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©2008 Roche
Specific gravity 23
pH 25
Leukocytes 27
Nitrite 29
Protein (Albumin) 33
Glucose 37
Ketones 41
Urobilinogen 43
Bilirubin 47
2 Blood (erythrocytes/hemoglobin ) 49
3 Urine culture
Urine cytology with Testsimplets
60
63
4 Automated Urinalysis 64
5 Detection of Microalbuminuria
with Micral-Test 77
Appendix
The kidneys and the efferent urinary tract 81
Cell atlas – urine sediment/urine cytology 86
3
History of urinalysis with test strips
appearance of the humours. An illness urine (from crystal clear via camel hair
therefore also shows itself in the urine.” white, blackberry red, and pale green to
This doctrine dominated medical thinking black), and corresponding conclusions
up to the 16th century. In pathology the were drawn about the patient’s illness
teaching of Galen of Pergamum was in (Fig. 2). The development went so far that
fact abandoned only in the 19th century. all that was wrong with the human body
was believed to be reflected as in a mirror
In the 10th century the Arab physician in the urine specimen. This view served as
Isaac Judaeus, basing himself on Galen’s a basis for the “urine fortune-telling,”
humoralism, developed a scheme of hu- which was so caustically criticized by
mours with which he raised the urine humanistic physicians in the 16th century.
findings to the level of an almost infallible
diagnostic criterion for all states of dis- In the 16th century Paracelsus prompted
ease. The extreme consequence of this examination of the urine by the methods
theory was so-called uromancy or uros- of alchemy, but the thinking of his time,
copy practiced in the Middle Ages (Fig. 1), tinged by ideas of magic and astrology,
which according to modern views was prevented his proposals from developing
devoid of any scientific basis. Over 20 into forerunners of medical and chemical
shades of color were distinguished in the analysis of the urine.
4
History of urinalysis with test strips
5
History of urinalysis with test strips
6
Indications for urine test strips
Urine test strips are a central diagnostic the result is obtained quickly
instrument, their ease of use yielding the test is easy and inexpensive
quick and reliable information on patho- high sensitivity (diagnostic sensitivity)
logical changes in the urine. Their signi- sufficiently high diagnostic specificity
ficance lies primarily in first-line diag-
nostics. Routine testing of the urine with A field study carried out in seven Euro-
multiparameter strips, allowing a deter- pean countries with over 11,000 urine
mination of the complete urine status, is samples illustrates the value of screening
therefore the first step in the diagnosis of with urine test strips (Fig. 3). A pathologi-
a very wide range of disease pictures. cal urine finding (after checking for nitrite,
protein, glucose, ketones, urobilinogen,
Indications for urine test strips: and blood) was diagnosed in 16% of “nor-
screening within the framework of mal healthy persons,” in 40% of out-
routine examinations patients, and in 57% of hospitalized pa-
treatment monitoring tients.
self-monitoring by patients
general preventive medicine With the aid of routine examinations early
symptoms of the following three groups
are identified:
Screening within the framework diseases of the kidneys and the uri-
of routine examinations nary tract
Within the framework of routine examina- carbohydrate metabolism disorders
tions urine test strips are used for screen- (diabetes mellitus)
ing both in hospitals and in general prac- liver diseases and haemolytic disor-
tice. The aim of screening is early identifi- ders
cation of likely patients by examination of
large groups of the population. No direct Diseases of the kidneys and
diagnoses are established on the basis of urogenital tract
the screening results, which serve only as Screening parameters:
a basis for further microscopic, bacterio- leukocytes
logical, or clinicochemical examinations of nitrite
the urine. protein
blood
Urine test strips can satisfy all the specific gravity
requirements for effective screening: pH
7
Indications for urine test strips
Diseases of the kidneys and the urogeni- The following non-specific symptoms
tal tract often remain asymptomatic for a occur time and time again in patients with
long time. Renal function disturbances urinary tract infections or pyelonephritis
