I.

Microscopic Examination
In 1926, the standardized quantitative microscopic examination of urine sediment made its
clinical laboratory debut. Microscopic examination of urine sediment continues to play an
important role in the initial diagnosis and monitoring of renal disease.
A. Cellular Elements or Formed Elements in Urine Sediment
A wide range of formed elements can be encountered in the microscopic
examination of urine sediment. These formed components can originate from throughout
the urinary tractfrom the glomerulus to the urethraor can result from contamination (e.g.
menstrual blood, spermatozoa, fibers, starch granules).
1. Red Blood Cells (Erythrocytes). The name erythrocyte comes from
the Greek word erythros which means red and the suffix -cyte,
meaning cell.
Microscopic Appearance. The RBCs in urine are viewed and
enumerated using high-power magnification because of their small
sizeapproximately 8 m in diameter and 3 m in depth. RBCs have no
nucleus; they normally appear as smooth biconcave disks, and they are
moderately refractile.
Red Blood Cells: Microscopic Features and Correlations
Microscopic Features
Typical formsmooth,
biconcave disks, 6-8 m in
diameter; no nucleus
Look-alike elements
Monohydrate calcium
oxalate crystals
Yeast cells
Correlation with physical and
Urine colornote that a
chemical examinations
normal appearing urine
can still have increased
RBCs present
Blood reactioncan be
negative owing to ascorbic
acid interference; degree
of interference varies with
reagent strip band
2. White Blood Cells (Leukocytes). Leukocyte is a collective term that
refers to any type of white blood cell. In health, the distribution of
WBCs in the urine essentially mirrors that of peripheral blood. The five
types of cells that can be present are neutrophils, lymphocytes,
basophils, eosinophils and monocytes (macrophages). Neutrophils ate
the WBC most often observed in urine because they predominate in
the peripheral blood.
Neutrophils
Microscopic Appearance. They measure approximately 14
m in diameter but can range from 10 to 20 m, depending on the
tonicity of the urine. Neutrophils are larger than erythrocytes. They

are spherical cells with characteristic cytoplasmic granules and

lobed or segmented nuclei. Unstained, neutrophils have a graying
hue and appeared grainy.
Eosinophils
In routine microscopic examination of unstained urine
sediment, the discrimination of eosinophils from neutrophils is
often impossible despite their bilobed nuclei and slightly larger
size. When specifically requested, urine specimens for
eosinophil detection should be cytocentrifuged and stained
using Hansel stain, which is a stain that is considered superior
to Wright;s stain in detecting neutrophils in urine.
Lymphocytes
These leukocytes, even though normally present in urine, are
usually not recognized because of their small numbers.
However, lymphocytes are more readily apparent and
identifiable when supravital stains are used or cytodiagnostic
urinalysis using Wrights or Papanicolaous stain is performed.
Monocytes and Macrophages (Histiocytes)
These are actively phagocytic cells that are capable of
phagocytizing bacteria, viruses, antigen-antibody complexes,
RBCs and organic and inorganic substances like fat and
hemosiderin. The primary functions of these cells are:
1. To defend against microorganisms;
2. To remove dead or dying cells and cellular debris;
and,
3. To interact immunologically with lymphoid cells.
Microscopic Appearance.
Monocytes range in diameter from 20-40 m. They have
a single and large nucleus that is round to oval and often
indented. The cytoplasm can be abundant and contains
azurophilic granules. Because monocytes are actively phagocytic
cells, large vacuoles often containing debris or organisms within
them can be observed.
Macrophages are derived from monocytes; when they
reside in interstitial tissues, they are often called histiocytes. They
can be as small as 10 m or as large as 100 m in diameter even
though their average diameter varies from 30-40 m. Because
macrophages are transformed form monocytes, they usually have
irregular, kidney-shaped nuclei and abundant cytoplasm
(vacuolated).
Monocytes and macrophages are identified more easily by
using supravital stains on the urine sediment or by making a
cytocentrifuged preparation followed by Wrights or
Papanicolaous stain.

