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Clinical significant urine elements related with renal diseases
Kridsada Sirisabhabhorn, MTDivision of Clinical Microscopy & Parasitology
Department of Medical Technology, Thammasat University Hospital
Topic objectives
• Understanding and recognition significant urine sediments association with types of renal diseases.
• Explanation about clinical significant urine sediment with pathophysiology to customers or physician.
224/09/58
Topic require……..
• Basic anatomy of urinary system
• Correctly classification urine element practice
• Understand of laboratory results associate with symptom
• Explanation with effective to physical or customers
324/09/58
Basic anatomy of urinary system
Source: http://visual.merriam-webster.com/images/human-being/anatomy/urinary-system.jpg424/09/58
Glomerularfiltration
Source: http://www.unckidneycenter.org/kidneyhealthlibrary/glomerulardisease.html
Source: http://classes.midlandstech.edu/carterp/Courses/bio211/chap25/chap25.htm
624/09/58
Classification of urinary disorders
1. Urinary tract infections
2. Urinary tract obstruction
3. Glomerular disorder
4. Renal tubular damage
5. Urinary system cancer / metastasis cancer
6. Genetic disorders
7. Association of other organ disorders
8. Accidental / Events / Trauma
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Period decision of kidney diseases
• Acute phase
Undergoing of kidney disease less than 6 months
• Chronic phase
Continue for long time period of kidney disease excess 6 months
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Initial evaluation phase of renal disease
• Acute phase.
- cell or epithelial cast, numerous count of clinical significant epithelial, normal shape and size of suspension cell and adherent cell. Occasionally found granular cast.
• Chronic phase
- granular cast, clue cell, macrophage, cell with inclusion, waxy cast, Hb cast, broad cast
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Urinary Tract Infection : UTI
• Urethritis
- Infection at urethra
• Cystitis
- Infection at bladder, urether
• Pyelonephritis
– Infection at renal pelvis
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1. Urinary Tract Infection : UTI• Etiology
- Infection by bacteria, fungus, parasite and virus
• Clinical symptom
- Dysuria, Oligouria, Lumba pain, fever
• Laboratory results
- gross examination : turbid / foul odor urine
- biochemistry examination : proteinuria, sometime nitrite pos.
- microscopic findings : high count wbc / bacteria numerous or fungus, parasite found, no cast
• urine sediment keys: bacteria, fungus, parasite, no cast
1224/09/58
Source: http://www.fastmed.com/health-resources/fastmed-blog/urinary-tract-conditions-infographic1324/09/58
Source: http://fellowshipoftheminds.com/2015/05/14/uti-most-common-bacterial-infection-increasingly-resistant-to-oral-antibiotics/
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Pyelonephritis• Etiology : bacteria infection at renal pelvis commonly cause such
Escherichia coli, Enterococcus spp. and fungus.• Symptom
-dysuria, oligouria, lumbar pain, fevel & chill, nausea & vomitting
• Biochemistry result- urine protein strip positive [proteinuria]- urine nitrite strip positive- urine culture positive
• Microscopic finding - high count of wbc- bacteria numerous- high count of wbc cast
Urine sediment keys : wbc cast & back pain,Proteinuria & fever chill
Source: http://thumbs.dreamstime.com/z/pyelonephritis-normal-kidney-chronic-51792876.jpg1724/09/58
Urinary tract obstruction
I. Obstruction at bladder
- Renal calculi
II. Obstruction at kidney [uroliths]
- Nephrolithiasis
http://www.naturalmedicine.lk/portfolio/renal-calculi-kidney-stones/renal-calculi-kidney-stones04/
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Location of calculi• Nephrolithiasis : calculi in the kidneys
• renal calculi or urolithiasis : calculi in the bladder and calcium is a major cause disease.
