A 27-year-old woman who drinks about 5 L of water a day as part of a fitness plan has dysuria and frequency. Her fresh midstream urine: SG 1.003, pH 6.5, nitrite positive, leukocyte esterase 2+, blood trace, protein negative. The sediment shows 25-30 cells/HPF that are larger than usual neutrophils, with two to four nuclear lobes and cytoplasmic granules that sparkle with Brownian movement, plus many rods, a few squamous cells and no casts. Her creatinine is normal. A trainee has reported the cells as 'renal tubular epithelial cells, suggest tubular injury'. How should the cells be reported?

Glitter cells: neutrophils swollen in dilute urine

Trichomonas vaginalis trophozoites

Renal tubular cells from tubular injury

Urothelial cells shed from an inflamed bladder

A 7-year-old boy has a raised purple rash over his buttocks and legs, colicky abdominal pain and painful ankles, starting 10 days after a cold. Platelets are 310 x 10^9/L (reference 150-450 x 10^9/L), PT and APTT are normal, and serum C3 is normal. Urine: SG 1.020, pH 6.0, protein 1+, blood 2+, nitrite and leukocyte esterase negative. Sediment: 15-20 RBC/HPF, many small and misshapen, including ring forms with knob-like blebs, and 1-2 cylinders/LPF with parallel sides and rounded ends packed with red cells. The urine findings indicate:

Glomerular bleeding from IgA vasculitis

Glomerular bleeding after streptococcal infection

Bladder bleeding from hemorrhagic cystitis

Bleeding from a platelet or clotting defect

A patient receiving cisplatin has a rising creatinine. The sediment shows 10-15 round cells/HPF, larger than neutrophils, each with one round, eccentric nucleus and no lobes; leukocyte esterase and nitrite are negative. The cells are most likely:

Spherical urothelial (transitional) cells

Why are broad casts wider than ordinary casts?

They form in widened tubules or in collecting ducts

Heavy proteinuria makes the matrix swell as it gels

They are molded in the glomerulus around capillary loops

Several ordinary casts fuse together in the bladder

A healthy 24-year-old army recruit gives a urine sample an hour after a 25 km march in summer heat. Protein trace, blood negative; 4-6 hyaline casts/LPF and an occasional finely granular cast; no tubular cells or cellular casts. The laboratory's reference interval for hyaline casts is 0-2/LPF. What is the best interpretation?

