URINARY PROFILES. Giovanni B Fogazzi, MD, Milano, Italy Giuseppe Garigali, BSc, Milano, Italy Nuša Avguštin, MD, Ljubljiana, Slovenia

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1 URINARY PROFILES Giovanni B Fogazzi, MD, Milano, Italy Giuseppe Garigali, BSc, Milano, Italy Nuša Avguštin, MD, Ljubljiana, Slovenia

2 THE FOUR PILLARS OF WISDOM OF URINARY MICROSCOPY 1. Sound laboratory methodology 2. Knowledge of all particles and their clinical meaning 3. Identification of the main urinary profiles (= combining urinary sediment findings with proteinuria and S-creatinine) 4. Placing of urinary findings into a wider laboratory and clinical context

3 MAIN URINARY PROFILES Isolated microscopic hematuria* Glomerular diseases Acute interstitial nephritis Acute kidney injury BK virus in kidney transplant recipients* Urological disorders Urinary tract infection * DEALT WITH IN OTHER PARTS OF THIS COURSE

4 GLOMERULAR DISEASES A WIDE SPECTRUM OF URINARY PROFILES

5 URINARY PROFILES IN GLOMERULAR DISEASES Isolated dysmorphic microscopic hematuria Isolated proteinuria Proteinuria+microscopic hematuria Gross hematuria (one shot,recurrent,persistent) The nephritic sediment The nephrotic sediment The nephritic+nephrotic sediment S-CREATININE NORMAL OR INCREASED EITHER ACUTELY OR CHRONICALLY

6 THE ACUTE NEPHRITIC SEDIMENT

7 ACUTE NEPHRITIC SYNDROME DEFINITION: A condition characterised by the rapid increase of serum creatinine associated with hematuria (either microscopic or gross) and variable proteinuria,with/without high blood pressure CAUSES: Proliferative and/or necrotizing glomerulonephritis (GN), either primary or secondary

8 PROLIFERATIVE GN GN characterised by increased numbers of cells (either local or from the circulation) within the glomeruli with/without necrotizing lesions

9 PROLIFERATIVE GN IN OUR UNIT (in decreasing frequency) IgA nephropathy Paucimmune crescentic/necrotizing GN Lupus nephritis (class III and IV) Mesangiocapillary GN Acute postinfectious Schönlein-Henoch purpura GN

10 A NORMAL GLOMERULUS

11 IgA NEPHROPATHY Increased number of mesangial cells, increase of mesangial matrix and dominant IgA deposits)

12 CRESCENTIC GN Crescents, either focal or diffuse, circumferential (A) or segmental (B) A B

13 THE NEPHRITIC SEDIMENT DISTINGUISHING PARTICLES: - RBCs (usually >50/HPF up to too many to count) - ERYTROCYTIC/hemoglobin CASTS ASSOCIATED PARTICLES: - WBCs (~1-10/HPF) - R-RTECs (0-1/HPF) - OTHER CASTS: epithelial, leukocytic, granular, waxy S-creatinine: rapid increase* Proteinuria: mild to 3.5 g/24 hours)

14 THE NEPHRITIC SEDIMENT Many RBCs, often but not always dysmorphic

15 THE NEPHRITIC SEDIMENT RBC casts

16 ACUTE NEPHRITIC SEDIMENT: ORIGIN OF RBCs Bonsib SM. Am J Pathol 1985; 119: Scanning electron microscopy investigation on acellular glomeruli. Numerous holes and gaps of different size in the glomerular basement membrane of a patient with necrotizing (non proliferative) GN

17 ACUTE NEPHRITIC SEDIMENT: ORIGIN OF WBCs Burkholder PM Am J Pathol 1969, 56: Transmission electron microscopy investigation of glomerular basement membrane in acute proliferative GN. PMN passage through holes of GBM (arrows)