White Blood Cells (WBCs): Microscopic Features and Correlations

Microscopic Features
Neutrophils
Spherical cells, 12-14 m in diameter

Look-alike elements

Correlation with physical and chemical

examinations

Granular cytoplasm
Lobed nuclei
Glitter cellsdilute urine (low SG)
Lymphoctyes
Spherical cells, 6-9 m in diameter
Mononuclear
Monocyte and macrophages
Spherical cells, 20-25 m in diameter
Granular cytoplasm
Mononuclear
Cytoplasm often vacuolated with
ingested debris
Renal tubular epithelial cells (collecting
duct cells)
Dead trichomonads
Crenated RBCs
Leukocyte esterase reactioncan be
negative despite increased WBCs
owing to excess hydration or when the
WBCs are lymphocytes
Negative nitrite reaction: suggestive of
inflammation or nonbacterial infection
Positive nitrite reaction: suggests
bacterial infection

3. Epithelial Cells
There are various types of epithelial cells seen in urine sediment.
Basically, there are three types: squamous, transitional (urothelial),
and renal tubular epithelial cells. The presence of large numbers of
some cell types can indicate an improperly collected specimen,
whereas increased numbers of others indicate a severe pathologic
process. Whenever there are epithelial cells with abnormal
characteristics such as unusual size, shape, inclusions, or nuclear
chromatin pattern, additional cytologic studies are necessary. These
cells may indicate neoplasia in the genitourinary tract or can result
from treatments, such as chemotherapy or radiation.

Cell Type
Squamous

Epithelial Cells: Microscopic Features and Clinical Significance

Site
Relative Size
Morphology
Clinical Significance
and Diameter
Females: line entire
40-60 m

Shape: thin,

Increased
urethra
flagstone-shaped
numbers due to
Males: distal portion of
with distinct cell
poor collection
urethra only
borders
technique (ex:

Abundant cytoplasm;
not a clean

Transitional

Renal

Bladder
Ureters
Renal pelves
Males: majority of urethra

Collecting duct cells

Convoluted tubular cells

20-40 m

Small ducts:
12-20 m

cytoplasmic
granulation increases
as cell ages

Nucleus ~8-14 m,*

centrally located; can
be anucleated or
multinucleated

Shape varies with

site:
Superficial cells
-round or pearshaped
Intermediate layer
-smaller and round
Basal layer
-small, elongated (or
columnar-like)

Moderate amount of
cytoplasm

Distinct cell borders

that appear firm

Nucleus ~8-14 m,*

round or oval,
centrally located
Small duct cells

Shape: polygonal or
cuboidal (Look for a
flat edge)

Nucleus: large,
covers 60-70% of
cell

catch)

Increased
numbers with
infection or
inflammation of
bladder, ureters,
renal pelves or
male urethra
Cell clusters or
sheets can occur
after
catheterization or
instrumentation
of urinary tract
(ex: cytoscopy)

Increased
numbers with
ischemic events:
Shock
Anoxia
Sepsis

Large ducts: 510 m

Large duct cells

Shape: columnar

Nucleus: ~6-8 m,
eccentric

Trauma

Distal tubular
cells: 14-25 m

Distal tubular cells

Shape: oval to round

Cytoplasm: grainy

Nucleus: small,
round, central or
eccentric

Increased
numbers with
toxic events:
Heavy metals
Hemoglobinuria
, myoglobinuria
Poisons

Drugs

Proximal
tubular cells:
20-60 m

Proximal tubular cells

Shape: large, oblong

or cigar-shaped with
indistinct cell
membrane (Note:
Resemble granular
casts with single

inclusion)
Cytoplasm: grainy
Nucleus: usually
eccentric; can be
multinucleated

4. Casts
Formation. Unique to the kidney, urinary casts are formed in the distal
and collecting tubules with a core matrix of uromodulin (formerly
known as Tamm-Horsfall protein). This glycoprotein is secreted by
the renal tubular cells of thick ascending limb of loop of Henle (i.e., the
straight portion of the distal tubules) and by the distal convoluted
tubules. Any urinary component, whether chemical or a formed
element, can be found incorporated into a cast.
General Characteristics. Because casts are formed within the
tubules, they are cylindrical and microscopically always appear thicker
in the middle than along their edges. They have essentially parallel
sides with ends that can be rounded or straight (abrupt).
Hyaline casts
These are composed mainly of a homogeneous uromodulin
protein matrix. They are the most commonly observed casts in
the urine sediment.
Appearance. These casts appear colorless in unstained urine
sediment, with rounded ends and in various shapes and sizes.
Stain. Hyaline casts become pink with Sternheimer-Malbin
stain, and their edges are more clearly defined.
Clinical Manifestations. Two or fewer hyaline casts per lowpower objective is considered normal in healthy individuals.
Increased numbers of hyaline casts can be found following
extreme physiologic conditions such as strenuous exercise,
dehydration, fever, or emotional stress. They also accompany
pathologic casts in renal disease and in cases of congestive
heart failure.
5. Oval Fat Bodies
Oval fat bodies are degenerating tubular epithelial cells filled that contain
refractile fat droplets. These fats have been absorbed by the tubular cells
after being leaked through abnormal glomeruli. They appear as grape-like
clusters of variable size and are highly refractile.
B. Unorganized