frequently lie dormant for many years, and require further clarification to avoid
leading eventually to often irreversible possible late consequences such as urae-
severe late damage. Kidney failure as the mia, hypertension, and cardiovascular
terminal stage of various primary and sec- complications:
ondary nephropathics (Fig. 4) can only be tiredness and exhaustion
treated by renal substitution therapy such chronic headaches
as dialysis or kidney transplantation. persistent lack of appetite
Effects are also possible on other organ loss of weight
systems, especially on the cardiovascular nausea and vomiting
system. The cardinal symptom of a urinary intermittent rises in temperature and
tract infection is the detection of signifi- fever of unclear origin (in children
cant bacteriuria (nitrite positive) and some 50% of urinary tract infections
leukocyturia (leukocytes positive) by are manifested by fever)
means of test strips. pale yellow skin color,
puffy appearance
“normal”
persons 16%
outpatients
40%
hospitalized
patients 57%
A field study carried out in seven European countries with over 11,000 urine samples
8
Indications for urine test strips
Cystic/polycystic
kidney diseases
7,5%
Others
10,9% Analgesics nephropathy
2,9%
Unclear Glomerulonephritis
origin 25,6%
14,6%
Pyelonephritis/ Source:
interstitial nephritis Demography of Dialysis and
18% Transplantation in Europe, 1993
9
Indications for urine test strips
10
Pre-analytical treatment and test performance
Reliable analytical results can only be Depending on the time and nature of the
obtained from a urine specimen that has urine specimen collection, a distinction is
been collected, transported and stored drawn between:
properly. To this day the diagnostic possi- spontaneous urine
bilities of urinalysis are often not utilized first morning urine (after a night’s
to the full because correct pre-analytical rest)
treatment cannot be ensured. second morning urine (collected
before noon)
Sample collection timed urine (usually 24-hour urine)
The urine collection and dispatch equip- midstream urine
ment should always comprise clean and bladder puncture urine
sterile disposable containers, made as a
rule from plastic. Important patient data The first morning urine has proved its
(surname, first name, date of birth, sender, worth for most test purposes. As a rule it
collection date and time) should be ensures sufficiently long residence of
affixed to the container in a waterproof urine in the bladder, and its composition
manner before the sample collection. is independent of the daily variations due
Wash hands. Take lid off First void a small Replace the lid
specimen container amount of urine on the specimen
and place into the toilet, container being
with inside surface then fill the specimen careful not to
facing upwards. container half full, touch the inside;
void remaining urine give the container
into the toilet. to the nurse or
laboratory.
11
Pre-analytical treatment and test performance
12
Pre-analytical treatment and test performance
13
Pre-analytical treatment and test performance
In sediment:
Bacteria 24 h Urinary pH Cells are lysed in
Casts 1–4 h Unstable dependence on pH and
Epithelial cells hours osmolality.
Erythrocytes 1– 4 h 1– 4 h Osmolality < 300 mmol/L
Leukocytes 1– 4 h 1– 4 h reduces storage stability
14
Pre-analytical treatment and test performance
15
16
Color/ Endogenous Suspicion of Exogenous causes
appearance causes Drug Foods Intoxications /
infections
17
Characteristics of urine test strips
from Roche
Nylon mesh
Reagent paper
Absorbent paper
Carrier foil
19
Characteristics of urine test strips from Roche
High sensitivity
An important evaluation criterion for the
quality of urine test strips is the practical
detection limit (Fig. 7), i.e. the concen-
tration of the substance determined at
which the test gives a positive result in
90 out of 100 different samples. The low-
er the detection limit, the more sensitively
can pathological changes be identified by
the test strip in question.
100
% positive results
90
50
practical
detection limit
concentration
of the analyte
0
20
Characteristics of urine test strips from Roche
21
Characteristics of urine test strips from Roche
Reference
1 High incidence of significant urinary ascorbic
acid concentrations in a West Coast popula-
tion – implications for routine urinalysis. Mal-
colm L. Brigden et al., Clin. Chem. 38 /3,
426 – 431 (1992).