18 SEQUENCE OF EVENTS LEADING TO NEPHRITIC SEDIMENT Glomerular proliferation ± necrosis Tubular epithelial damage RBC & WBC passage through gaps of GBM and their extravasation into Bowman s space Detachment of tubular cells from tubular basement membrane RBC & WBC passage into the tubular lumen Tubular cells within the tubular lumen RBC & WBC entrapment within the matrix of casts forming in the tubules Tubular cells entrapment within the matrix of casts forming in the tubules Hematuria Leukocyturia RBC & WBC cylindruria Tubular cells and epithelial casts in the urine

19 THE URINE SEDIMENT IN PROLIFERATIVE GNs The examination over time of the urine sediment is of particular importance in patients with chronic renal diseases which can recur after a phase of remission, such as lupus nephritis and small vessel vasculitis WHY? Together with other laboratory tests, the U-sed allows to evaluate whether the disease is quiescent rather than relapsing

20 THE NEPHROTIC SEDIMENT

21 THE NEPHROTIC SYNDROME DEFINITION: A condition characterized by proteinuria >3.5 g/24 hours, hypoalbuminemia, hypercholesterolemia and variable edema CAUSES: Non proliferative glomerular diseases, either primary or secondary

22 NON PROLIFERATIVE GN GNs characterised by a normal number of cells within the glomerulus without necrotizing lesions

23 NON PROLIFERATIVE GN IN OUR UNIT (in decreasing order) Membranous nephropathy Focal segmental glomerulosclerosis Minimal change disease Renal amyloidosis Lupus nephritis (class V) Diabetic nephropathy

24 A NORMAL GLOMERULUS

25 MEMBRANOUS NEPHROPATHY Diffuse thickening of the glomerular basement mebranes associated with subepithelial/intramembranous deposits, mostly of IgG

26 FOCAL SEGMENTAL GLOMERULOSCLEROSIS Areas of glomerular sclerosis with at times increased mesangial cellularity Sclerotic area

27 DIABETIC NEPHROPATHY Diffuse mesangial expansion + sclerotic acellular nodules in the advanced phase Sclerotic acellular nodule

28 THE NEPHROTIC SEDIMENT DISTINGUISHING PARTICLES: - No or few RBCs (usually not exceeding 20 to 30/HPF) - Fatty particles ASSOCIATED PARTICLES: - RTECs - CASTS: granular, fatty, epithelial (waxy in amyloidosis?) S-creatinine: normal to increased Proteinuria: >3.5 g/24 hours)

29 URINARY LIPIDS IN NS Fatty droplets (isolated or in clumps) Oval fat bodies Fatty casts Cholesterol crystals

30 LIPID DROPLETS OVAL FAT BODIES

31 FATTY CAST CHOLESTEROL CRYSTAL

32 MASSIVE LIPIDURIA

33 MECHANISMS OF LIPIDURIA Lipid ultrafiltration due to altered GBM permeability Lipid reabsorption by proximal tubular cells Intracellular transport into lysosomes Active expulsion of lysosomes from the cells and tubular cellular detachment from tubular basement membrane

34 LIPIDURIA IN PATIENTS WITH NEPHROTIC SYNDROME Ravignaux M-H et al Significance of cytolipiduria during a nephrotic syndrome Néphrologie 1991;12:12-16 NUMBER % WITH SEVERE LIPIDURIA (%) Membranoproliferative GN 12/ /12 (42) Amyloidosis 10/ /10 (50) Membranous nephropathy 18/ /18 (56) Focal segmental glomeruloscclerosis 14/ /22 (40) IgA nephropathy 4/7 57 1/4 (25) Intra-extracapillary GN 6/ /6 (33) Minimal change nephropathy 10/ /10 (20)

35 FATTY PARTICLES IN GNs Fairley KF. Urinalysis. In: Diseases of the Kidney 5th Ed. Schrier RW and Gottschalk CW Eds. 1993, Boston, Little, Brown & Company, p 354

