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.

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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

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Basic anatomy of urinary system

Source: http://visual.merriam-webster.com/images/human-being/anatomy/urinary-system.jpg424/09/58

Source: https://classconnection.s3.amazonaws.com/1092/flashcards/766648/png/nephron.png524/09/58

Glomerularfiltration

Source: http://www.unckidneycenter.org/kidneyhealthlibrary/glomerulardisease.html

Source: http://classes.midlandstech.edu/carterp/Courses/bio211/chap25/chap25.htm

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Glomerular filtration rate (GFR)

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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

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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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Cystitis

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Cystitis

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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

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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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Renal calculi

http://www.dilipraja.com/stone_files/stone_general.jpg2224/09/58

Renal calculi

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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

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intracapillary hypercellularity

Source: http://kidneypathology.comeze.com/07.htm2624/09/58

http://www.unckidneycenter.org/kidneyhealthlibrary/postinfectiousgn.html2724/09/58

Source: http://geekymedics.com/2010/10/

27/glomerulonephritis/

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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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Glomerulonephritis

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Glomerulonephritis

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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

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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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Nephrotic syndrome

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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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Acute renal tubular necrosis [ATN]

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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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Kridsada Sirisabhabhorn, MT

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Neurogenic disorders

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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

ESRD / CRF

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Source: http://www.kidney-treatment.org/chronic-nephritis-prognosis/1097.html

ESRD

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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