22
Specific gravity
Clinical significance
The diagnosis of kidney function distur-
bances (e.g. a reduced concentration
capacity) by determining the specific
23
pH
Reference ranges
Course over the day: pH 4.8 –7.4
Morning urine: pH 5 – 6
pH
Test principle
Br Br Br Br
+ -
O OH –H O O
+
+H
- -
SO3 SO3
R R
- +
OH Phenolphthalein O Na
COOH + COOH
+ –H
N =N N(CH3)2 N=N N(CH3)2
+
H +H
red Methyl red yellow
Acidic urine: mixed color Orange Alcaline urine: mixed color green
25
pH
26
Leukocytes
Leukocytes
Test principle
O OH + HO
NH Esterase NH
O O
N SO2 N SO2
H H
Indoxyl ester Indoxyl
OH OH
+
+ N N R1-
N N N N
R2
H H
Indoxyl Diazonium salt Dye (violet) R2 R1
27
Leukocytes
pH values in the range of 4.5 – 9, explained on the one hand by the more
nitrite in the presence of urinary tract frequent occurrence of urinary tract in-
infections, ascorbic acid, and ketones fections in women and on the other by the
do not exert any influence risk of contamination of the urine spe-
cimens by leukocytes from a vaginal dis-
Sources of error charge. One must therefore reckon with
If the urine is strongly colored, this a positive leukocyte test in 30 – 40 % of
intrinsic color could mask the color spontaneous urine specimens from
formed by the strip reaction women.
Protein excretion in excess of 500
mg/dL and glucose excretion of over The great majority of positive leuko-
2 g/dL could lead to a weaker color de- cyte findings is due to the presence
velopment, as could high doses of ce- of a bacterial urinary tract infection.
phalexin and gentamicin
Preservatives falsify the test result If an inflammation is chronic or healed
(false-positive reading in the case of up, in particular, it is not rare to obtain a
formaldehyde, false-negative in case positive leukocyte reaction and yet fail to
of boric acid). Medication with imipe- find any bacteria in the urine. This condi-
nem, meropenem and clavulanic acid) tion is known as “abacterial” leukocyturia.
could lead to false-positive results. In chronic pyelonephritis leukocyturia is
often the only symptom in the intervals
Clinical significance between the acute episodes – the addi-
Leukocyturia is an important guide symp- tional symptoms associated with the
tom of inflammatory diseases of the kid- acute course, such as fever, kidney pains,
neys and efferent urinary tract, e.g. proteinuria and erythrocyturia, are absent.
bacterial infections: cystitis, urethritis,
acute and chronic pyelonephritis Abacterial leukocyturia can in addition
abacterial infections due to yeasts, constitute important evidence for the
fungi and viruses presence of tuberculosis or tumours.
parasite infestations, e.g. schistosomi-
asis Clarification of leukocyturia
glomerulopathies The following procedure is recommended
analgesics nephropathies for further differential diagnostics:
intoxications clarification of proteinuria, haematuria,
urine-voiding disturbances nitrituria
determination of the microbial count
Leukocyturia occurs substantially more microscopic examination of the sedi-
often in women than in men. This is ment for leukocyte casts
28
Nitrite
Nitrite
Test principle
+
+ - H +
+
OH H
H2N–SO2 N N + H2N – SO2 N=N
+
OH
N
H N
H
Diazonium salt Coupling component Azo dye (red)
29
Nitrite
False-positive results may be due to: Normal nutrition as a rule ensures a suffi-
bacterial contamination of urine left to ciently high content of nitrate in the urine
stand for too long for the detection of bacteria. The most fre-
treatment with medicines containing quent pathogen responsible for urinary
phenazopyridine tract infections, E. coli, and most of the
other urine-pathogenic organisms (Kleb-
Clinical significance siella, Aerobacter, Citrobacter, Salmonella,
Presence of nitrite in the urine is one of and to some extent also enterococci,
the most important symptoms of a bacte- staphylococci, and Pseudomonas) reduce
rial urinary tract infection. A positive test urinary nitrate to nitrite and can therefore
strip result in the nitrite field is a reliable be detected indirectly with test strips.
pointer to the presence of an acute infec-
tion.
