The color of urine: then and now-a comprehensive review of the literature with emphasis on intracytoplasmic pigments encountered in urinary cytology.

The color of urine, once considered by uroscopists to give the most important clues to the diagnosis, still can provide some diagnostic clues in modern medicine. Pigmented cells are an uncommon and surprising find in urine cytology and can at the same time provide important diagnostic clues or represent a dangerous pitfall. We present a review of the significance of pigmented cells in urine cytology. The presence of intracellular pigment granules; their color, size, shape, and variation in size and shape; as well as their staining reactions with special stains can provide useful diagnostic insight, especially when interpreted in the cytologic context (type of pigmented cell and its degree of atypicality) and patient's clinical context. The main differential diagnosis of cytoplasmic pigmented granules includes hemosiderin, lipofuscin, and melanin, each having a different pathogenesis and significance. The goal of this paper is to describe the morphological, histochemical, and ultrastructural characteristics of the pigments seen in urinary cytology, and to review the benign and malignant conditions associated with them.

A case of warm autoimmune haemolytic anaemia with intravascular haemolysis: a rare presentation.

Autoimmune haemolytic anaemia (AIHA) is a rare (prevalence 0.2 -1.0 per 100,000 population) but a potentially fatal condition. Diagnosis of AIHA is based mainly on Direct Agglutination Test (DAT/Coomb's test). AIHA is classified into warm (optimal autoantibody reactivity at 37°C) and cold (optimal autoantibody reactivity at 4°C) types. Based on the presence or absence of an underlying cause, it is divided into primary (idiopathic) and secondary (secondary to lympho proliferative disorders, autoimmune disease, drugs and non-haematological malignancies). Warm type accounts for about 70% of cases with AIHA. It can occur at any age, but mostly after 40 years. Haemolysis in warm AIHA is mediated by IgG alone or IgG with complement. Once immunoglobulins are bound, the red cells are taken up by the macrophages of the reticulo-endothelial system which has receptors for the Fc fragments of the immunoglobulins. As the red cells are haemolysed extravascularly this occurs mainly in the spleen. Intravascular haemolysis is unusual in warm AIHA, although it can occur rarely, as warm autoantibodies can fix complements. We report severe warm AIHA in an adult with evidence of intravascular haemolysis, which is an unusual presentation.

Tissue and urinary haemosiderin in chronic leg ulcers.

OBJECTIVE: The aim of this study was to assess the relationship between urinary and tissue haemosiderin in chronic leg ulcers, and its value as a diagnostic test for venous ulceration. METHODS: 45 patients with chronic leg ulcers were recruited to the study (24 venous, 6 ischaemic, 6 lymphoedematous, 5 rheumatoid and 4 sickle cell). Punch biopsy of the ulcer edge was taken and early morning urine samples were collected. Positive Prussian-blue urinary haemosiderin granules were measured with a haemocytometer following Perls' staining. The percentage area of histological section staining positively with Perls' was measured using image analysis. RESULTS: 84 urine samples and 46 ulcer biopsies were collected. Urinary haemosiderin was present in 92% of venous ulcer patients, but was absent in the ischaemic ulcer patients (p<0.0001). Significantly more urinary haemosiderin granules were detected in venous ulcer patients compared with patients who had lymphoedema (p<0.05). Tissue haemosiderin was detected in all ulcer types investigated. No correlation was found between the amounts of haemosiderin deposited in the tissue and the amount found in urine (r(2)=0.06). CONCLUSIONS: Haemosiderin is present in the urine of most patients with venous ulcers but not in ischaemia ulcers.

Urine hemosiderin: a novel marker to assess the severity of chronic venous disease.