Source: http://www.aasthahealthcare.com/Renal-Calculi-stones-Treatment.html2024/09/58
Urinary stones
• Etiology : Substances: calcium, uric acid, magnesium ammonium phosphates (or struvite), or cystine.Occasionally, calcium salts and uric acid, PTH
• Symptoms : flank pain, dysuria, suprapubic pain, may be intense nausea with or without vomiting
• Lab. Result : X-ray, high count normal / isomorphic rbcand crystalluria such cystein, calcium oxalate, uric acid, struvate, recognized with urine pH.
may be combine with urinary tract infection.
• Urine sediment keywords : high count normal rbc and crystalluria
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Glomerular disorders
1. Glomerular damage [GD]
2. Glomerulonephritis [GN]
3. Nephrotic syndrome [NS]
4. Renal failure [NS]
5. End stage of renal failure [ERF]
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The type of glomerular injuries
• Antibody deposition
• Complement activation
• Glomerulosclerosis
• Cellular proliferation
2524/09/58
Source: https://cias.rit.edu/media/uploads/faculty-s-projects/287/1265_showcase_project_detail_item.jpeg2924/09/58
Fig. 1. Classification of dysmorphicerythrocytes: D1, D2, andD3 cells. D1 cells show a ring-likeshape and severe cytoplasmiccolor loss with membranousprotrusions or blebs. D2 cellsshow a doughnut-like shape andmoderate cytoplasmic color losswith membranous protrusions orblebs. D3 cells show a doughnutlikeshape and mild cytoplasmiccolor loss without membranousprotrusions or blebs
Nagahama, D.,Yoshiko, K., Morita, M.W.Y., Iwatani, Y. and Matsuo, S. 2005. A useful new classification of dysmorphic urinary erythrocytes. Clin Exp Nephrol 9:304–9. 3024/09/58
Glomerulonephritis : GN• Etiology
- autoimmune reaction after infected bacteria or virus antigen ex. Steptococcus spp. Dengue, HIV- SLE, DNA Ab- Diabetes- Hypertension
• Symptom- Hematuria : smoky brown urine- Oligourine- Edema, lumba pain, malaise, anorexia
• Lab. Diagnosis- biochemistry : high conc. Level of Creatinine, BUN, urine protein strip positive [proteinuria] - urinalysis & microscopic finding : smoky urine, high count of rbc, wbc and cast, rbc morphology with dysmorphic or bizzare, rbc cast, hemoglobin cast
• Key of urine sediment : dysmorphic rbc, rbc or hb cast, numerous of cell
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Nephrotic syndrome : NS
• Etiology- Diabetes- Hypertension- SLE-Tumor / Neoplasm- Drugs- Glomerulonephritis***
• Signs & Symptoms- Pitting edema- Shortness of breath- Ascites- Fatigue- Depression- Loss of appetite
3424/09/58
NS pathogenesis
Source: https://quizlet.com/7797815/nephrotic-syndrome-amyloidosis-82-flash-cards/3524/09/58
• Lab. Results
- biochemistry
high conc. level of BUN, Crea., low conc. level of serum protein, hyperlipidemia, high level K+
- urinalysis
hematuria & smoky urine, heavy protein urine [3+-4+], lipiduria, high count of cell & cast, prominent hyaline cast, rbc with dysmorphic, oval fat bodies & fatty cast, cholesterol crystal
• Urine sediments keys
rbc with dysmorphic, oval fat bodies & fatty cast, cholesterol crystal
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Renal tubular damage
Source: https://www.studyblue.com/notes/note/n/chapter-26-acute-renal-failure-and-chronic-kidney-disease/deck/5967283
http://library.med.utah.edu/WebPath/RENAHTML/RENAL157.html
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Acute renal tubular necrosis [ATN]• Etiology
- hypoxia : anemia, hypotension, ischemia
- exposed toxic agent : antibiotic; penicillin, ampicillin and rifampicin, Lithium and cyclosporine, dye used for radiological studies
- degradation : long life span of renal tubular cell
• Symptom
- fatigue, daytime drowsiness, thirst- excessive thirst, confusion, nausea, edema of feet and abdomen wall
• Lab. Result
- biochemistry : electrolytes- level of sodium and potassium is low in blood, high creatinine and high blood urea nitrogen (BUN)
- urinalysis : diluted urine, maintain sp.gr. at 1.010 [unconcentrated urine]