30
Nitrite
Sex
Group
Normal
subjects 2.4 0.6 3.3 0.9 3.7 0.7 5.9 1.7 1.8 0.4 9.8 2.2
Outpatients 8.8 4.4 3.4 4.1 4.7 6.2 8.2 5.9 9.8 9.9 16.7 8.5
Inpatients 10.8 12.9 11.7 10.4 17.3 13.0 17.1 17.2 16.0 13.5 20.6 18.6
31
Protein (Albumin)
Protein
Test principle
Cl Cl Cl Cl -
O OH O O
Cl Cl Cl Cl
Protein
- -
Br SO3 -H
+ Br SO3
Br Br Br Br
Br Br
Yellow Green
3',3",5',5"-tetrachlorphenol- Anion of this compound
3,4,5,6-tetrabromsulfophthalein
(neutral form)
33
Protein (Albumin)
Daily course of
mg/h urinary protein excretion
3
Protein in urine, mg/h
0
000 400 800 1200 1600 2000 2400
34
Protein (Albumin)
35
Glucose
(< 30 mg/dL)
Glucose
Test principle
CH2OH CH2OH
O OH O
GOD
OH + O2 OH O + H2O2
HO H HO
OH OH
POD
H2N NH2 + H2O2 H2O + dye (blue)
3,3',5,5'-Tetramethylbenzidin
37
Glucose
Ketones do not interfere, and the pH of Other metabolic products and drug
the urine similarly does not exert any metabolites which have a reducing action
influence on the test result. However, be- and can exert an influence on the reac-
fore its analysis with test strips the urine tion, such as the degradation products of
must not be acidified. salicylates, normally occur only in small
amounts in the urine and cause inter-
Sources of error ference only in their sum.
The best known interference factor for
enzymatic glucose detection in urine, the False-positive results can occur as a
presence of ascorbic acid (vitamin C), has result of the presence of residues of per-
been largely eliminated in this test. At oxide-containing or other strongly oxidiz-
glucose concentrations of 5.5 mmol/L ing cleaning agents in the urine contain-
(100 mg/dL) and higher even high ascor- er.
bic acid contents practically never lead to
false-negative test results. Clinical significance
The determination of glucose in urine has
a high diagnostic value for early detection
mg/min
Renal threshold for glucose
600
Amount of glucose transported
n
tio
400 fi ltra
ru lar
me
Glo
tion
r resorp
Tubula
Renal threshold
200
tion
ose excre
y gluc Glucose concentration
Urinar in plasma
0
0 100 200 300 mg/100 mL
38
Glucose
of diabetes mellitus and for course control hold, which in diabetics is on average
or self-monitoring by patients. On the oth- higher than in healthy persons. In older
er hand, absence of glucosuria does not patients in particular the renal threshold
exclude a disturbance of the glucose is often so high that no glucose appears in
metabolism, and in particular it does not the urine despite diabetic blood glucose
exclude diabetes mellitus. Another point levels.
to note is that glucosuria may also be due
to clinical conditions other than diabetes. In spite of all these restrictions, detection
of urinary glucose is of major significance
Glucosuria develops when the tubular for early detection, control, and self-mon-
reabsorption of glucose in the kidneys itoring of diabetes.
(the renal threshold) is exceeded (Fig. 15).
The renal threshold is normally at a blood The following conditions are seen as risk
glucose level of 150 –180 mg/dL (8.3 –10 factors for diabetes mellitus:
mmol/L), but it is often elevated in older obesity
people and in persons who have had dia- hyperlipoproteinaemia
betes mellitus for many years. hyperuricaemia
gout
Diabetes mellitus hypertension
Every second to third diabetic has not coronary, cerebral, and peripheral
been identified. The reason for this is the blood flow disorders
paucity of symptoms at the beginning of diseases of the liver and the bile tract
the disease. Older diabetics in particular chronic urinary and respiratory tract
tend to view their complaints, such as infections
quick fatigability, frequent passage of chronic skin diseases
urine, slow healing of wounds, and failing
visual acuity, as part of the “normal age- Further risk factors are:
ing process” and never suspect that the Age over 40
underlying cause might be a metabolic Familial predisposition to diabetes
disease. However, early diagnosis is of Mothers of children with a large
decisive importance, because early treat- weight at birth (over 4.5 kg)
ment can prevent or at least postpone the
delayed damage. Renal glucosuria
If the renal threshold is significantly lowe-
Most diabetics exhibit glucosuria. The red owing to reduced glucose reabsorp-
degree of the glucose excretion depends tion in the renal tubules, increased glu-
on the severity of the metabolic distur- cose excretion will be found in the urine
bance and on the individual renal thres- even if the blood glucose is normal, below
39
Glucose
40
Ketones
Ketones
Test principle
O O
Na2 [Fe(CN)5NO] + CH3–C–R + NaOH Na3[Fe(CN)5N=CH–C–R] + H2O
OH
41
Ketones
takes place in the organism owing to All diabetics should check their urine for
insufficient supply of energy in the form of ketones on a regular basis. In juvenile and
carbohydrates. insulin-dependent diabetics in particular,
in whom coma may develop within a few
Predominance of lipolysis over lipogenesis hours, a check for ketones in urine should
leads to increased free fatty acid levels in therefore always form part of self-moni-
serum, and on their breakdown in the liv- toring, side by side with the checks on
er more acetyl-coenzyme A is formed than urinary glucose.