OBJECTIVE: Impaired venous drainage in severe chronic venous insufficiency (CVI) leads to microcirculatory overload, characterized by erythrocyte diapedesis and subsequent extravascular hemolysis, resulting in typical dermal hemosiderin deposition. We hypothesized that hemosiderin, normally absent, could be present in the urine in CVI. METHODS: The three-phase study included 117 patients with CVI and 12 healthy control subjects, all of whom had undergone clinical examination and duplex scanning. In phase 1, current methods were used to test urine for hemosiderin in 61 persons: 12 healthy control subjects, 24 patients with mild CVI (clinical class C1 to C3), and 25 patients with severe CVI (clinical class C4 to C6). In phase 2, the concentration of urinary hemosiderin was determined in 45 consecutive patients with CVI, CEAP class 1 to 6. A score of 0 was assigned when typical hemosiderin granules were absent at microscopic examination, a score of 1 when one to three granules per field were detected; 2 when four to six granules were detected; and 3 when more than six granules were observed. Phase 3 included 23 patients with CVI (clinical class 2 to 6). Hemosiderin concentration was determined and a score assigned before patients underwent surgical procedures to correct primary CVI. Both hemosiderin testing and duplex scanning were repeated after 6 months. RESULTS: Phase 1: Urine hemosiderin testing to determine presence or absence of CVI in patients with reflux detectable at duplex scanning yielded the following values: positive predictive value, 96% (95% confidence interval [CI], 86% to 100%); negative predictive value, 88% (CI, 68% to 97%); sensitivity, 94% (CI, 72% to 99%); specificity, 91% (CI, 83% to 99%); and diagnostic accuracy, 95% (CI, 86% to 99%). Phase 2: Hemosiderinuria score enabled classification of clinical severity of CVI. Mean scores, respectively, were clinical class 1, 0.18 +/- 0.12; class 2, 0.75 +/- 0.47; class 3, 1.67 +/- 0.21; class 4, 1.86 +/- 0.26; class 5, 2.50 +/- 0.28; and class 6, 1.92 +/- 0.21 (P <.001). Phase 3: At 6-month follow-up, hemosiderin score was improved, from 2.48 +/- 0.12 preoperatively to 0.78 +/- 0.18 postoperatively (P <.0001). A score of 0 or 1 was associated with successful surgery, whereas a score of 2 or 3 reflected persistence of reflux. CONCLUSIONS: Determination of presence of hemosiderin in the urine is a new, sensitive, cost-effective, noninvasive, and repeatable test that enables detection of substantial microcirculatory overload in patients with CVI.

Effects of ultra-marathon training and racing on hematologic parameters and serum ferritin levels in well-trained athletes.

Hematologic parameters and serum ferritin levels were measured in groups of experienced ultra-marathon runners under control conditions, 2 days after a 160-km ultra-marathon, and for up to 14 days after a 56-km ultra-marathon. Under resting conditions, 14% of the runners had subnormal serum ferritin levels compared to 2% of a control group and not one of a group of trained swimmers. Serum ferritin levels that were markedly elevated after both ultra-marathon races returned to pre-race levels only 6 days after the 56-km ultra-marathon and continued to fall in athletes who did not exercise for a further 8 days. Other hematologic changes that were present after either of the ultra-marathon races included: immediate post-race hemoconcentration (shown by increased mean red cell count, hemoglobin level, and packed cell volume) and increased mean corpuscular volume, followed by hemodilution that was greatest 48 h after the 160-km race; an increased mean corpuscular hemoglobin concentration and reticulocyte production index; transient leukocytosis, monocytosis, lymphocytopenia, eosinophilopenia, and the appearance of band cells. With the exception of the increase reticulocyte production index and the reduced packed cell volume, all other hematologic parameters had returned to control levels 6 days after the 56-km race. This study shows that serum ferritin levels may be subnormal in a proportion of distance runners and that daily training and ultra-marathon racing in particular may cause these levels to remain elevated for between 6--14 days. Thus, when hematologic parameters are measured in distance runners, it should be remembered that recent prolonged exercise may (1) produce a "dilutional anemia," (2) by increasing serum ferritin levels, mask a true iron deficiency, and (3) that these changes may require up to 6 days to return to normal.

The clinical significance of ferritinuria.