• Urine sediment key words
Renal tubular epithelial [RTE] & Renal tubular epithelial cast [RTE cast]
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Association of other organ disorders
• Neurogenic dysfunction
- bladder nerve or spinal cord damage
- urinary incontinence
- difficulty controlling urine flow stream
• Urine sediments keys
- spermatozoa in male old age urine
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Association of other organ disorders
• Liver / Hepatic dysfunction
- Cirrhosis, Hepatitis virus, Hepatic failure, Hepatic blood vessel circulation failure
Renal Tubular Necrosis: RTN
Urine sediments keys : deeply brown color urine, numerous count of renal tubular cell cast with
bilirubin, leucine crystal,
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Cancer / benign / metastasis cancer
• Bladder cancer
• Metastasis cancer
• Diagnosis
- CT scan, cystoscopy, urine cytology
• Urinalysis
- hematuria but non specific condition for indicating disease
- sometime may be found abnormal or atypical cell in urine sediments
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Source: https://www.fairview.org/HealthLibrary/Article/83246
Source: http://cancer.uvahealth.com/cancers-we-treat/urological-cancer/bladder-cancer
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Accidental / Events / Trauma
• Pregnancy
• Accidents
- Usually present bloody urine or freshly hematuria with isomorphic rbc
- non specific urine sediment indication
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Polycystic kidney disease
• Multiple cystic at kidney seem like grapelike
• Etiology : genetic defect
• Symptom : lumbar & abdomen pain, hypertension, hematuria
• Urine sediment finding : non specific urine sediment usually present hematuria
Source: http://www.uth.tmc.edu/GeneWise/Dysmorph/images/kidney.png4924/09/58
End Stage Renal Disease : ESRD / Chronic renal failure : CRF
• Nephrons not functioning well enough [<10%]• GER < 30• Etiology : All disease of above • Symptom
- fatigue- nausea & vomiting- pruritus- dysuria- loss of appetite
• Lab. results- biochemistry : highly level of serum BUN, Cre. - urinalysis : little of urine excretion, broad waxy cast, broad granular cast, high count of cells and cast, present several types of clinical significant sediment [telescopic urine sediment]
Require to kidney transplant Death5024/09/58
1. Polycystic kidney disease : Hematuria [non-specific]
2. Pyelonephritis : Wbc casts & caudate cells
3. Renal calculi : Isomorphic rbc & crystalluria
4. Tubular necrosis [TN] : Renal tubular epithelial cast & renal tubular epithelial
5. Glomerulonephritis : Dysmorphic rbc & rbc cast
6. Nephrotic syndrome : Oval fat bodies, fatty cast & cholesterolcrystal
7. Renal failure [RF] : Broad granular, Broad waxy and waxy cast with telescopic urine sediments
8. Neoplasm : Abnormal cells, maybe with sheet cause of over cell perforation.
9. Cystitis : Numerous of wbc and bacteria, but no cast.
Conclusions of clinical specific urine elements with major types of kidney diseases
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References
• Kridsada Sirisabhabhorn. Manual of Clinical Microscopy and Clinical parasitology practice. 2015: 144 p.
• Manual of training in Urinalysis : Intergrationand Validation of Laboratory Results by Assis. Prof. Dr. Yupin Aniwatangkoora and Assoc. Prof. Dr. Nattaya Sae-ung. Faculty of Associated Medical Sciences, Khon KaenUniversity, Thailand
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Laboratory practise today 1. Unknown urine sediment slide / group + case
information
I. Urinary grading
II. Urine element key words
2. Class discussion / representative presenter
- Case description
- Urinary grading result
- Indicating clinical significant urine sediment
- Assumption related to group of renal diseases
- Case discussion
3. Class conclusion class
4. Quiz : fill full short message / matching 5524/09/58
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