can be utilized by other metabolic pro-
cesses, e.g. the tricarboxylic acid cycle. Progressive ketoacidotic metabolic dys-
This excess is converted into acetoacetic regulation may occur if the diabetic
acid, which in turn is partly transformed patient is not sufficiently well managed
into β-hydroxybutyric acid and to a with insulin. The condition is character-
smaller degree into acetone. ized by ketone excretion in urine, an
odour of acetone on the breath, and
Ketonuria in diabetes mellitus increased urinary levels of glucose.
Detection of ketones in the urine (aceto-
acetic acid and acetone) is particularly
important in diabetes mellitus for check- Ketonuria of non-diabetic origin
ing metabolic decompensation. Ketones are also found in the urine in the
following situations:
Precomatose and comatose states in dia- Fasting states
betes are almost invariably accompanied Slimming diets low in carbohydrates,
by ketoacidosis, with the exception of or protein-rich nutrition, or total star-
hyperosmolar comas. Relative or absolute vation diets. The acid-base turnover,
insulin deficiency causes reduced glucose however, remains fully compensated if
utilization in fat and muscle cells and trig- good kidney function is ensured by
gers increased lipolysis. The resulting sufficient intake of fluids. Checking for
ketones in combination with other patho- ketones also serves in such cases as a
physiological changes of the dysregula- control of compliance with the diet
ted metabolism (dehydration, electrolyte Acetonaemic vomiting in small
shifts) can lead to diabetic coma. children
Fever, especially in the presence of
Diabetic coma is a life-threatening event, infectious diseases
and ketonuria is an early symptom of the Pernicious vomiting in pregnancy
metabolic dysequilibrium. Congenital metabolic diseases
42
Urobilinogen
Urobili-
nogen
Urobilinogen
Test principle
+ -
H3C–O N N BF4 + Urobilinogen Acid Azo dye (red)
medium
Diazonium salt
43
Urobilinogen
44
Urobilinogen
45
Urobilinogen
46
Bilirubin
Bilirubin
Test principle
Cl
+ - Acid
N N BF4 + Bilirubin Azo dye (red-violet)
medium
Cl
Diazonium salt
47
Bilirubin
48
Blood (erythrocytes/hemoglobin)
Blood
Test principle
Blood
CH3 CH3
CH3 CH3
OOH OOH
CH3 CH3
2,5-Dimethylhexan- 3,3',5,5'-Tetramethylbenzidin
2,5-dihydroperoxid
CH3 CH3
Hemoglobin
CH3 C CH2 CH2 C CH3 + dye (blue-green)
Myoglobin
OH OH
49
Blood (erythrocytes/hemoglobin)
50
Blood (erythrocytes/hemoglobin)
Kidney stone
Pyelonephritis
Ureteral tumour
Ureteral stone
51
Blood (erythrocytes/hemoglobin)
52
Blood (erythrocytes/hemoglobin)
53
The test strip sieve
Test-strip finding 3
Leukozyturie Haematuria Proteinuria Nitrituria pH>7
All results negative, no suspicious signs in the One or more of the test strip results
medical history or the clinical picture: are positive:
no further urinalysis necessary. indication for targeted microscopic
Microscopic examination of the urine can thus and/or bacteriological examination
be avoided in about half of the cases. of the urine.