A transient effect of exertion; repeat after rest

Contamination of the sample by fibers and mucus

Early glomerulonephritis needing nephrology review

Acute tubular necrosis caused by heat injury

Microscopic examination: cells and casts

20 DOH Abu Dhabi (HAAD) lab licensing practice questions on Microscopic examination: cells and casts, part of Urinalysis and Body Fluids. The first 20 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 27-year-old woman who drinks about 5 L of water a day as part of a fitness plan has dysuria and frequency. Her fresh midstream urine: SG 1.003, pH 6.5, nitrite positive, leukocyte esterase 2+, blood trace, protein negative. The sediment shows 25-30 cells/HPF that are larger than usual neutrophils, with two to four nuclear lobes and cytoplasmic granules that sparkle with Brownian movement, plus many rods, a few squamous cells and no casts. Her creatinine is normal. A trainee has reported the cells as 'renal tubular epithelial cells, suggest tubular injury'. How should the cells be reported?
1. ATrichomonas vaginalis trophozoites
2. BGlitter cells: neutrophils swollen in dilute urine
3. CRenal tubular cells from tubular injury
4. DUrothelial cells shed from an inflamed bladder
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Answer: B · Glitter cells: neutrophils swollen in dilute urine
In very dilute urine, neutrophils take up water and swell, and their granules show Brownian movement that makes them sparkle; these are glitter cells. They are still neutrophils, as the lobed nuclei and the positive leukocyte esterase show, and with the positive nitrite and many rods they point to a urinary tract infection. Renal tubular cells have a single round, often eccentric nucleus without moving granules, and urothelial cells have one central nucleus. Trichomonads have flagella, an undulating membrane and jerky movement. Glitter cells are counted as white cells; they were once linked to pyelonephritis, but they mainly reflect the low specific gravity.
- A: Trichomonads have flagella and jerky motility and no lobed nucleus.
- C: Tubular cells have one round nucleus and no granules in Brownian movement.
- D: Urothelial cells have a single central nucleus, not a lobed one.
Question 2 · Hard
A 7-year-old boy has a raised purple rash over his buttocks and legs, colicky abdominal pain and painful ankles, starting 10 days after a cold. Platelets are 310 x 10^9/L (reference 150-450 x 10^9/L), PT and APTT are normal, and serum C3 is normal. Urine: SG 1.020, pH 6.0, protein 1+, blood 2+, nitrite and leukocyte esterase negative. Sediment: 15-20 RBC/HPF, many small and misshapen, including ring forms with knob-like blebs, and 1-2 cylinders/LPF with parallel sides and rounded ends packed with red cells. The urine findings indicate:
1. AGlomerular bleeding after streptococcal infection
2. BBladder bleeding from hemorrhagic cystitis
3. CGlomerular bleeding from IgA vasculitis
4. DBleeding from a platelet or clotting defect
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Answer: C · Glomerular bleeding from IgA vasculitis
The cylinders are red cell casts, which form only when red cells enter the tubules, so they place the bleeding in the nephron, almost always the glomerulus; dysmorphic red cells with blebs (acanthocytes, G1 cells) support this. Palpable purpura on the buttocks and legs with abdominal pain and arthritis in a child is IgA vasculitis (Henoch-Schönlein purpura), and its nephritis comes from IgA immune complexes in the glomeruli. Post-streptococcal glomerulonephritis follows a streptococcal throat or skin infection and lowers C3, but C3 is normal here. Bladder bleeding gives uniform red cells and no red cell casts, and the normal platelet count and clotting tests exclude a bleeding disorder.
- A: Post-streptococcal disease lowers C3, which is normal here, and does not cause this rash.
- B: Bladder bleeding gives uniform red cells and no red cell casts.
- D: Platelets, PT and APTT are normal, and red cell casts show glomerular bleeding.
Question 3 · Hard
A patient receiving cisplatin has a rising creatinine. The sediment shows 10-15 round cells/HPF, larger than neutrophils, each with one round, eccentric nucleus and no lobes; leukocyte esterase and nitrite are negative. The cells are most likely:
1. ARenal tubular epithelial cells
2. BDegenerating neutrophils
3. CSmall lymphocytes
4. DSpherical urothelial (transitional) cells
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Answer: A · Renal tubular epithelial cells
Cisplatin is toxic to the renal tubules, and injured tubular cells, especially the round or oval distal tubular cells, are easily mistaken for white cells. A single off-center round nucleus, a size larger than neutrophils and a negative leukocyte esterase all favor tubular cells. More than two tubular cells per high-power field suggests active tubular injury, so these cells should be identified and reported, not counted as white cells. A supravital stain or a cytocentrifuge preparation helps when the identity is unclear.
- B: Neutrophils keep their esterase even when they degenerate, so the pad would be positive.
- C: Lymphocytes are smaller than neutrophils, with a thin rim of cytoplasm.
- D: Spherical urothelial cells usually have a central nucleus, and the drug history points to tubular injury.
Question 4 · Medium
Why are broad casts wider than ordinary casts?
1. AHeavy proteinuria makes the matrix swell as it gels
2. BThey are molded in the glomerulus around capillary loops
3. CThey form in widened tubules or in collecting ducts
4. DSeveral ordinary casts fuse together in the bladder
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Answer: C · They form in widened tubules or in collecting ducts
A cast takes the shape of the lumen in which it gels. Broad casts form where the lumen is wide: in tubules that have dilated in chronic damage, or in collecting ducts, which drain many nephrons, when flow slows greatly. They are usually waxy or granular and are linked to advanced kidney disease and a poor outlook, hence the old name renal failure casts. Their width reflects stasis and nephron loss, not the material inside.
- A: Protein adds to the matrix but does not widen a cast beyond its tubule.
- B: Casts do not form in the glomerulus; uromodulin is secreted by tubular cells.
- D: Casts do not fuse in the bladder; their width comes from the lumen where they formed.
Question 5 · Hard
A healthy 24-year-old army recruit gives a urine sample an hour after a 25 km march in summer heat. Protein trace, blood negative; 4-6 hyaline casts/LPF and an occasional finely granular cast; no tubular cells or cellular casts. The laboratory's reference interval for hyaline casts is 0-2/LPF. What is the best interpretation?
1. AA transient effect of exertion; repeat after rest
2. BContamination of the sample by fibers and mucus
3. CEarly glomerulonephritis needing nephrology review
4. DAcute tubular necrosis caused by heat injury
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Answer: A · A transient effect of exertion; repeat after rest
