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Your Practical Guide to Urine Analysis

Siemens Healthcare Diagnostics

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Hydrochloric Acid – acidification using concentrated hydrochloric acid is recommended for 24-hour urine collections. 1950 – ACETEST® Reagent Tablets. Hindus describe ‘honey urine. • Void directly into clean. “A properly collected urine sample is the first stage in the generation of quality clinical information” Disclaimer This is a training guide and does not replace the package insert for each test. This test was the forerunner of the wide range of convenience urine tests made by Siemens and used all over the world. If unable to do this. This will affect microscopy but NOT the reagent strip tests. Preservatives Thymol – a commonly-used preservative. Please refer to the pack insert for further information.C. Late 19th Century Ehrlich devises diazo reaction for bilirubin. The leucocyte reagent pad may be inhibited to varying degrees. 1980s and 1990s A range of instruments for the automated and semiautomated assessment of multiple reagent test strips are developed.’ 400 B.1 gm/dl (1 g/L) or greater. Mid-19th Century • Heller develops ring test for albumin. This is the most frequently-used specimen for steroid determinations. • 1909 – Benedict develops qualitative/ quantitative method to detect sugar. dry container/bedpan. Boric acid is generally added for the preservation of bacteria in urine. • Prolonged exposure of unpreserved urine at room temperature may result in microbial proliferation. 1949 – HEMATEST® Reagent Tablets. Use uncentrifuged urine and mix prior to testing. with resultant changes in pH. please read and operate instruments and strips according to Siemens instructions. Hippocrates stresses uroscopy 7th Century A. OR • Refrigerate specimen immediately at 4-8 °C. 1827 Bright discovers that ‘dropsy’ can be signalled by a urine test. • Bacterial growth from contaminating organisms may cause positive blood reactions from the peroxidases produced. and allow to return to room temperature before testing.D. the concentration must not be excessive as this will prevent growth of bacteria during culture. The Clinitek Status® provides a full audit trail and removes the subjectivity of visual testing. 2003 The launch of Clinitek Status®. 1957 ALBUSTIX® and KETOSTIX® Reagent Strip 1960s and 1970s A range of multianalyte reagent test strips are developed. The era of the ‘pisse-prophet. easy to use automated urine testing solution. • Sterile containers are best. the first dip-andread test strip.09:Layout 1 22/04/2009 09:40 Page 2 Contents Specimen Collection 2 History of Urine Analysis 7 Clinical Significance of Test Results 3 Specimen Collection 8 Factors Affecting Urine Chemistry Tests on Siemens Reagent Test Strips 4 Correct Technique for Visual Reading of Reagent Strip Tests 10 Test Selection Made Easy 5 Quality Assurance 11 Urinary Tract Infection Testing Pathway 6 Chemical Principles of Reagent Strip Tests 12 Services You Can Rely on for Better Patient Care History of Urine Analysis 1500 B. • Label container where possible. 1941 CLINITEST® Reagent Tablets introduced for the measurement of reducing sugars. distillation and precipitation. and will also preserve cellular structures.D. However. A simple. Ureasplitting organisms convert urea to ammonia. Sample Preparation • First-voided morning urine is best for routine analysis (most concentrated). Prior to preparing any test.04.C. test within 4 hours. 3 .40619_PRACGUIDE_Rebrand. • Trommer introduces test for glucose.’ 1674 Thomas Willis recommends evaporation. 13th Century A. 1953 – ICTOTEST® Reagent Tablets. Urine containing glucose may decrease in pH as organisms metabolise the glucose. Formaldehyde may give false positive results for glucose determinations using the tablet test. may give false positive reactions for albumin determinations. Egyptian writings refer to ‘polyuria. 1956 CLINISTIX® Reagent Strips. • Red and white blood cells may be lysed upon standing. Note: • It is especially important to use fresh urine to obtain the best results with the tests for bilirubin and urobilinogen. • A highly alkaline pH may cause false positive results with the protein test area. while continually improving the reagent tests. 1830 Routine urine analysis consists of: • Visual observation • Test for protein • Test for urea. as these compounds are relatively unstable when exposed to room temperature and light. Early 20th Century • Folin introduces colorimetric method to estimate creatinine. causing an alkaline shift in pH. • Bird publishes description of urine crystals. Protospharius suggests diagnosis through urine colour.C.’ 700 B. • Bence-Jones discovers new protein. 2 1673 Dekkers describes test to detect protein. in amounts of 0. • It is best to test samples immediately. Tablet Tests 1945 – ALBUTEST® Reagent Tablets.