Fig. 21: Rational urine diagnostics according to the Ò t est strip sieve ” concept
55
The test strip sieve
approximately 95%, while in the case of Cell lysis is accelerated by the following
sediment analyses only about 80 – 85% of conditions:
relevant urine specimens can be recog- low specific gravity or osmolality of
nized as conspicuous. the urine
high pH (pH > 7)
The “test strip sieve” does not detect var- long standing time of the urine
ious types of crystalluria and hyaline (> 2 hours)
casts, but the diagnostic informative pow- high room temperature
er of these parameters is low.
In contrast, the haemoglobin from ery-
Microscopy/test strip comparison throcytes and the esterase from leuko-
Test strips allow a direct or indirect detec- cytes are still detectable with urine test
tion of the microscopic elements listed in strips after several hours. Moreover, the
Fig. 22. centrifugation of the urine specimen nec-
essary for subsequent microscopy leads
For red and white blood cells the two to an appreciable loss of the cells.
methods are in good agreement, as long
as the cells are still intact and micro- The concentration values on the test color
scopically detectable. scales and the reflectance photometric
printouts of the results (erythrocytes/µL,
With increasing lysis low or false-negative leukocytes/µL) for test strips are based on
results are obtained in the microscopic comparisons with chamber counting. The
examination. conversion into numbers of cells per high
power field is inexact, because sediment
examination has still not been standard-
ized and its result is influenced by various
factors such as the sample volume or the
duration of centrifuging.
56
Microscopic assessment of the sediment
57
Microscopic assessment of the sediment
Reference interval: 0 – 5 per field of view, Hyaline casts are transparent, colorless,
> 30% of dysmorphic and structureless formations of Tamm-
erythrocytes points to Horsfall protein, a mucoprotein secreted
their glomerular origin. by the distal tubules. They often appear in
the urine following physical exertion, pro-
Leukocytes longed standing, or fever, and they have
Almost exclusively granulocytes (diameter no diagnostic significance.
10 –12 µm).
Sources of error: In the case of women Granular casts are observed most often
spontaneous urine in the presence of chronic glomeru-
gives up to 40% of lonephritis. Droplets of plasma proteins or
false-positive results fragments of lysed cells are included in
due to vaginal contam- the matrix.
ination.
58
Microscopic assessment of the sediment
Leukocyte casts similarly point to a Fat droplets are as a rule due to contam-
renal origin of the leukocyturia, which can ination with ointments, residues of sup-
be differentiated from a leukocyturia due positories, or catheter lubricants.
to cystitis or a vaginal discharge.
Crystals are usually treated as artefacts
Epithelial casts consist of desquamating because they are only formed pH-
tubular epithelium and are indicative of dependently in cooled urine on standing.
ischaemically or toxically determined tu- Diagnostic significance is attributed only
bule cell necroses. With time they degen- to the extremely rare crystals of cystine
erate to granular and finally wax-like (colorless hexagonal plates), leucine (yel-
casts. low-brown spheres with radial banding),
and tyrosine (clusters of fine, colorless,
Renal insufficiency casts are 2–6 times shiny needles).
as wide as the other cylindrical casts. They
are formed in dilated tubules or in collecting Fungi (most often yeasts) are usually the
tubules when the flow of urine has been result of contamination; fungal infections
strongly slowed down. are rare.
59
Urine culture
Pre-packed immersion nutrient media are The excess urine is allowed to flow off
suitable for primary culture and for micro- the medium carrier; the last few drops
bial count determinations of gram-posi- on the lower edge of the carrier held
tive and gram-negative bacteria, and also vertically are removed by suction
as a medium for transport between the using a swab.
doctor and the test laboratory. CLED agar The nutrient medium carrier is next
can be used for growing all organisms, placed back in its tube and incubated
and it is particularly good for urinary tract for 16 – 24 hours at 35 – 37 °C.
pathogens. MacConkey agar largely sup-
presses the growth of gram-positives with
the exception of enterococci. Proliferation
of Proteus is largely suppressed on both
these agars. Other nutrient media are also
available, e. g. for selective growth of
Pseudomonas. Gonococci, mycobacteria,
and other relevant organisms do not grow.
