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Granular casts are cylindrical protein structures formed within kidney tubules from cellular debris; their presence in the urine indicates active damage or inflammation within the kidney tubules themselves. They are seen in acute tubular necrosis (ATN) — kidney damage from toxins, severe dehydration, or reduced blood flow — as well as in chronic kidney disease and glomerulonephritis. While a few granular casts per low-power field can be a normal finding after intense exercise, their presence in the context of elevated creatinine or proteinuria is a significant finding requiring nephrology evaluation.
Positive granular casts indicate renal tubular injury. Coarsely granular muddy brown casts are the hallmark of acute tubular necrosis from ischemia or nephrotoxic drugs.
Optimal is none detected. Any granular casts are significant and indicate intrarenal pathology.