Strenuous exercise, heat and dehydration reduce renal blood flow and make the urine concentrated and acidic with slow tubular flow, which raises hyaline casts and occasional granular casts. With a negative blood pad, only trace protein, and no red cell casts, tubular cells or pigmented casts, this is a physiologic finding. A repeat specimen after 24-48 hours of rest should be normal. Persistent casts, or blood and tubular cells after an extreme effort, would raise concern for exertional rhabdomyolysis and tubular injury.
- B: Fibers are flat and refractile and mucus forms long wavy threads; neither explains casts with rounded ends.
- C: Glomerulonephritis gives dysmorphic red cells, red cell casts and more protein.
- D: Tubular necrosis sheds tubular cells, tubular cell casts and coarse pigmented casts, all absent here.
Question 6 · Easy
In a standardized manual sediment examination, casts are counted in at least 10 fields and reported as the average number per:
1. AWhole coverslip area
2. BLow-power field (10x objective)
3. COil-immersion field (100x objective)
4. DHigh-power field (40x objective)
Answer and explanation in LearnFree account
Question 7 · Medium
Which part of the nephron sheds the largest renal tubular cells, which are often oblong with a coarsely granular cytoplasm and can be confused with short casts?
1. AProximal convoluted tubule
2. BThin limb of the loop of Henle
3. CCortical collecting duct
4. DDistal convoluted tubule
Answer and explanation in LearnFree account
Question 8 · Hard
Phase-contrast sediment results: 20-30 red cells/HPF, of which 40% are dysmorphic and 9% are acanthocytes (G1 cells); protein 2+; no casts in 20 low-power fields. The laboratory regards acanthocytes of 5% or more as indicating glomerular origin. What is the best interpretation?
1. ALower urinary tract bleeding, because no casts are seen
2. BBleeding from a stone in the ureter or bladder
3. CGlomerular bleeding, even though no red cell casts are seen
4. DCrenation artifact from a concentrated urine specimen
Answer and explanation in LearnFree account
Question 9 · Hard
A laboratory's procedure centrifuges 12 mL of urine and resuspends the sediment in 0.5 mL. A staff member resuspends one specimen in 1.0 mL instead and counts 8-10 red cells/HPF. How does this count most likely compare with the standard procedure?
1. AAbout half the count the standard method gives
2. BAbout a quarter of the standard method count
3. CThe same, because the cell number is unchanged
4. DAbout twice the count the standard method gives
Answer and explanation in LearnFree account
Question 10 · Hard
A 70-year-old man with known bladder carcinoma has visible hematuria. Red cell casts are reported, but on review the structures are irregular clumps of uniform red cells with no matrix and no parallel sides. How should the sediment be reported?
1. ARed cell clumps without casts, fitting bladder bleeding
2. BMixed cellular casts, pointing to acute pyelonephritis
3. CRed cell casts, pointing to bleeding in the glomerulus
4. DGranular casts formed from degenerated red cells
Answer and explanation in LearnFree account
Question 11 · Easy
Whatever cells or granules they contain, all urinary casts are built on a matrix of which protein?
1. AFibrinogen
2. BImmunoglobulin light chains
3. CUromodulin (Tamm-Horsfall protein)
4. DAlbumin
Answer and explanation in LearnFree account
Question 12 · Medium
Which set of conditions in the tubular lumen most favors the formation of casts?
1. ASlow flow, acidic pH and high solute concentration
2. BFast flow, acidic pH and low solute concentration
3. CFast flow, alkaline pH and low solute concentration
4. DSlow flow, alkaline pH and low solute concentration
Answer and explanation in LearnFree account
Question 13 · Hard
After 40 minutes of seizures, a 30-year-old man has dark urine: blood 3+, 0-2 red cells/HPF, many coarse reddish-brown granular casts and some tubular cells. The plasma is clear, and CK is 52,000 U/L (reference below 200 U/L). The casts are best reported as:
1. ABilirubin-stained casts from liver damage
2. BRed cell casts from glomerular bleeding
3. CHemosiderin-laden casts of chronic hemolysis
4. DHeme-pigment granular casts of tubular injury
Answer and explanation in LearnFree account
Question 14 · Medium
In urine, acanthocytes (G1 cells) can be told apart from crenated red cells because acanthocytes:
1. AAre ring-shaped with one or more knob-like blebs
2. BAppear as faint, empty outlines with no hemoglobin
3. CHave many short, evenly spaced spicules around the edge
4. DRegain a normal disc shape in dilute urine
Answer and explanation in LearnFree account
Question 15 · Medium
In a kidney transplant recipient, urine cells with an enlarged nucleus filled by a smooth, ground-glass inclusion (decoy cells) most suggest:
1. ABK polyomavirus reactivation
2. BAcute T-cell-mediated rejection
3. CCytomegalovirus infection of tubules
4. DUrothelial carcinoma
Answer and explanation in LearnFree account
Question 16 · Medium
Many clusters and sheets of benign-looking urothelial cells in a urine collected by bladder catheter most often reflect:
1. AAcute tubular necrosis
2. BUrothelial carcinoma of the bladder
3. CCells dislodged by the catheter
4. DAcute pyelonephritis
Answer and explanation in LearnFree account
Question 17 · Hard
A 23-year-old woman's pre-employment urine shows blood 2+, protein negative, nitrite and leukocyte esterase negative, 15-20 red cells/HPF of uniform, smooth shape, 0-2 white cells/HPF and no casts. She mentions that her period started yesterday. What is the best next step?
1. ARequest a urine culture for urinary infection
2. BRepeat the urinalysis after her period has ended
3. CRefer her for cystoscopy to exclude a bladder tumor
4. DReport probable glomerular bleeding to the doctor
Answer and explanation in LearnFree account
Question 18 · Easy
Spherical, polyhedral or tailed (caudate) epithelial cells with a central round nucleus, from the lining of the renal pelvis, ureters and bladder, are:
1. AColumnar urethral epithelial cells
2. BSquamous epithelial cells
3. CUrothelial (transitional) cells
4. DRenal tubular epithelial cells
Answer and explanation in LearnFree account
Question 19 · Hard
A 62-year-old man with a mechanical aortic valve has anemia, a raised LDH and an undetectable haptoglobin. His urine contains coarse golden-brown granules, free and inside tubular epithelial cells, that turn blue with Prussian blue stain. These findings most indicate:
1. ABilirubin from liver disease
2. BChronic intravascular hemolysis
3. CMyoglobin from muscle injury
4. DBleeding from the glomerulus
Answer and explanation in LearnFree account
Question 20 · Medium
Cuboidal cells with straight edges and a central nucleus are seen in fragments of three or more joined cells. Where do they come from, and what do they suggest?
1. ABladder urothelium; recent catheterization
2. BCollecting duct; severe tubular injury
3. CProximal tubule; normal cell turnover
4. DDistal urethra; specimen contamination
Answer and explanation in LearnFree account