36 THE URINE SEDIMENT IN ACUTE INTERSTITIAL NEPHRITIS

37 WHAT IS AIN? It is a condition characterized by AKI associated with acute cellular infiltrate of the renal interstitium (mainly with lymphocytes, monocytes and plasma cells; less frequently also PMNs and/or eosinophils) With possible extrarenal symptoms such as fever, skin rash, arthralgia, lumbar pain, etc With different causes

38 CAUSES OF AIN (Praga M & Gonzáles E. Kidney Int 2010; 77: )

39 URINARY FINDINGS IN AIN

40 COMMON VIEW A few and unspecific changes Namely: Low-grade tubular proteinuria (NOT detected by dipstick!!) * Leukocyturia with/without eosinophiluria Hematuria (either microscopic or macroscopic) * NSAIDs: glomerular proteinuria in nephrotic range

41 EXPERTS VIEW (1) (Praga M & Gonzáles E. Kidney Int 2010; 77: ) Microscopic hematuria is found in almost two-thirds of the patients, although the presence of red blood cell casts is rare. A very common finding (>80% of cases) is leukocyturia, frequently accompanied by leukocyte casts.

42 EXPERTS VIEW (2) (Perazella MA & Markowitz GS. Nat Rev Nephrol 2010;6:461)

43 URINE SEDIMENT FINDINGS IN THE LITERATURE (BIOPSY-PROVEN CASES)* Patient number 318 RBCs 171 (53.7%) WBCs 211 (66.3%) RTECs --- Casts 27 (8.5%) -granular 13 (4.0%) -undefined 10 (3.1%) - cellular 2 (0.6%) -leukocytic 1 (0.3%) -erythrocytic 1 (0.3%) *23 papers, from 1975 to 2010, selected because of adequate information on U-sed (drug-induced 17; general 6, including 2 pediatric series)

44 RBC CASTS IN THE URINE-1 Nine patients with biopsy-proven drug associated AIN. RBC casts found in the urine sediment of a 19-year-old man (11.1%) with AIN due to penicillin

45 RBC CASTS IN THE URINE-2 Red Blood Cell Casts In Acute Interstitial Nephritis Jerald F. Sigala, MD; Claude G.Biava, MD; Henry N. Hulter, MD Arch Intern Med 138: , 1978 A 45-year-old woman receiving hydralazine and hydrochlorothiazide therapy was found to have a reduced glomerular filtration rate, a positive antinuclear antibody reaction, and RBC casts in the urinary sediment. Glomeruli with normal morphology were found on renal biopsy; however a mild interstitial nephritis was observed that predominantly involved the distal tubules.. Although RBC casts have been thought to be diagnostic of glomerular diseases, the present case demonstrates that tubulointerstitial disease can be responsible for RBC cast formation.

46 RBC CASTS IN THE URINE-3 RBC casts in the urine sediment of 4 out of 12 patients with unspecified AIN (33.3%). Neither details nor comments found in the paper

47 Number 21 (biopsy-proven) M:F 12:9 Age 55.4 ± 19.6 (17-80) S-creatinine at RB 4.5 ± 3.2 ( ) Proteinuria (g/24hrs) Cause AIN: OUR RETROSPECTIVE EXPERIENCE ( ) 19/21 (90.4%) 1.3 ± 2.7 ( ) 7 NSAID 5 Antibiotics 4 Unidentified 3 Salazopyrin 2 Other (PPI: 1; Doxazosin 1)

48 URINE SEDIMENT FINDINGS (1) U-sed PARTICLE OUR COHORT (21) LITERATURE (318) WBCs 12 (57.1%) 211 (66.3%) RBCs 10 (47.6%) 171 (53.7%) RTECs 3 (14.2%) --- CASTS 20 (95.2%) 27 (8.5%) Hyaline 19 (90.4%) --- Hyaline-granular 17 (80.9%) --- Granular 13 (61.9%) 13 (4.0%) Waxy Erythrocytic 6 (28.5%) 1 (0.3%) Epithelial (RTECs) 3 (14.2%) --- Leukocytic 3 (14.2%) 1 (0.3%)

