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.
I'm not gonna get into explanations because
I've done that plenty on the tables above
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.
this is dysmorphic RBC.
Let's move in to sediment with neutrophils.
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?
Neutrophils, specific for kidney?
No, it could be urethritis, cystitis
or it could be pyelonephritis.
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.
Now we have oval fat body.
Once again, I'm not
showing you a cast.
An oval fat body polarization,
you tell me quickly, what is your
differential in terms of classification,
Nephritic, or nephrotic?
So as you lose more protein,
your lipid accumulates
due to cholesterol,
What about hyaline,
do you remember this?
Do you see these critters in your urine?
you could barely see them.
So make sure you're seeing
something in the urine,
It's the first time I'm
showing you a cast.
literally aggregates, so it looks
like blocks going to the urine.
Now as dangerous as it may
seem, actually it's not.
So therefore acellular and could be just
part of a patient who's been working out.
And you expect to find hyaline cast.
What are these? aggregates of protein.
Now we'll talk about
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.
Now you tell me where is
your damage taking place?
Nephritic or nephrotic?
Remember H - there it is again,
hematuria, hypertension, RBC cast
At least know that.
Let me add in one more, might as well.
Do you lose protein
What was my question?
Do you lose protein
Yeah, you do.
Is it as significant as nephrotic?
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.
This is an RBC cast.
This is a WBC cast.
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.
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.
Tell me about your patient, pain
back here by the hips, flanks
that's what it's called.
Fever? Of course.
Okay continue, what other type
of cell might that be?
It might be eosinophils.
If it's eosinophil, then you're
thinking, good, interstitial damage
drug induced perhaps,
Tubal interstitial nephritis.
This one is a cast but
these are dead cells.
And these dead cells well the patient
here I'll give you history, I have to.
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.
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
What happened to cardiac output?
In addition I gave you positive JVD
and also I gave you pitting edema.
right-sided heart failure, good.
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.
Good, this is renal azotemia,
acute tubular necrosis.
What caused the necrosis
of these tubular cells?
So if you have decreased cardiac output,
could you have ischemia to the kidney?
You have decreased cardiac output.
Do you see the significance?
The cast are numerous, and you
have ATN, they're dead cells.
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.
Take a look at this.
There's a difference between this cast
which may seem a little translucent
and could potentially confuse
you with hyaline cast.
But if your patient was exercising,
and you see something not like this
but a little bit thinner,
that'll be a hyaline cast.
If your patient has
and you find this big
fat cast in the urine
not so good, huh?
Yes you might be thinking
about chronic renal failure,
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.
on urinalysis, if it's WBC
- infection, inflammation.
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.
What type of RBC is more
specific for the glomerulus?
Good, a dysmorphic RBC.