HANDS-ON COURSE

BEDSIDE URINARY MICROSCOPY

GIOVANNI BATTISTA FOGAZZI LECTURES SERIES
URINARY SEDIMENT: Part 1: Methods
G.B. Fogazzi, Milan, Italy

Dr G.B Fogazzi
Research Laboratory on Urine, Unit Operativa di Nefrologia
Fondazione IRCCS, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena
Milan, Italy

Sedimntul urinar

Intrducere

Asecte metodologice

Particulele din sedimentul urinar cu importanta nefrologica

Sedimentul urinar in practica clinica

Concluzii
INTRODUCERE
O perspectiva istorica

Din punct de vedere istoric, tim c sedimentul urinar a fost introdus in practica
clinica la sfritul anilor 1830 n Paris la Spitalul La Charit de Franois Rayer i elevul su
Eugne Napolon Vigla. Pn la sfritul secolului 19, toate particulele principale au fost
identificate i principalele profilele de urin au fost descrise. Cu toate acestea, n secolul
urmtor, secolul 20, examinarea sedimentului urinar a cunoscut doar un declin progresiv cu
doar foarte puine excepii. O excpti a fost lucrarea original i important a lui Thomas
Addis n anii 1920, iar cellalt a fost publicarea, n 1982, a lucrarii publicate de Fairley i
Birch cu privire la utilitatea evaluarii morfologiei eritrocitelor urinare prin microscopie cu
contrast de faz la pacienii cu hematurie.
Care este situaia de astzi? n cele mai multe cazuri, sedimentele urinare sunt
examinate n laboratoare centrale departe de patul i fr echipamentul i cunotinele
corecte, precum i cu visul de a ncredina ntreaga sarcina instrumentelor automate.
Acestea sunt deja pe pia, unul fiind UF 100, care se bazeaz pe citometrie de flux, iar
cellalt iQ200, care se bazeaz pe imaginile obinute de o camer video. Nu n ultimul rnd,
de prea multe ori examenul sediment urinar este neglijat chiar de nefrologi.
Slide 8
Aspecte metodologice principale

recoltare corecta
metoda standardizata pentru manipularea urinei
Un microscop curat
Un raport corect

Methodological aspects are very important for urine sediment. The main methodological
aspects include: a correct urine collection; a standardised method for the handling of the
urine; the use of a proper microscope and the use of a proper report to describe the
findings. All these aspects are described in detail in the document published by the
European Urinalysis Group 5 years ago as a supplement of the Scandinavian Journal of
Clinical and Laboratory Investigation (2000; Vol 60, Suppl 231) as well as in our book
(Fogazzi GB, Ponticelli C, Ritz E. The Urinary Sediment. An Integrated View 2nd Edition.
Oxford , Oxford University Press, 1999).

Slide 10

As to urine collection, its important to give the patient written and simple instructions.
According to the strategy of the single lab, we can ask the patient to supply the first or the
second urine of the morning. In our lab, we ask for the second urine, since overnight urine,
due to its prolonged permanence in the bladder can favour the lysis of particles. We suggest
the patient to avoid strenuous physical effort in the hours preceding the test, since this may
influence in various ways the findings (for instance by causing haematuria and/or
cylindruria). We advise the patient to clean the external genitalia in an ordinary way. In this
respect, we do not suggest special procedures since the more the procedures suggested
are complicated, the less the patient is compliant. In order to avoid contamination, the male
has to uncover the glans and female to spread the labia of the vagina. For the same reason,
we always suggest to collect midstream urine. Its important to remember that urine
collection during menstruation must be avoided because of the high probability of blood
contamination. It is also important to use a proper urine container (with a capacity of at
least 50 to 100 mL, an opening of at least of 5 cm to allow easy collection of urine for both
men and women, a wide base to avoid accidental spillage, a cap to avoid leakage, a label for
patient identification). It is no more time for the patient to collect the urine into jugs,
bottles, cans, etc.
Slide 11

