16 A3. Urinalysis and
uroepithelial cancer, malignant transitional cells can be found, which collection, transportation, and preservation of urine specimens: Approved
show abnormal size and shape, increased number and size of nuclei, guideline. 3rd ed. Wayne, PA: Clinical and Laboratory Standard Institute;
and enlarged nucleoli. These cells also can be identified in unstained 2009.
samples by phase contrast microscopy.47 6. Fogazzi GB. The Urinary Sediment: An Integrated View. 3rd ed. Milan:
Elsevier; 2010.
Nonspecific Urinary Abnormalities 7. Canavese C, Airoldi A, Quaglia M, et al. Recognizing purple bag
syndrome at first look. J Nephrol. 2013;26:465–469.
Some urine sediment findings are nonspecific. This occurs when vari- 8. Lee W, Kim Y, Chang S, et al. The influence of vitamin C on the urine
able numbers of hyaline or hyaline-granular casts are found with or dipstick tests in the clinical specimens: a multicenter study. J Clin Lab
without low numbers of erythrocytes (either isomorphic or dysmorphic), Anal. 2017 sep; 32 (5). doi:10.1002/jcla.22080.
leukocytes, common crystals, or small numbers of superficial transitional 9. Lam MO. False hematuria due to bacteriuria. Arch Pathol. 1995;119:
epithelial cells. 717–721.
10. Lamb EJ, MacKenzie F, Stevens PE. How should proteinuria be detected
and measured? Ann Clin Biochem. 2009;46:205–217.
AUTOMATED ANALYSIS OF URINE SEDIMENT 11. Hermida FJ, Soto S, Benitez AJ. Evaluation of the urine/protein/creatinine
The three main types of automated instruments using different tech- ratio measured with the dipstick Clinitek Atlas PRO 12. Clin Lab.
2016;62:735–738.
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12. Price CP, Newall R, Boyd JC. Use of protein/creatinine ratio
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and graphics (“scattergrams”), but no images, of the identified particles. proteinuria: a systematic review. Clin Chem. 2005;51:1577–1586.
Compared with manual microscopy, the instrument shows a satisfactory 13. Lane C, Brown M, Dunsmuir W, et al. Can spot urine protein/creatinine
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the particles present in the sample, which are pooled and shown on Opin Nephrol Hypertens. 2006;15:625–630.
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16. Antunes VVH, Veronese FJV, Morales JV. Diagnostic accuracy of the
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 CHAPTER 4 Urinalysis 52.e1

SELF-ASSESSMENT
QUESTIONS
1. The reagent strip for protein:
A. Detects all types of proteins present in the urine
B. Is not adequate for the evaluation of the renal patient
C. Is not influenced by the pH of the urine
D. Is not influenced by the specific gravity of the urine
2. Phase contrast microscopy coupled with polarized light:
A. Is the correct approach for urine sediment examination
B. Does not offer any advantage over bright-field microscopy alone
C. Only phase contrast is useful
D. Only polarized light is useful
3. The automated urine sediment analyzers available today:
A. Are adequate for the evaluation of the renal patient
B. Require high volumes of urine
C. Identify renal tubular epithelial cells
D. Are not adequate for the evaluation of the renal patient