60
Urine culture
61
Urine culture
Interpretation Remark
If each side of the nutrient medium The nutrient medium carriers must be
carrier shows < 10,000 organisms/mL, kept in unopened tubes at 15 – 25 °C
the specimen has most probably been until the expiry date. They must not
contaminated and the result is not be frozen. Carriers showing signs of
significant. mould or bacterial growth must not be
The bacteriuria is significant when used. Water of condensation does not
both sides of the carrier give a count interfere as long as the nutrient layer
of over 100,000 organisms/mL. is not appreciably shrunken.
This reference value applies when
only one organism is present; if there
are two or more species the bacteri-
uria is again usually due to contami-
nation.
Further procedure
The nutrient medium carriers must
be dispatched to the test laboratory
within 24 hours.
As a rule the frequently encountered
local pathogens such as enterobacte-
riaceae, non-fermenting gram-nega-
tive bacilli, staphylococci, streptococci,
and fast growing Candida strains are
routinely cultured. Less frequent
microorganisms, such as Mycoplasma,
Mycobacteria, and anaerobes are cul-
tured only when this is specially
requested. Resistance tests are done
in the usual way.
62
Urine cytology with Testsimplets
63
Automated Urinalysis
Urisys 1100
Parameter
Specific gravity 610 nm
pH 610 nm / 565 nm
Leukocytes 565 nm
Nitrite 565 nm
Protein 565 nm
Glucose 565 nm
Ketone 565 nm
Urobilinogen 565 nm
Bilirubin 565 nm
Erythrocytes 610 nm
Compensation 565 nm
Table 3: Wavelengths
64
Automated Urinalysis
in-built container are automatic. The improved accuracy near the limit of detec-
results are automatically saved in the tion.
memory and printed out.
In calculating the result, a correction for
Fully automatic urinalysis systems interference by the intrinsic color of the
Manual dipping and insertion of the test urine is made by measuring a blank field
strips is not necessary. The urine samples on the test strip (compensation field). In
are applied from sample tubes using a addition, the result of the Specific Gravity
rotor or rack. Sample identification, the test is automatically corrected if the pH is
test procedure and disposal of the used high.
test strips into an in-built container are
fully automatic. The results are automati- Although urinalysis systems using reflec-
cally saved in the memory and printed out. tance photometry evaluate the test field
color changes with high precision, it is not
Urinalysis systems evaluate test strips by possible to completely eliminate all differ-
reflectance photometry using selective ences in the composition of the sample
light-emitting diodes with a wavelength material which could have an effect on
and measurement time tailored exactly to color development, so urinalysis systems –
the chemical reaction and color develop- unlike instruments for the measurement
ment of the test field concerned. Compar- of blood glucose or Reflotron – only yield
ed with visual assessment, this produces semi-quantitative results.
620 nm 650 nm
620 nm / 555 nm 620 nm / 555 nm
555 nm 555 nm
555 nm 555 nm
620 nm 555 nm
555 nm 555 nm
555 nm 555 nm 4
555 nm 555 nm
555 nm 555 nm
620 nm / 555 nm 620 nm / 555 nm
555 nm 555 nm
65
Automated Urinalysis
As well as correct determination of the system, Urisys 1800 was launched in 2004
test strip result with the objective of and received an update to cobas u 411
achieving a high level of standardization, system mid of 2007.
urinalysis systems must fulfil the data-
processing requirements of the laboratory The compact Urisys 1100 system enables
environment. The urinalysis systems sup- even the medical practice, the small hos-
plied by Roche can be connected to bar- pital laboratory or hospital ward to make
code scanners for automatic sample iden- use of the advantages of instrumental
tification and to external printers to print urinalysis.