000 to 1. Immerse totally one Chek-STIX strip. A few precautions will ensure meaningful results for patient management. Siemens tests are scientifically designed to react progressively and produce colour changes in the case of positive reactions at the times specified.40619_PRACGUIDE_Rebrand.04. 3. Invert tube once more. Always check the pack insert” Precautions It is important to make sure the tests are being used and stored properly. After the appropriate time. Allow to stand for 30 minutes. uncentrifuged urine. The product may also be used as a check of user technique as well as an aid to teaching. 1.0 g/L Urobilinogen Positive Colours may be atypical Nitrite Positive Leucocytes Positive “Expected results may change from the above. For enhanced convenience and standardisation. Do not Do Do read package insert carefully before testing 4 2. 4. run the edge against the rim of the urine container to remove excess urine. Example Test The control solution generated by Chek-STIX Positive solution gives results on Siemens strips in the same manner as urine specimens. by filling to graduation line. Always record the results. Dip briefly and remove immediately to avoid dissolving out reagents. with expected values as shown in the pack insert. Solution is now ready to test reactivity of Siemens strips or user technique.N Chek-STIX has been developed specifically so the user can be assured of the reactivity of the reagent areas of Siemens multiple reagent strips.3-1. Place 12 ml of distilled water in test tube provided. wellmixed. use a CLINITEK analyser to read the reagent strip and print the results.5 mmol/L Bilirubin Positive Ketones Small-Moderate Specific Gravity 1. Cap tube tightly. compare test areas closely with the corresponding colour chart on the bottle label or bench reader at the time specified. Hold strip close to colour blocks and match carefully.09:Layout 1 22/04/2009 09:41 Page 4 Correct Technique for Visual Reading of Reagent Strip Tests Quality Assurance Procedure Use Chek-STIX for checking reactivity of Siemens test strips procedure Chek-STIX strips offer a convenient method of generating an artificial urine sample which will give a positive or negative result to all Siemens multiple strip tests. 3. Expected Results Do replace cap immediately and close tightly Do check expiry date on bottle before use Do not remove desiccant from bottle Do not touch test areas of the strip Do not take out more strips than are required for immediate use 5 . Accurate timing is essential for reliable quantitative results. Always check the appearance of the urine sample as it may give useful information. If the strips are reacting properly a positive result will be seen on each test area. While removing the strip. Completely immerse all reagent areas into fresh.0-8. Invert the tube gently back and forth for 2 minutes. Hold the strip in a horizontal position to prevent possible mixing of chemicals from adjacent reagent areas or soiling of hands with urine. “Don’t forget to read the package insert carefully” 2. Remove and discard Chek-STIX strip. 1.0 Protein 0. Glucose 5.015 Blood Moderate-Large pH 7.

