Various Morphology on Urinalysis

by Carlo Raj, MD

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    00:01 Various morphology on urinalysis, Now based on all the tables that we've seen, Ultimately, you also want to be able to identify your various crystals, cells and cast and the next section here, that's exactly what we're doing.

    00:14 I'm not gonna get into explanations because I've done that plenty on the tables above Let's begin.

    00:20 So we have something, a test known as your phase contrast microscopy and that'd be the best to then identify what's known as dysmorphic RBC What does dysmorphic RBC mean to you? It's an RBC in which it gets disfigured as it passes through the glomerulus Protrusion from the RBC membrane result to damage from glomerular inflammation There is a difference between dysmorphic RBC versus just finding RBCs There's signs of hematuria or of glomerular origin.

    00:51 this is dysmorphic RBC.

    00:53 Let's move in to sediment with neutrophils.

    00:56 Well the arrow here is then pointing to a bilobed neutrophil and if you're thinking neutrophil, would you tell me as to what test is going to be positive here? is it esterase or nitrites? Good, esterase.

    01:09 Neutrophils, specific for kidney? No, it could be urethritis, cystitis or it could be pyelonephritis.

    01:18 So what'd be more specific for the kidney? a WBC cast, which is not what this is, you understand what I'm showing you? in a previous discussion when I showed you the dysmorphic RBC, none of those were casts.

    01:31 Now we have oval fat body.

    01:33 Once again, I'm not showing you a cast.

    01:36 An oval fat body polarization, "maltese cross" you tell me quickly, what is your differential in terms of classification, Nephritic, or nephrotic? Good, nephrotic Excellent.

    01:49 So as you lose more protein, your lipid accumulates due to cholesterol, nephrotic syndrome.

    01:55 What about hyaline, do you remember this? Do you see these critters in your urine? you could barely see them.

    02:04 So make sure you're seeing something in the urine, those transaparent, translucent cast.

    02:11 It's the first time I'm showing you a cast.

    02:13 literally aggregates, so it looks like blocks going to the urine.

    02:18 Now as dangerous as it may seem, actually it's not.

    02:22 So therefore acellular and could be just part of a patient who's been working out.

    02:27 And you expect to find hyaline cast. What are these? aggregates of protein.

    02:32 Now we'll talk about another cast.

    02:33 Now do you see the diference between cast and cells? So cast will look exactly like that - aggregates of cells or proteins Now a cellular cast here is an RBC cast.

    02:43 Now you tell me where is your damage taking place? Good, kidney.

    02:48 Nephritic or nephrotic? Nephritic, excellent.

    02:52 Remember H - there it is again, hematuria, hypertension, RBC cast At least know that. Let me add in one more, might as well.

    02:59 Do you lose protein in nephritic? What was my question? Do you lose protein in nephritic? Yeah, you do.

    03:08 Is it as significant as nephrotic? No.

    03:11 Are we clear? So nephritic will be less than 3.5 grams of protein, Nephrotic will be greater than 3.5g of protein Every single time that we go though discussion, i'm gonna keep adding information in there based on the foundation that you already have.

    03:25 This is an RBC cast.

    03:26 This is a WBC cast. Stop there.

    03:30 What's your first question? Okay, so I found a WBC cast so what kind of cells are these or aggregates of two things, it could either be neutrophil or eosinophil.

    03:42 If it's a neutrophil, give me diagnosis, Is it urethritis, is it cystitis or pyelonephritis? If ir's a neutrophil and it's a WBC cast, it has to be pyelonephritis.

    03:54 Tell me about your patient, pain back here by the hips, flanks that's what it's called. Fever? Of course.

    04:02 Okay continue, what other type of cell might that be? It might be eosinophils.

    04:07 If it's eosinophil, then you're thinking, good, interstitial damage drug induced perhaps, Tubal interstitial nephritis.

    04:17 This one is a cast but these are dead cells.

    04:22 And these dead cells well the patient here I'll give you history, I have to.

    04:26 The history here is the following: The patient has congestive heart failure and has right sided failure and positive JVD, pitting edema, so on and so forth.

    04:37 you take a look at the labs and you take a look at your BUN Creatinine ratio and you find that to be elevated and let's say that a little while longer, and by little while longer - weeks maybe and you find that your BUN:Creatinine ratio has decreased Put all these together, what did I give you I gave you a congestive heart failure.

    04:57 What happened to cardiac output? Decreased.

    05:02 In addition I gave you positive JVD and also I gave you pitting edema.

    05:07 What side? right-sided heart failure, good.

    05:10 Decreased cardiac output, I said initially the labs were an increase in BUN:creatinine ratio So all we have at this point is a prerenal azotemia, don't we? Told you weeks have gone by, now at this point the patient presents with a decreased BUN:creatinine ratio What's my diagnosis? especially you find these cast.

    05:31 Good, this is renal azotemia, acute tubular necrosis.

    05:35 What caused the necrosis of these tubular cells? ischemia.

    05:41 So if you have decreased cardiac output, could you have ischemia to the kidney? Of course You have decreased cardiac output.

    05:49 Do you see the significance? The cast are numerous, and you have ATN, they're dead cells.

    05:55 These casts are a sign of acute tubular necrosis And if they get let's say a little bit of mixed in with maybe blood and protein, Might be called muddy brown granular cast, it's what you've heard of.

    06:10 Take a look at this.

    06:12 There's a difference between this cast which may seem a little translucent and could potentially confuse you with hyaline cast.

    06:20 But if your patient was exercising, and you see something not like this but a little bit thinner, that'll be a hyaline cast.

    06:28 If your patient has diabetic nephropathy and you find this big fat cast in the urine not so good, huh? Yes you might be thinking about chronic renal failure, refractile degeneration of renal tubular cells, further further damage, huge waxy broad you could probably get on this thing and ride down the river it is huge, waxy and broad.

    06:54 on urinalysis, if it's WBC - infection, inflammation.

    06:58 Neutrophils, that is not telling you where exactly except for the fact it's in the urinary tract Hematuria, RBCs, once again, if you find just RBCs, you have no idea if it's a kidney origin or if it's the maybe the bladder origin, right? But you do know somewhere in the urinary tract.

    07:17 What type of RBC is more specific for the glomerulus? Good, a dysmorphic RBC.

    About the Lecture

    The lecture Various Morphology on Urinalysis by Carlo Raj, MD is from the course Urinalysis.

    Included Quiz Questions

    1. Acute tubular necrosis
    2. Nephrotic syndrome
    3. Dehydration
    4. Nephritic syndrome
    5. Chronic renal failure
    1. It is often due to a reversible etiology.
    2. It has a refractile quality with distinct margins.
    3. Casts show degenerating renal tubular cells.
    4. Diameter of the cast is increased due to tubular atrophy.
    5. They are often present with red cell casts.
    1. Oval fat bodies
    2. Calcium oxalate crystals
    3. Fatty casts
    4. Cystine crystals
    5. Hyaline casts
    1. Light microscopy is used to visualize them.
    2. Phase-contrast microscopy is used to visualize them.
    3. Hematuria is of glomerular origin.
    4. Protrusion from the RBC membrane is due to glomerular inflammation.

    Author of lecture Various Morphology on Urinalysis

     Carlo Raj, MD

    Carlo Raj, MD

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