Urinary ferritin levels were measured by a "2-site" immunoradiometric assay in normal volunteers and in patients with various hematologic disorders. The mean urinary ferritin concentration in normal subjects averaged 2.2 microgram/liter, only 3% of the serum ferritin level. Elevated urinary ferritin levels averaging 45 microgram/liter were observed in patients with hematologic malignancies, but there was a proportional increase in serum ferritin so that the urinary level still averaged only 7% of the serum value. The highest urinary ferritin values (mean 170 microgram/liter) were associated with chronic hemolytic anemia, and in these patients, urinary ferritin rose disproportionately in relation to the serum, averaging 82% of it. This higher urinary level apparently reflects increased ferritin in renal tubular cells due to glomerular filtration of unbound hemoglobin, a mechanism that is supported by a highly significant correlation between urinary ferritin and serum haptoglobin levels. In normal subjects and in patients with malignancy, the source of urinary ferritin appears different, since a highly significant correlation was observed between urinary ferritin and reticuloendothelial iron stores as measured by serum ferritin or total iron-binding capacity. In this setting, the most likely source of urinary ferritin is the iron contained in renal tubular cells, which is apparently in equilibrium with body iron stores.

Urinary ferritin protein in subjects with prosthetic heart valves and other disorders.

Twenty-four-hour urine ferritin protein excretion (UFPE) was elevated in the great majority of patients with prosthetic cardiac valves. In this group, there was a positive correlation with the presence of haemosiderin in the urine and with another indirect measure of reduced red-cell survival, namely, serum lactic dehydrogenase. In a number of hospital patients with various disorders, UFPE was also increased. In this latter group, however, there was no constant accompanying haemosiderinuria or elevation of lactic dehydrogenase. The measurement of UFPE can be added to the list of screening tests for intravascular haemolysis, but analysis of the different isoferritins in urine is necessary to fully understand the mechanism of excretion in the different groups.

Traumatic hemolysis after aortofemoral bypass. A study of 25 cases.

The prevalance of traumatic intravascular hemolysis was estimated in 25 patients following aortofemoral bypass. Stigmata of mild red cell fragmentation were noted in approximately one third of the patients, but in only one of them was hemolysis of sufficient severity to be of clinical significance. The case history and laboratory findings in this patient are described in detail. This study indicates that traumatic hemolysis should be considered as a possible cause of anemia developing after aortofemoral bypass.

Chronic hemolysis following mitral valve replacement. A comparative study of the Björk-Shiley, composite-seat Starr-Edwards, and frame-mounted aortic homograft valves.

Hemolysis was assessed in 86 patients after mitral valve replacement. Twenty-four patients had mitral valve replacement with a Björk-Shiley valve, 32 patients with a Starr-Edwards composite-seat valve, and 30 patients with an irradiated frame-mounted aortic homograft valve. Hemolysis was determined by red cell survival and autologous 51Cr-tagged red cells, LDH, serum haptoglobin, hemosiderinuria, reticulocyte count, red cell fragment count, and hemoglobin estimation. The degree of hemolysis was classified as mild, moderate, or severe. Thirty-five per cent (nine of 24) of the Björk-Shiley group showed mild hemolysis, whereas 85 per cent (28 of 32) of the Starr-Edwards group had evidence of hemolysis-of these, a third were mild and the rest moderate. The homograft series did not show any comparable evidence of hemolysis. Statistical analysis of the parameters of the study comparing homograft with Björk-Shiley valves showed no significant difference except in red cell survival, which showed a highly significant difference (p less than 0.001). Comparing homograft with Starr-Edwards valves, all parameters showed highly significant differences (p less than 0.001).

Urinary iron in patients with sickle cell anamia.

Urinary iron excretion was measured in patients with sickle cell anemia and relateddiseases. Iron concentration in urine was determined by atomic absorption spectrophotometry and daily total iron excretion was calculated from this and total daily urine volume. Normal subjects excreted a mean of 88 pg Fe per day (95 per cent confidence limitsof 0 to 120 pg). Nine persons with sickle cell trait had normal Fe excretion rates.However, abnormally high iron excretion was present in the first urine sample obtainedfrom 27/31 patients with SS, 3/7 with SC, 1/2 with CC, and 1 with S-thalassemia. Iron excretion varied very significantly from day-to-day in individual patients. The results of studies attemting to relate this to increase excretion during activityas compared to rest were negative. No clear relationship of iron excretion to painfulcrisis could be shown, but remarkable rises in urine iron occurred in two patients who developed a hyperhemolytic crisis. These studies suggest that urinary iron reflects intravascular hemolysis primarily. No correlation was evident between urine iron and the patients' age, transfusion history, or serum iron values suggesting increased urinary iron excretion cannot be attributed to iron overload in sickle cell anemia.