CE U P D A T E — U R I N A L Y S I S II
Deborah A. Brock, MHS, MT(ASCP)SH
Identifying Calcium Oxalate
Crystals in Urine
Crystals most often identified in urine usually do
not indicate disease. In some instances, however,
such as lithiasis (stone formation), crystals gener-
ally considered to be normal may have clinical
significance. Less commonly, crystals may be
excreted in pathologic conditions, such as liver
disease, inborn errors of metabolism, and renal
damage. It is essential, therefore, to identify and
report urine crystals correctly. In this article, we
explain how crystals form and provide guidelines
for their identification.
Urine Crystal Formation
Urine crystals form when a crystalline compound
becomes supersaturated or when that com-
pound's solubility properties are altered.
Inorganic salts, such as oxalate and phosphate,
and organic salts, such as uric acid and cystine,
can precipitate and appear in urine as true crystals
or as amorphous material. In vitro urine crystal
formation occurs most often when the tempera-
ture of the urine decreases (for example, when the
specimen is left to stand or is refrigerated) and the
type of crystal precipitated is pH dependent.
Crystal formation in vivo is enhanced when urine
flow through renal tubules decreases. Reduction
of fluid flow through the tubules, along with pH
changes in the ultrafiltrate, maximizes the con-
centration of solutes and results in the presence
of crystals in freshly voided urine.
Color and Structure
Knowledge of the color and structure of urine
crystals is essential for crystal identification. A
good atlas of urinary sediment is imperative
Downloaded from https://academic.oup.com/labmed/article-abstract/26/11/733/2659301
by guest
on 27 February 2018
Janice M. Hundley, MS, MT(ASCP)SH
ABSTRACT Proper identification of urine crystals is
essential in the routine microscopic examination of urine
sediment. Knowledge of structure, solubility, and pH charac-
teristics of urine crystals comes with training and experience.
References are available that provide excellent photographs
and illustrations to assist with recognition. In addition, these
references provide guidelines for specialized testing or polar-
ization characteristics of specific urine crystals to further
assist in identification. Although crystals most often seen in
urine generally are unrelated to pathology and are considered
normal, they must be properly identified and reported
because, occasionally, they may have clinical significance.
For example, calcium oxalate has been considered one
of the normal crystals, but it has been linked to lithiasis.
This is the second article in a three-part continuing educa-
tion update series on urinalysis. Other articles in the series
focus on urine sediment diagnosis and urine cytodiagnostics.
when one is trying to identify urinary crystals. From the Medical
Texts by Graff,1 Brunzel, 2 and Ringsrud and Laboratory
Technology Program,
Linne3 contain excellent photographs and illus- Trident Technical
trations of urine crystals. With training and expe- College, Charleston,
rience, laboratorians can identify most crystals SC (Ms Brock), and
with this information. Occasionally, additional the Department of
testing may be required for crystals that are either Medical Laboratory
Sciences, Medical
very pleomorphic or rarely seen.
University of South
Carolina, Charleston
pH and Crystal Solubility (Ms Hundley).
When the laboratorian is uncertain about the Reprint request to
identity of a crystal, he or she may examine the Ms Brock, Medical
pH of the urine. Inorganic salts are less soluble in Technology Program,
Trident Technical
neutral or alkaline urine, and organic salts are
College, 7000 Rivers
less soluble in acidic urine. The pH of the urine is Ave, PO Box 118067,
a major criterion in determining whether a com- Charleston, SC
pound will precipitate out of solution. It is 29423-8067.
NOVEMBER 1995 VOLUME 26, NUM BER 1 1 LABORATORY MEDICINE 733
 Fig 1. Common octahedral (dihydrate) shape of calcium oxalate Fig 2. Ovoid (monohydrate) shape. A dumbbell shape when viewed
crystals.(Magnification x 450.) from the side; fans out as it dissolves. (Magnification x 450.)

Fig 3. Ovoid (monohydrate) shape of calcium oxalate crystals. Fig 4. Ovoid (monohydrate) shape of calcium oxalate crystals.
(Polarized microscopy, magnification x 450). (Brightfield microscopy, magnification x 450).

important, therefore, to know which crystals are
most likely to be found in acidic, neutral, or
alkaline urines. It may be helpful to remember
that abnormal crystals, including drug crystals,
usually are found in acidic urine. Product data
sheets that contain information on the urinary
excretion of drugs (eg, form of the drug excreted,
solubility properties) are valuable resources in
identifying drug crystals.
Changing the pH of the urine also helps in
identifying or confirming the identification of
urine crystals. Crystals will dissolve or precipitate
based on pH change, which usually is facilitated
by the addition of a dilute alkaline or acidic solu-
tion. Because most laboratorians do not memo-
rize which crystal dissolves with what chemical,
Strasinger4 and Brunzel2 provide tables for quick
reference that provide the characteristics of
urinary solutes, such as pH and solubility. It is
convenient to keep the recommended concentra-
tions of hydrochloric acid, acetic acid, and sodi-
um hydroxide available for solubility testing for
identification or confirmation of urine crystals.
Solubility tests, however, should be performed
only after all other microscopic evaluations have
been completed to avoid acid or alkaline addi-
tives that can alter or destroy other significant
urinary elements such as red blood cells.
Polarization
Crystals most often are identified using only
bright-field microscopy. Definitive identification
by this method alone, however, may not be possi-
ble for crystals that are morphologically similar to
other urinary elements. In these instances, polar-
ized light microscopy may help differentiate the
elements by their birefringent properties, which
depend on the elements' chemical and physical
composition. Birefringent or anisotropic sub-
stances are those that, when viewed through
crossed polarizing filters, have the ability to break
direct light waves into two rays. They will appear
to be bright against a black background. In con-
trast, substances that do not polarize are referred
to as isotropic. Overviews of the principle of
polarization can be found in Brunzel,2 Ringsrud,3
and Strasinger.4