Readings are not affected by urinary buffer variations. Commonest Causes of Posoiive Results Urinary tract infection due to nitrite-producing organisms. heart failure. Due to urinary tract disorders. buffer. Myoglobin. no substance excreted in urine other than glucose is known to give a positive result. non-reactive ingredients. which is normally present in urine. as with gallstones. so a “negative” result does not rule out the presence of these proteins. infection. released from muscle. sodium hydroxide. benign prostatic enlargement.005 to readings obtained from urines with pH values equal to or greater than 6. (pH < 7. late-stage primary biliary cirrhosis.g. 4-tetrahydrobenzo (h)-quinolin. N. Decreased uptake by liver. inborn red cell disorders including sickle cell disease. Significance of Positive Results A measure of total solute concentration health varies widely according to the need to excrete water and solutes. carcinoma of pancreas. Bence-Jones protein and muco-protein. which gives a broad range of colours covering the pH range 5 to 8. Commonest Causes of Positive Results Urinary tract infection. Sensitivity / Specificity Test has sensitivity of 7 to 14 µmol/L bilirubin. Any degree of pink colour is considered ‘positive. The resulting colour ranges from orange through green to dark blue. 3-ol. Biliary tract obstruction. The commonest cause of high values is the use of stale urine: such specimens should not be used. Chemical Principles This test is based on the pKa change of certain pre-treated polyelectrolytes in relation to ionic concentration. Reagents paradiethyl-aminobenzaldehyde. In the presence of an indicator. Leucocytes Reagents Derivatised pyrrole amino acid ester. e. Acetone and ß-hydroxybutyrate are released at the same time. druginduced intrahepatic cholestasis. colours range from deep blue-green through green and yellowgreen in urines of increasing ionic concentration. Sterilisation of colon by administration of unabsorbable antibiotics.30 g/L. Commonest Causes of Positive Results Characteristic findings High values are found in dehydration. haemolytic breakdown of red cells in urine (especially when dilute and when testing is delayed after voiding). reabsorption into the blood stream. CLINITEST. glomerular involvement in systemic lupus erythematosus.g. e. 1.B. Clinically unimportant albuminuria. Sensitivity / Specificity The test is capable of detecting 150 to 620 µg/L free haemoglobin or 5 to 20 intact red blood cells per microlitre in urines with an S. Colour ranges from yellow for “negative” through yellowgreen.0 = Alkaline). crises in sickle cell disease or red cell glucose-6-phosphate dehydrogenase deficiency. to nitrite. Commonest Causes of Positive Results In patients with raised blood glucose concentration: •Diabetes mellitus •Glucose infusion In patients without raised blood glucose concentration: •Pregnancy •Renal glycosuria. including glomerulonephritis. but the pH may be changed by certain medications. as in acute and chronic glomerulonephritis. + + + indicating approximately 500 cells/µL. late-stage cirrhosis.030.15 to 0. neomycin. but does not react with acetone or beta-hydroxybutyric acid. with “trace” result indicating albumin concentration of between 0.09:Layout 1 22/04/2009 09:41 Page 6 Chemical Principles Reagent Strip Tests Glucose Reagents glucose oxidase. Blood Significance of Positive Results Intact red cells in urine are found with diseases of the kidneys or urinary tract. pH Significance of Positive Results Urinary pH usually reflects the pH of body fluids. Sensitivity / Specificity The test reacts with acetoacetic acid in urine.g. non-reactive ingredients. non-reactive ingredients. gives a diffuse reaction indistinguishable from that given by free haemoglobin. diabetes insipidus.5. The colour ranges through various shades of tan. peroxidase. Nitrite Reagents para-arsanilic acid. Glucose Significance of Positive Results Glucose is found in urine when its concentration in plasma exceeds the renal threshold. Test is less sensitive to globulin. Leucocytes Significance of Positive Results Some of the leucocytes which have entered inflamed tissue from the blood are shed into the urine. The test for leucocytes is a specific enzymatic reaction which is able to detect lysed cells in addition to undamaged cells. The test is based on the protein-error-ofindicators principle. except when due to in urine. The pKa of some indicators is changed when they bind to protein. Excess albumin in urine is usually due to increased permeability of the basement membrane of glomeruli. (Prevention/restrictio n of bilirubin entering the gut).005 with refractive index values. in which paradimethyl aminobenzaldehyde reacts with urobilinogen in a strongly acid medium to produce a brownorange colour. 