49 URINE SEDIMENT FINDINGS (2) RBCs + WBCs + casts 8 Only casts 6 WBCs + casts 2 Only WBCs 1 RBCs + casts 1 RTECs + casts 1 RBCs + RTECs + casts 1 WBCs + RTECs + casts 1 TOTAL 21

50 COMMENT In our retrospective study, compared to the 23 papers we have reviewed, we found: 1.A much higher frequency of all casts (with the exception of the waxy ones, which we did not apparently find in any sample) 2.An unexpectd high frequency of RBC casts (6/21: 28.5%), which is close to that reported by Köhler et al, but is much higher than that found in the literature

51 POSSIBLE EXPLANATIONS 1. The care with which in our laboratory we examine the urinary sediments 2. For RBC casts, our finding in the urine is supported by their presence in the renal tubules (3/6 pts). Quite surprisingly, RBC casts are usually not reported among the pathological features of AIN, the only paper reporting on them being that by Geevasinga et al (Clin Gastroenterol Hepatol, 2006; 4: ) on AIN due to proton pump inhibitors

52 Interstitial inflammation Disruption of interstitial vessel wall HOW DO URINARY RBC CASTS FORM IN AIN? RBC extravasation within the interstitium Passage of RBC into tubular lumen through TBM gaps Packing of RBC within the tubular lumen RBC cast cylindruria

53 CONCLUSION 1. In our experience, the urinary sediment findings in AIN are somewhat different from those reported in the literature 2. The finding of RBC casts in the urine sediment DOES NOT rule out the diagnosis of acute interstitial nephritis

54 2012; 60:

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56 EOSINOPHILURIA STILL A SENSITIVE AND SPECIFIC MARKER OF AIN? EOSINOPHILS (BY MGG)

57 EOSINOPHILURIA IN AIN AUTHOR STAIN URINARY EOSINOPHILS Galpin 1975 Wright s AIN (>33%): 9/9 (100%) Other conditions: 0/43 Linton 1980 Wright s AIN (>33%): 6/9 (67%) Corwin 1985 Wright s AIN (>1%): 8/9 (88%) Other conditions: 27/56 (48%) Nolan 1986 Hansel s vs Wright s* AIN ( 1%): 10/11 (91%) Other conditions: 11/66 (17%) Corwin 1989 Ruffing 1994 Hansel s vs Wright s* Hansel s vs Wrigh ts AIN: 5/8 (63%) Other conditions: 13/144 (9%) AIN (>1%): 6/15 (40%) Other conditions: 10/36 (28%) * = Hansel s more sensitive than Wright s

58 MURIITHI AK et al (Clin J Am Soc Nephrol 2013; 8: ) Retrospective study on 566 pts, all with a RB and the search for Ueos by Hansel s stain Ueos >1% = 179 pts AIN: 28/91 (31%) Other conditions: 151

59 Ueos IN BIOPSY-PROVEN KIDNEY DISEASES <1% >1% >5%

60 Ueos IN AIN Ueos >1%: 28/91 (1-5%: 10; >5%: 18) >1% Cutoff >5% Cutoff Sens Spec PPV NPV Pos LR Neg LR Positive LR >10 = good evidence to rule in a disease Negative LR <0.1 = good capacity to rule out a disease

61 CONCLUSIONS Clin J Am Soc Nephrol 2013; 8:

62 ACUTE KIDNEY INJURY (AKI)

63 DEFINITION Decline of renal function occurring over hours or days with/without reduced urine output in a variable clinical context

64 CAUSES PRE-RENAL Intravascular volume depletion of whatever cause RENAL Glomerulonephritis Acute interstitial nephritis Large or small vessel disease Intratubular obstruction Acute tubular necrosis (ATN) POST-RENAL Acute urinary tract obstruction In clinical practice it is very important to distinguish prerenal AKI from AKI associated with ATN