Downloaded from https://academic.oup.com/labmed/article-abstract/26/11/733/2659301

by guest 7 3 4 LABORATORY MEDICINE VOLUME 26 ; NUMBER 11 NOVEMBER 1995
on 27 February 2018
 Identification Process myoglobinuria), the DIFFERENTIATING YEAST, RED BLOOD
We use the example of calcium oxalate to describe blood portion of the CELLS, A N D CALCIUM OXALATE
the process that should be used to identify a urine urine reagent strip will CRYSTALS
crystal. This crystal has one characteristic form be positive. This alone Solubility
that is easily identifiable by structure—the octa- does not rule out the in 3%
Acetic Acid Polarization
hedral or envelope form (Fig 1). Calcium oxalate concomitant presence
also can appear as an oval biconcave disk, com- of calcium oxalate Yeast
monly referred to as the ovoid form. When crystals, however. Red b l o o d cells
viewed from the side, it appears as a dumbbell or Confirmation of
a figure 81 (Fig 2). This form sometimes requires calcium oxalate crystals Calcium oxalate
the use of solubility testing and polarizing can be made by polar- crystals
microscopy for proper identification. ized light microscopy. Calcium oxalate crystals
The more well-known octahedral shape of cal- will be birefringent (Figs 3 and 4), and red blood
cium oxalate is the dihydrate form, which cells and yeast will not polarize. Confirmation of
appears as two pyramids joined at their bases. red blood cells can be made by adding 3% acetic
The appearance of squares scribed with lines that acid to urine. Red blood cells will be lysed by the
intersect in the center is the picture when viewed acid while calcium oxalate crystals and yeast will
from one end. The ovoid form of calcium oxalate be unaffected (Table).
is the shape encountered less frequently. This
shape represents the monohydrate form of calci- S u m m a r y
um oxalate.5'6 The accurate identification of crystals is impor-
Studies have indicated that the concentration of tant. Urine pH and the crystal's physical charac-
calcium in the urine determines the type of crystal teristics of color and structure usually provide
formed. Lower calcium concentrations precipitate adequate information for crystal identification.
the monohydrate form, whereas higher calcium When a rare or unusual form of a crystal is pre-
concentrations precipitate the dihydrate form.7 sent, it may be necessary to test the crystal's solu-
Calcium oxalate crystals are found primarily in bility characteristics or use polarizing
acidic urine but also are seen in neutral and even microscopy.© Test Your
alkaline urine. When seen in urine with an alka- Knowledge
Look for the CE
line pH, the dihydrate form of calcium oxalate References
Update exam on
tends to maintain its classic, easily identifiable 1. Graff SL. A Handbook of Routine Urinalysis. Philadelphia,
Pa: JB Lippincott Co; 1983. Urinalysis in the
shape. The monohydrate form, however, may 2. Brunzel NA. Fundamentals of Urine and Body Fluid December issue of
appear puffy with the edges fanned out (see Fig 2). Analysis. Philadelphia, Pa: WB Saunders Co; 1994. Laboratory Medicine.
The presence of calcium oxalate crystals in 3. Ringsrud KM, Linne JJ. Urinalysis and Body Fluids: A Participants will earn
Color Text and Atlas. St Louis, Mo: Mosby; 1995. 3 CMLE credit hours
urine often is insignificant and may be linked to 4. Strasinger SK. Urinalysis and Body Fluids. 3rd ed. for 1995. o
0
an oxalate-rich diet. Foods such as tomatoes, Philadelphia, Pa: FA Davis; 1994:92-93. u
spinach, rhubarb, garlic, oranges, and asparagus 5. Colando K. Topics in chemistry: urinalysis problem. Am J
Med Tech. 1978:45:146.
are high in oxalates. Oxalic acid, a breakdown 6. Davidson I, Henry JB: Clinical Diagnosis by Laboratory
product of ascorbic acid, precipitates ionized cal- Methods. Philadelphia, Pa: WB Saunders; 1974; 77.
cium.8 Identification of these urinary crystals is 7. Grover PK, Ryall RL, Marshall VR. Effect of urate on cal-
cium oxalate crystallization in human urine: evidence for a
important, however, because urolithiasis is asso- promotory role of hyperuricosuria in urolithiasis. Clin Sci.
©
c
0
ciated with crystal formation, 9 ' 10 and calcium 1990;79:19.
oxalate is the most common cause of renal calculi 8. Lehmann C. Identification of renal calculi by computer- «
ID
ized spectroscopy. Clin Lab Sci. 1991;4(4):211.
in the United States (67%).8 9. Urivetzky M, Kessaris D, Smith AD. Ascorbic acid over-
Although the classic dihydrate octahedral form dosing: A risk factor calcium oxalate nephrolithiasis. / Urol.
is identified readily and seldom goes unnoticed, 1992;147:1215-1218.
10. Abdel-Halim RE. Crystalluria and Its Possible
the less familiar monohydrate ovoid form may be Significance. Scand J Urol Nephrol. 1993;27:145-149.
mistaken for red blood cells or yeast. Because
urine pH offers little assistance, other means such
as correlation of chemical tests with microscopic
and polarization properties must be used to dif-
ferentiate calcium oxalate from these elements. In
the presence of hematuria (or hemoglobinuria or

Downloaded from https://academic.oup.com/labmed/article-abstract/26/11/733/2659301

by guest NOVEMBER 1995 VOLUME 26, NUMBER 11 LABORATORY MEDICINE
on 27 February 2018