6 Bilirubin This test is based on the coupling of bilirubin with diazonium dichloroaniline in a strongly acid medium. Protein Significance of Positive Results Strip tests will detect a range of proteins but are most sensitive to albumin.000 to 1. nephrotic syndrome.g. tumours. In clinical studies involving over 1000 specimens. glucose-6-phosphate dehydrogenase deficiency and final elimination by the kidney. non-reactive ingredients.9 mmol/L (1/4%) glucose as a trace.0 = Acid. Bilirubin Significance of Positive Results Bilirubin in urine indicates an excess of conjugated bilirubin in plasma. pre-eclampsia (toxaemia of pregnancy). and is more sensitive to free haemoglobin than intact red blood cells.g. Chemical Principles Chemical Principles Chemical Principles The test is based on the double indicator principle. 2. non-reactive ingredients. as in postural (orthostatic) proteinuria. Sensitivity / Specificity Quantitative test. The test is based on the Ehrlich reaction. The test detects as little as 0. Urobilinogen Significance of Positive Results Urinary excretion of urobilinogen reflects the combined effects of production of bilirubin. ‘trace’ indicating approximately 5 to 15 cells/µL. buffer Chemical Principles This test is based on the development of a pink or maroon colour by the reaction of acetoacetic acid with nitroprusside. non-reactive ingredients. e.5 and 8. diazonium salt. Commonest Causes of Positive Results Clinically important albuminuria. acquired immune-and drug-induced haemolysis. poly (methyl vinyl ether/maleic anhydride). of 1. hereditary spherocytosis. ineffective erythropoiesis. This pyrrole then reacts with a diazonium salt to produce a purple complex.3. In impaired kidney function as in chronic renal failure. potassium depletion. Commonest Causes of Positive Results Haematuria (intact red cells) Due to kidney disorders. Commonest Causes of Positive Results Increased excretion. pH > 7.’ Sensitivity / Specificity The test is specific for nitrite. because some organisms are unable to convert nitrate to nitrite.g.5. but may also be affected by the ability of the kidneys to eliminate hydrogen ions and by infection of the urinary tract by organisms containing an enzyme which promotes production of ammonia from urea.G.005.5 mmol/L of glucose is detectable. Decreased excretion Biliary tract obstruction. Infection is by far the commonest cause of urinary tract inflammation. changing colour when protein is added at a constant buffered pH. buffer.’ 5. e. Sensitivity / Specificity Quantitative test that detects urobilinogen concentrations as low as 3 µmol/L in urine. N. The test is more sensitive than the copper reduction test. Commonest Causes of Positive Results Liver cell injury. the result correlates within 0.5.g. hypokalaemia. in viral hepatitis and cirrhosis. which is not found in urine in the absence of a urinary tract infection. Commonest Causes of Positive Results Low values are found in acidaemia. fever. A negative result does not exclude infection.0 depending on the rate of elimination of hydrogen ions. Diabetic ketoacidosis (grossly uncontrolled insulin-dependent diabetes). Ketones Reagents sodium nitroprusside. The appearance of green spots on the reacted reagent pad indicates the presence of intact erythrocytes in urine. N. the sensitivity was 91. Reagents 2. carcinoma of the head of pancreas.5 mmol/L acetoacetic acid. Low values are found in individuals with intact renal function and high fluid intake. 3. biliary atresia in infants. In general. 4-dichloroaniline diazonium salt. in thalassaemias Nitrite Significance of Positive Results Most of the organisms which infect the urinary tract contain an enzyme system which catalyses the conversion of nitrate. The test is less sensitive in urines with a high S. paracetamol overdose.g. e. most often seen in children. Colours change from orange through yellow and green to blue. Chemical Principles This test is based on the conversion of nitrate (derived from dietary metabolites) to nitrite by the action of certain species of bacteria in the urine. chronic renal failure.B. green to green-blue for “positive” reactions. conversion of bilirubin to urobilinogen in the gut. 7 . as in viral or drug-induced hepatitis. Ketones Specific Gravity Significance of Positive Results Indicates accumulation of acetoacetate secondary to excessive breakdown of body fat. especially when acute inflammation of urinary tract. particularly with fever and/or vomiting. Chemical Principles This test is based on the principle that esterases found in granulocytic leucocytes catalyse the hydrolysis of a derivatised pyrrole amino acid ester to liberate 3-hydroxy-5phenyl pyrrole.5. Approximately 5. urinary tract infection with ammoniaforming organisms. including stones. Commonest Causes of Positive Results Fasting. 3. buffer.40619_PRACGUIDE_Rebrand. starvation.B. Free haemoglobin has either been excreted from plasma or liberated in-vivo or in-vitro from red cells in the urine. hypercalcaemia. Ketotic hypoglycaemia in young children. e. which catalyses the reaction of the reagent with the chromogen. (Prevents/reduces bacterial conversion of bilirubin to urobilinogen). Colours range from green to brown Chemical Principles Sensitivity / Specificity The test is specific for glucose. Specific Gravity Reagents bromthymol blue. polycystic kidneys.G.04. High values are found in alkalaemia (except when due to potassium depletion). Clinical Significance of Test Results pH Protein Urobilinogen Reagents methyl red: bromthymol blue: non-reactive ingredients. buffer. Sensitivity / Specificity The test determines the specific gravity of urines in the range 1.’ tetramethylbenizidine . which will detect 13. potassium iodide. tumours. e. Chemical Principles This test is based on the peroxidase-likeactivity of haemoglobin. Chemical Principles The test is based on a double sequential enzyme reaction utilising glucose oxidase and peroxidase with a potassium iodide Chromagen. diabetic ketoacidosis and lactic acidaemia. Haemoglobinuria (free haemoglobin) Severe haemolysis. In health the pH of uncontaminated urine varies between 4. Absence of urobilinogen cannot be determined by this method. renal tubular acidosis. due to vomiting and consumption of large amounts of antacids. buffer. Blood Reagents disopropylbenzene dihydroperoxide. by gall-stones. e. buffer. with a sensitivity of 13 to 22 µmol/L nitrite in urines of normal specific gravity. Reagents tetrabromphenol blue. increased production. Sensitivity / Specificity The test provides quantitative differentiation of urine pH in the range 5 to 8. Sensitivity / Specificity This test provides a semi-quantitative result for the presence of leucocytes. non-reactive ingredients.4% when compared with the chamber count of numbers of 10 and more cells/µL. For increased accuracy add 0.

e. May give false – Lodine (Etodolac) Hypochlorite or chlorine no effect false + false + Peroxide no effect false + false + Nalidixic false + no effect no effect Cephalosporins give black colours no effect no effect Probenecid false + no effect no effect High specific gravity no effect decreases sensitivity no effect Low specific gravity no effect intensifies colour no effect May give false + Positive or atypical colour. please contact our Technical Solutions Centre on: 0845 600 1955” 9 . Protein Highly buffered alkaline urines May cause false + Quaternary ammonium salts. Can also cause false + by reacting with reagent area.09:Layout 1 22/04/2009 09:42 Page 8 Factors Affecting Urine Chemistry Tests on Siemens Reagent Test Strips Glucose Bilirubin DIASTIX Reducing sugars other than glucose CLINITEST CLINISTIX (Multiple Strips) Galactose + no effect no effect Lactose Fructose Maltose + + + no effect no effect no effect no effect no effect no effect Pentose + no effect no effect High concentrations of L-Dopa may cause false + false – false – Ketones no effect no effect high concentrations May mask a small reaction (May give red and other colours) Phenothiazines High doses can cause hepato-cellular damage giving true + Chlorpromazine metabolites development.g.5 g/L protein Ferrous sulphate peroxidase Acid High protein diet – like activity gives + reaction Glucose Urea Urines containing glucose or urea greater than 1% may cause a low specific gravity reading relative to other methods Myoglobin Gives a + reaction Prolonged exposure of unpreserved urine at room temperature pH For increased accuracy. Presence of Cephalexin. 0. only measures red cells and.g. e. Ascorbic acid High concentrations reduce the sensitivity N.B.40619_PRACGUIDE_Rebrand. Ketones Mesna Red/Violet colour L-Dopa Atypical colours PKU (large quantities of phenylketones) + BSP Test (Bromosulphthalein) False + Phenazopyridine Atypical colour Captopril May give false + Specific Gravity Blood pH Protein Elevated readings may be obtained in the presence of 1-7.005 may be added to the readings from urines with pH equal to or greater than 6.04. Cephalothin. milk and other dairy products Prolonged exposure of unpreserved urine at room temperature Antacid buffers. since these readily lyse. Urobilinogen Nitrite Leucocytes PAS (p-aminosalicylic acid) metabolites Atypical colours Ascorbic acid Large quantities may cause false – reaction Decreased Test Results Elevated glucose concentration Azo dye metabolites Mask reaction (phenazo-pyridine gives an orange/red colour) High Specific Gravity Sensitivity is reduced High specific gravity Urine not freshly voided False – Lodine (Etodolac) May give false+ Azo dye metabolites (phenazopyridine) Could mask or mimic + reaction. rifampicin and phenazopyridine high concentrations moderate concentrations high concentrations may cause false + may cause false – may slightly depress colour development. The commonest cause of a so-called false-positive reaction for blood is that the laboratory method. microscopy. Chlorhexidine May cause false + Phenazopyridine May give atypical colour. development High doses of salicylates 8 false + false – false – “For technical and product support information or queries. Captopril May cause decreased reactivity. citrus fruits.5. oxalic acid or Tetracycline Masked colour reaction Nitrofurantoin (brown urine) Any substance that causes abnormal urine colour Boric Acid Inhibits reaction to varying degrees. Urine not freshly voided may depress colour Ascorbic acid Azo dye metabolites and other highly coloured compounds. a positive result for haemoglobin with the blood test can be obtained without any cells being present when the urine is ultimately examined under the microscope Ammonium chloride medication Alkaline Diet high in vegetables. Benzalkonium chloride.