65 URINARY MARKERS IN AKI: PRE-RENAL vs ATN PRE-RENAL ACUTE TUBULAR NECROSIS Osmolality >500 <500 Specific gravity >1.020 <1.020 Sodium <20 >40 FE Na <1 >2 NEW BIOMARKERS: KIM-1; NGAL; IL-18,etc

66 The two conditions can also be distinguished on the basis of the urinary sediment findings as suggested by a number of studies

67 THE URINE SEDIMENT IN AKI: RECENT STUDIES

68 Nephron Clin Pract 2008; 110: c145-c150 The study, performed on a small number of patients (No = 18), shows that a cast score index based on the number of granular and epithelial casts, is useful in identifying patients with more severe AKI associated with ATN

69 Clin JASN 2008; 3: hospitalized patients with AKI investigated by the means of a urine sediment score system based on the number of: GRANULAR CASTS & RTECs

70 CONCLUSION S The study, based on a large cohort of patients, shows that a urine sediment score based on granular casts and RTE cells is useful in differentiating AKI patients with ATN from those without (prerenal AKI) However, it must be noted that some overlaps are found between the two conditions especially when the number of granular casts and RTECs are 1-5/HPF

71 Prospective study on 197 hospitalized patients with AKI (63 pre-renal, 134 ATN) AIMS: Clin J Am Soc Nephrol 2010; 5: To investigate the correlation between U-sed score and AKI stage (based on S-creat level only) 2.To investigate a U-sediment score (based on the No of granular casts and RTECs) as predictor of AKI worsening (= S-creat increase from the time of consultation, need for dialysis, or in-hospital death)

72 CONCLUSIONS U-score based on the number of RETCs and of GCs is associated with AKI stages and with the risk of worsening of AKI U-score is a better predictor of worsening of AKI than changes of S-creati from baseline U-score reflects cell death and apoptosis in the renal tubules Urine microscopy should remain as a standard practice and a valuable tool in the diagnosis and assessment of AKI

73 Clin JASN 2011; 6: Prospective study on 249 patients with AKI Aims: to test the utility of new and traditional urine biomarkers of AKI in predicting primary and secondary outcomes New biomarkers: N-GAL, KIM-1, IL 18 Traditional biomarkers: FeNa, FeUrea, urine microscopy (No of granular casts and RTECs)

74 CONCLUSIONS 1.A single protein marker measurement or microscopy score at the first rise in Screat is able to risk stratify patiens for progression to higher AKI stage or in-hospital death irrespective of AKI aetiology 2.FeNa and FeUrea are not useful for AKI prognosis in this cohort of patients

75 IN CONCLUSION All these studies demonstrate that Granular casts Renal tubular epithelial cell casts Renal tubular epithelial cells Are good markers of AKI associated with ATN

76 THE ATN MARKERS (1) RTECs and renal tubular fragments Renal tubular epithelial cell casts

77 THE ATN MARKERS (2) Granular casts

78 GENERAL RULE Pre-renal AKI Only hyaline and hyaline-granular casts ATN RETCs ± RETC casts ± granular casts The higher the number the more likely and severe the tubular damage Without forgetting exceptions and/or overlaps!

79 IN ADDITION ATN can be present in all diseases which affect the renal parenchyma acutely such as Glomerulonephritis Acute interstitial nephritis Large or small vessel disease Intratubular obstruction In these conditions granular casts, RTEC casts and RTECs can be found in association with other particles

80 PARTICLES ASSOCIATED WITH THE PARTICLES OF ATN IN ACUTE DISEASES OF RENAL PARENCHYMA Many RBCs & RBC casts Active proliferative GN WBCs ± WBC casts Acute interstitial nephritis Myoglobin casts Rhabdomyolysis Crystals Crystalline nephropathy

