24-hour urine for protein excretion Referral to nephrologist Renal biopsy?

Rule out urological cause Treat underlying condition?

Urine cytology


Renal tract imaging

Epithelial cells

Microscopy may also reveal squamous, transitional, and renal tubular cells.

• Squamous cells originate from the vagina, urethra, or trigone and typically appear large with irregular cytoplasm and a small, central nucleus

• Transitional cells are smaller with prominent cytoplasm staining, and have a large nucleus. The features of malignant transitional cells are discussed later in the chapter on urine cytology

• Renal tubular cells are larger and uncommon but, if present, suggest a glomerular pathology

2. Casts

The Tamm-Horsfall mucoprotein, excreted by the renal tubular epithelial cells, forms the basic medium for all renal casts by entrapping any cells (e.g., RBC, WBC, and sloughed renal tubular cells) within the tubular lumen. Hyaline casts, containing only mucoproteins, are excreted normally and therefore are not considered pathological. Conditions that increase hyaline cast excretion include pyelonephritis, chronic renal failure, and physical exercise.

Careful microscopic inspection of cast contents will disclose a number of underlying conditions (see Table 1.5).

3. Crystals

A number of distinct crystals can be identified in the urine of normal patients, but are more frequently seen in the urine of patients with stone disease. Crystal precipitation is dependant on urine pH.

TABLE 1.5. Urinary casts


Clinical Significance


Present in normal urine (T in dehydration and

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