40619_PRACGUIDE_Rebrand. ward or surgery.04. timely and cost-effective patient management in the clinic. and enables appropriate.09:Layout 1 22/04/2009 09:42 Page 10 Test Selection Made Easy Urinary Tract Infection Testing Pathway If ALL of the following are Creatinine Albumin NEGATIVE DISCARD Nitrite Leucocytes Blood or Protein Report as no evidence of infection Leucocytes Nitrite Urobilinogen Urine Specimen Protein Visual Appearance Clear Test with Multistix* 8SG/10SG If ANY of the following are pH POSITIVE Blood Nitrite Leucocytes Blood or Protein Specific Gravity Ketones Culture + Microscopy Culture + Microscopy Bilirubin 10 100 100 25 100 100 100 100 100 100 50 50 50 50 25 25 25 2304 Multistix* 8SG 2283 Multistix* GP 2740 N-Multistix* SG 2741 Multistix* SG 2743 Labstix* SG 2815 N-Labstix* 2814 Bili-Labstix* 2810 Labstix* 2877 Hema-Combistix* 2857 Uristix* 2872 Albustix* 2816 Hemastix* Microalbustix Clinitek Microalbumin Microalbumin 9 Obviously infected or blood stained 2300 Multistix* 10SG Code No Product Pack size Glucose This approach gives the power to confidently avoid sending noninfected urine samples for microscopy and culture. 11 .

uk/diagnostics Global Siemens Healthcare Headquarters Siemens AG Healthcare Sector Henkestrasse 127 91052 Erlangen Germany Telephone: +49 9131 84-0 www. is committed to providing clinicians with the vital information they need for the accurate diagnosis. Multistix and all associated marks are trademarks of Siemens Healthcare Diagnostics Inc. Please contact your local representative for availability. treatment and monitoring of patients. in conjunction with highly responsive service.siemens. Global Division Siemens Healthcare Diagnostics Inc 1717 Deerfield Road Deerfield.com/diagnostics .co. IL 60015 0778 USA www. Surrey GU16 8QD UK Telephone 01276 696000 E-mail: info. Siemens Global Headquarters Siemens AG Wittelsbacherplatz 2 80333 Muenchen Germany Local Contact Information Siemens Healthcare Diagnostics Ltd Sir William Siemens Square. the leading clinical diagnostics company.com www. Our comprehensive portfolio of performance-driven systems. unmatched menu offering and IT solutions.com/diagnostics Practical guide to urine analysis leaflet I Printed in UK I © 04/2009 Siemens Healthcare Diagnostics. enhance operational efficiency and support improved patient care.40619_PRACGUIDE_Rebrand. is designed to streamline workflow.siemens.diagnostics.09:Layout 1 22/04/2009 09:42 Page 12 Siemens Healthcare Diagnostics. Product and service availability may vary from country to country and is subject to varying regulatory requirements. Camberley.med.siemens. Frimley. All other trademarks and brands are the property of their respective owners.com/healthcare www.siemens.04.gb@siemens.