81 ATN ASSOCIATED WITH INTRATUBULAR PRECIPITATION OF CRYSTALS H&E stain Polarized light

82 UROLOGICAL DISORDERS

83 UROLOGICAL DISEASES Urothelial adenoma/carcinoma Urolithiasis Urinary tract obstruction Other disorders Share the same U-sed findings (+ specific features in some conditions)

84 SHARED U-sed FINDINGS Isomorphic hematuria (mild to gross H) with/without Leukocyturia with/without Transitional cells S-creatinine normal or increased, either acutely or chronically Proteinuria usually absent unless there is gross haematuria. In this case proteinuria is due to the loss of whole blood, which also contains albumin (up to ++++ by disptick)

85 SPECIFIC U-sed FINDINGS IN UROLOGICAL DISEASES Crystals (urolithiasis) Atypical/malignant transitional cells (urothelial neoplasia) Eggs of Schistosoma haematobium

86 A UROLOGICAL SEDIMENT (Many WBC, a few isomorphic RBC and some deep transitional cells)

87 NORMAL TRANSITIONAL CELLS DEEP SUPERFICIAL

88 ATYPICAL/MALIGNANT UROEPITHELIAL CELLS

89 Clin Chim Acta 2015, 439:

90 URINARY TRACT INFECTION

91 THE URINARY SEDIMENT OF URINARY TRACT INFECTION WBC + bacteria ± isomorphic RBCs ± superficial transitional cells Without kidney involvement WBC + bacteria ± isomorphic RBCs ± leukocytic casts ± RTECs With kidney involvement S-Creatine normal or increased Proteinuria absent to mild (tubular)

92 WBC & BACTERIA

93 UTI vs URINE CONTAMINATION FROM GENITAL SECRETIONS INFECTION WBC + Bacteria with/without Isomorphic RBCs Superficial transitional cells CONTAMINATION WBC ± Bacteria with/without Isomorphic RBCs Massive amounts of squamous cells Candida and/or Trichomonas vaginalis

94 LARGE AMOUNTS OF SQUAMOUS EPITHELIAL CELLS DUE TO GENITAL CONTAMINATION

95 CANDIDA TRICHOMONAS VAGINALIS

96 URINARY TRACT INFECTION DUE TO PARASITES: SCHISTOSOMIASIS

97 URINARY SCHISTOSOMIASIS (Schistosoma Haematobium) Endemic in many geographic areas (colored areas), from the Middle- East to Northern, Western and South-Eastern Africa

98 LIFE CYCLE

99 CLINICAL MANIFESTATIONS Isolated isomorphic microscopic hematuria Recurrent bouts of gross hematuria (which in rural Africa are also known as male menstruation ) Obstructive uropathy due to granulomas/fibrosis Bladder carcinoma Glomerulonephritis

100 BLADDER SCHISTOSOMIASIS Eggs of Schistosoma haematobium surrounded by intense infiltrates of eosinophils and other inflammatory cells. From: CDC/ Dr. Edwin P. Ewing, Jr. as reported in: Public Health Image Library (PHIL)

101 URINARY FINDINGS Data collected at Tanguiéta Hospital, Bénin Republic, West Africa DIAGNOSTIC PARTICLE: - Eggs of Schstosoma H ASSOCIATED PARTICLES: - Isomorphic RBCs (100%) - WBCs (including eosinophils)(92%) - Bacteria (34%) - Superficial transitional cells (28%) S-creatinine: normal or increased Proteinuria: absent/present (variable amount)

102 SCHISTOSOMA HEMATOBIUM EGGS The shell Terminal spike Miracidium Terminal spike Size x µm

103 DIAGNOSIS OF URINARY SCHISTOSOMIASIS To increase the egg yield (hence sensitivity): 1) The patient is asked to perform a physical effort (e.g., a run) 2) The urine is collected between 10 am and 2 pm The quantitation of the eggs is used to estimate the severity of the infection

104 THANK YOU FOR YOUR KIND ATTENTION