Crystals. These result from the precipitation of urine solutes out of solution. They
are not normally present in freshly voided urine but form as urine cools to room or
refrigerator temperature (depending on storage). When crystals are present in
freshly voided urine, they indicate formation in vivo and are always clinically
significant.
Contributing Factors. Several factors influence crystal formation, including:
1. Concentration of solute in the urine;
2. The urine pH; and,
3. The flow of urine through the tubules
Normal Crystals Found in Normal Urine Specimen
1. Uric acid. Uric acid crystals occur in many forms; the most common form is the
rhombic or diamond shape. They may appear colorless when they are thin or when
the urine is low in uroerythrin (a urine pigment). Uric acid crystals can be present
only if the urine pH is less than 5.7.
2. Amorphous urates. When the urine pH is acid (between pH 5.7 and 7.0), uric acid
exists in its ionized form as a urate salt.
3. Calcium oxalate. The most common shape of calcium oxalate crystals is their
octahedral or pyramid form. They are colorless and may vary significantly in size.
They are the most frequently observed crystals in human urine because they can
form in urine at any pH.
4. Amorphous phosphates. This noncrystalline form of phosphates resembles fine,
colorless grains of sand in sediment. Like amorphous urates, amorphous
phosphates have also no clinical significance.
5. Calcium phosphate. They are classified as alkaline crystals because they are
usually present in neutral or slightly basic urine specimens; however, they can also
form in slightly acidic urine.
6. Triple phosphate. Triple phosphates (NH4MgPO4, ammonium magnesium
phosphate) crystals are colorless and appear in several different forms. The most
common and characteristic forms are three- to six-sided prisms with oblique terminal
surfaces, the latter described as coffin lids.
7. Ammonium biurate. These crystals appear as yellow-brown spheres with striations
on the surface. Irregular projections or spicules can also be present, giving these
crystals a thorny apple appearance. They can form in alkaline or neutral urine.
8. Calcium carbonate. Calcium carbonate crystals appear as tiny, colorless granular
crystals. These crystals are not frequently found in the urine sediment and have no
clinical significance.
Crystal
Uric acid
Amorphous urates
Calcium oxalate
Amorphous
phosphates
Calcium phosphate

Acid
+
+
+

Urine pH
Neutral

Alkaline

+
+

Triple phosphate
Ammonium biurate
Calcium carbonate

+
+
+

Abnormal in Urine Sediment

1. Cholesterol. These crystals appear as clear, flat, rectangular plates with notched
corners. They can be present in acidic urine and, because of their organic
composition, are soluble in chloroform and ether. They are rarely observed in
urine sediment but can be seen with the nephrotic syndrome and in conditions
resulting in chyluria: the rupture of lymphatic vessels into the renal tubules as a
result of tumors, filariasis and so on.
2. Cystine. These crystals appear as colorless, hexagonal plates with sides that are
not always even. These clear, refractile crystals are often laminated or layered
and tend to clump. Present primarily in acidic urine, cystine crystals are clinically
significant and indicate disease, that is, congenital cystinosis or cystinuria.
3. Tyrosine and Leucine. Tyrosine crystals appear as fine and delicate needles
that are colorless or yellow, while leucine crystals are highly refractile, yellow to
brown spheres. They have concentric circles or radial striations on their surface
and can resemble fat globules. These amino acids are abnormal and are present
in the urine of patients with overflow aminoaciduriasrare inherited metabolic
disorder.
Crystal
Cholesterol
Cystine
Hippuric acid
Leucine
Sulfa
Tyrosine

Abnormal Crystals in Urine Sediment

Microscopic Appearance
Colorless flat plates with notched or broken corners
Colorless, hexagonal plates
Colorless to yellow needles or prism-like structures
Yellow-brown spherical crystals showing concentric circles
Yellow to brown-green rosettes or bundles of needles
Colorless to pale yellow sheaves of needles

Source (Oval Fat Bodies):

Oval Fat Bodies. (n.d.). Retrieved on April 15, 2015, from MediaLab Inc. website:
https://www.medialabinc.net/spg30248/oval_fat_bodies.aspx