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Microscopic examination: cells and casts

A patient receiving cisplatin has a rising creatinine. The sediment shows 10-15 round cells/HPF, larger than neutrophils, each with one round, eccentric nucleus and no lobes; leukocyte esterase and nitrite are negative. The cells are most likely:

Why are broad casts wider than ordinary casts?

In a standardized manual sediment examination, casts are counted in at least 10 fields and reported as the average number per:

Which part of the nephron sheds the largest renal tubular cells, which are often oblong with a coarsely granular cytoplasm and can be confused with short casts?

Phase-contrast sediment results: 20-30 red cells/HPF, of which 40% are dysmorphic and 9% are acanthocytes (G1 cells); protein 2+; no casts in 20 low-power fields. The laboratory regards acanthocytes of 5% or more as indicating glomerular origin. What is the best interpretation?

A laboratory's procedure centrifuges 12 mL of urine and resuspends the sediment in 0.5 mL. A staff member resuspends one specimen in 1.0 mL instead and counts 8-10 red cells/HPF. How does this count most likely compare with the standard procedure?

A 70-year-old man with known bladder carcinoma has visible hematuria. Red cell casts are reported, but on review the structures are irregular clumps of uniform red cells with no matrix and no parallel sides. How should the sediment be reported?

Whatever cells or granules they contain, all urinary casts are built on a matrix of which protein?

Which set of conditions in the tubular lumen most favors the formation of casts?

After 40 minutes of seizures, a 30-year-old man has dark urine: blood 3+, 0-2 red cells/HPF, many coarse reddish-brown granular casts and some tubular cells. The plasma is clear, and CK is 52,000 U/L (reference below 200 U/L). The casts are best reported as:

In urine, acanthocytes (G1 cells) can be told apart from crenated red cells because acanthocytes:

In a kidney transplant recipient, urine cells with an enlarged nucleus filled by a smooth, ground-glass inclusion (decoy cells) most suggest:

Many clusters and sheets of benign-looking urothelial cells in a urine collected by bladder catheter most often reflect:

A 23-year-old woman's pre-employment urine shows blood 2+, protein negative, nitrite and leukocyte esterase negative, 15-20 red cells/HPF of uniform, smooth shape, 0-2 white cells/HPF and no casts. She mentions that her period started yesterday. What is the best next step?

Spherical, polyhedral or tailed (caudate) epithelial cells with a central round nucleus, from the lining of the renal pelvis, ureters and bladder, are:

A 62-year-old man with a mechanical aortic valve has anemia, a raised LDH and an undetectable haptoglobin. His urine contains coarse golden-brown granules, free and inside tubular epithelial cells, that turn blue with Prussian blue stain. These findings most indicate:

Cuboidal cells with straight edges and a central nucleus are seen in fragments of three or more joined cells. Where do they come from, and what do they suggest?