○ Not detected by reagent
strip protein tests
URINARY CASTS – ○ Increased with stress and
exercise
EASY REVIEWER ● Protein gels more readily with:
○ Urine stasis
○ Acidic pH
○ Sodium and calcium
General Facts About
Casts Steps of Cast Formation
● Casts are the only elements 1. Uromodulin aggregates into protein
unique to the kidney fibrils
● Formed in the distal convoluted 2. Fibrils interweave into a loose
tubules and collecting ducts network
● Shape: parallel sides, rounded 3. Network becomes a solid structure
ends 4. Urinary elements attach
● Represent conditions inside the 5. Detachment from epithelial cells
nephron 6. Cast is excreted
● May contain cells, bacteria,
granules, pigments, or crystals
● Examined using low-power
magnification
● Best seen under subdued light (low
TYPES OF CASTS
refractive index)
● Reported as average number per
low-power field (lpf)
● Cast matrix dissolves in dilute,
1. Hyaline Casts
alkaline urine
● Most frequently seen
● Presence of casts = cylindruria
● Composed almost entirely of
uromodulin
● Normal: 0–2 per lpf
● Seen after:
Cast Composition & ○ Exercise
○ Dehydration
Formation ○ Heat exposure
○ Emotional stress
● Main component: uromodulin
● Other proteins: albumin,
immunoglobulins
Pathologic Associations
● Uromodulin:
● Acute glomerulonephritis
○ Found in normal and
● Pyelonephritis
abnormal urine
● Chronic renal disease
● Congestive heart failure
Appearance Seen In
● Colorless ● Pyelonephritis
● Low refractive index ● Acute interstitial nephritis
● Difficult to see ● Glomerulonephritis (with RBC casts)
● Wrinkled or convoluted = aging cast
● Occasional granules or cells may be Appearance
attached
● Contain neutrophils
● Granular appearance
● Multilobed nuclei
● Free WBCs should be present
2. RBC Casts
● Indicate bleeding within the
nephron
● Primarily associated with 4. Bacterial Casts
glomerulonephritis
● Must be accompanied by: ● Bacilli bound to protein matrix
○ Free RBCs ● Seen in pyelonephritis
○ Positive blood reagent ● May be mixed with WBCs
strip ● Difficult to differentiate from granular
casts
Appearance ● Confirmed by Gram stain
● Orange-red
● Fragile
● May appear fragmented
● Aging casts become homogenous
5. Epithelial Cell (RTE)
blood casts Casts
Clinical Significance ● Indicate advanced tubular
destruction
● Glomerulonephritis ● Associated with:
● Nephron capillary damage ○ Heavy metals
○ Drug or chemical toxicity
○ Viral infections
○ Allograft rejection
● Small round or oval cells
3. WBC Casts ● May resemble WBC casts
● Signify infection or inflammation
in the nephron
● Marker for pyelonephritis (upper
UTI) 6. Fatty Casts
● Seen with lipiduria ● Disintegrating cellular casts
● Associated with: ● Tubular cell breakdown
○ Nephrotic syndrome
○ Toxic tubular necrosis
○ Diabetes mellitus
○ Crush injuries
9. Waxy Casts
Appearance ● Represent extreme urine stasis
● Seen in chronic renal failure
● Highly refractile
● Brittle, highly refractile
● Contain fat droplets or oval fat
● Jagged ends and notches
bodies
● Homogenous appearance
● Maltese cross under polarized light
● Confirmed with Sudan III or Oil Red
O
10. Broad Casts
● Also called renal failure casts
7. Mixed Cellular Casts ● Indicate severe tubular destruction
● Form in collecting ducts
● Contain more than one cell type
● Most common types:
● Common combinations:
○ Broad granular
○ RBC + WBC →
○ Broad waxy
glomerulonephritis
● Seen in renal failure
○ WBC + RTE or bacteria →
pyelonephritis
● Predominant cast determines
diagnosis
KEY EXAM POINTS
● Casts = kidney origin
● Hyaline casts can be normal
8. Granular Casts ● RBC casts = glomerular bleeding
● WBC casts = pyelonephritis
● Coarse or fine granules
● Waxy & broad casts = chronic
● May be nonpathologic or
renal failure
pathologic
● Always confirm presence of free
cells
Nonpathologic
● Exercise
● Increased cellular metabolism
Pathologic