What about a standardized method for the handling of urine? Why is standardization of the
handling of the urine important? It is important because only with a standardized method
we can obtain quantitative reproducible results. The slide shows the method that we use in
our lab. We ask the patient to supply the second urine of the morning produced over a
period of 2 hours; then, we centrifuge a 10 mL aliquot of urine for 10 minutes at 400 G ,
which correspond to 2,000rpm with our centrifuge. Then, we remove with a pump a fixed
volume of supernatant urine, which is 9.5 mL. Then, with a Pasteur pipette, we gently but
thoroughly re-suspend the sediment in the remaining 0.5 mL of urine. Then, with a
precision pipette, we transfer 50 mL of resuspended urine to a glass slide, which is covered
with a coverslip of a fixed surface, namely 32 x 24 mm . Then, we examine the samples at
low and high magnification (160x and 400x) within 3 hours from urine collection. For routine
practice, we express the particles as lowest/highest number seen by microscopic field. When
we want to produce scientific results, we count the number of the cells found over 20 high
power field, as we will see in the last part of my speech (see The urinary sediment findings
in proliferative and non proliferativer glomerular diseases). With this method we were able
to obtain reproducible results, which in addition correlated significantly with the number of
particles found by the counting chamber.
Slide 12

And now the microscope. The microscope must be of good quality, must be equipped with a
low and high magnification, and must, and I want to stress must, be equipped with phase
contrast and polarized light.
Slide 13

This is the microscope we use in our lab. Why phase contrast?

Slide 14

Its very simple to explain. On the right you see bright-field, and on the left you see phase
contrast. You see that with phase contrast the particles are much better seen against the
background than with bright-field, and this without the use of stains! I want to stress that
the European Guidelines strongly recommends the use of phase contrast microscopy.
Slide 15

Slide 16

And why polarized light? Polarized light is extremely useful to correctly recognize the
crystals. For example, you see uric acid crystals as seen by phase contrast microscopy (slide
15), and what happens when we use polarized light (slide 16). Under polarized light, uric
acid crystals assume a typical polychromatic appearance, which is useful to identify them.
Slide 17

Polarized light is also important to correctly identify lipid particles,

Slide 18

which under polarized light appear as Maltese crosses which is, shining particles
containing a black cross whose arms are regular and symmetrical. This feature allows the
identification of lipid particles, especially when they come with an atypical appearance.
Slide 19

Now, the urinary sediment report. This is the report we use in our lab. After the patient
details, we have pH, density (or specific gravity), haemoglobin and leukocyte esterase as
detected by dipstick. Then the particles: erythrocytes (with their morphological
classification; see below), leukocytes, tubular cells, transitional cells (from the deep and
superficial layers of the uroepithelium), squamous cells, casts, lipids, crystals, bacteria, and
yeasts. We also have a space for a brief conclusive comment. I want to stress the
importance of having in the report the findings obtained by dipstick. Why this?
Slide 20

Let me give you an example. You see in this slide a sample with a pH of 6.0, a density of
1.006, a +++ haemoglobin and +++ leukocyte esterase by dipstick. However, by
microscopy we find a low number of erythrocytes and leukocytes, which is in contrast with +
++ haemoglobin and +++ leukocytes esterase. Is there any explanation for this
discrepancy? Yes there is. The discrepancy is due to the fact that low density causes the
lysis of erythrocytes and leukocytes, which therefore cannot be seen by microscopy. In
contrast, in other instances we may have negative haemoglobin and many erythrocytes by
microscopy. This may be due, for example, to the presence of large concentrations of
Vitamin C in the urine, which reduces the sensitivity of dipstick for haemoglobin. Therefore,
it is always important to match the findings obtained by dipstick with those obtained with
microscopy and to try to explain them. Thus, our comment for the sample shown in the
slide is: Mild erythrocyturia and leucocyturia. Please note the discrepancy between dipstick
for haemoglobin and leukocyte esterase and microscopy. This is probably due to cell lysis
caused by low density. The final message on this point is that examining the urine only by
dipsticks or only by microscopy exposes to the risk of false results. This risk is reduced
when both methods are used on the same sample.

THE SECOND PART WILL BE PUBLISHED ON SEPTEMBER 28TH