the findings, and the results of the meas-
urements can be transferred to the labo-
ratory computer system or PC. Fully auto-
matic urinalysis systems such as Urisys
2400 and semi-automatic systems such as
Miditron M and Miditron Junior II have
already proved themselves over a period
of years in the hospital laboratory. As a
logical development of Miditron M a new
Detector
orange green
Test strip
66
Automated Urinalysis
3 Detector 5 Microprocessor
4 Analogue-digital converter
1 LED
6 Result
The LED (1) emits light of a defined wave- Finally, the system compares the reflec-
length on to the surface of the test pad (2) tance values with the defined range limits
at an optimum angle. The light hitting the (reflectance values that are programmed
test zone is reflected from the surface in the analyzer for each parameter) and
more or less intensely depending on the outputs a semi-quantitative result (6). Re-
color produced on the test pad, and is sults can be printed out or transferred to
picked up by the detector (3), a photo- the laboratory computer system.
transistor positioned directly above the
test zone. The phototransistor sends an Before each measurement the optical sys-
analogue electrical signal to an A/D con- tem is tested and corrected for variations
verter (4), which changes it to digital form. in LED brightness and detector sensitivity
The microprocessor (5) then converts this using internal reference settings. The cor-
digital reading to a relative reflectance rect positioning of the test strip under the
value by referring it to a calibration stan- optical system is checked during the
dard. measurement. If the strip is not in the cor-
rect position the result is not printed out,
and the instrument instead asks for the
measurement to be repeated.
67
Automated Urinalysis
68
Automated Urinalysis
69
Automated Urinalysis
70
Automated Urinalysis
71
Automated Urinalysis
72
Automated Urinalysis
73
Detection of microalbuminuria
with Micral-Test
Detection field
Capture zone
Conjugate fleece
Covering foil with
depth-of-immersion mark
Liquid reservoir
75
Detection of microalbuminuria with Micral-Test
76
Detection of microalbuminuria with Micral-Test
77
Detection of microalbuminuria with Micral-Test
Micral-Test
Scheme of the reaction
G + G
Antibody-gold Albumin Antigen-
conjugate (red) (antigen) antibody
complex
Micral-Test
Scheme of the reaction
G +
Flees
Excess Immobilized Immobilized
antibody-gold albumin antigen-antibody
conjugate complex
Micral-Test
Scheme of the reaction
G
The red antibody-gold conjugate charged with albumin from the urine causes a white to red
coloration of the detection field, depending on the albumin concentration in the specimen.
78
The Kidneys and the Efferent Urinary Tract
The urinary apparatus is made up of: dropwise to the renal pelvis as urine. The
two kidneys urine then passes into the ureters and
two ureters through them into the bladder. The blad-
the urinary bladder der is a muscular hollow organ in which
and the urethra urine is collected. The amount of urine
finally excreted daily through the urethra
The kidneys are the most important is approximately 1.5 L.
excretion organ in the human organism.
Every 24 hours around 1500 L of blood
flow through the kidneys, which filter off Function and importance of the
daily 170 L of primary urine from this urinary organs
blood volume. Primary urine is a blood The organs of the efferent urinary tract
“ultrafiltrate” and consists of water, salt, comprise:
and dissolved low-molecular blood con- the renal calices
stituents. The water is largely reabsorbed, the renal pelvis
and all substances needed by the organ- ureters
ism are taken up again. The remaining bladder
“worthless” substances are conveyed the urethra
Kidney
Ureter
Bladder
Urethra
79 6
The Kidneys and the Efferent Urinary Tract
Ureters
The ureters have a length of 24 to 34 cm
as measured from the renal pelvis to the
point at which they enter the bladder.
Urine is conveyed down into the bladder
by peristaltic contractions of the ureters.
Bladder
The bladder is an elastic muscular hollow
organ in which the urine is collected.
Urine is voided by muscular contractions
of the bladder wall, the abdominal wall,
and by the muscle tone of the elastic sys-
tem.
Urethra
The urethra is the final excretion channel
for urine. The female urethra is shorter
than the male, and this is the reason
why urinary tract infections are more
common in women than in men.
80
The Kidneys and the Efferent Urinary Tract
Pyramids
Renal artery
Renal pelvis Renal papillae
81
The Kidneys and the Efferent Urinary Tract
Nephrons
The kidney consists of 1– 3 million tubular
structures known as nephrons. The
nephrons can be subdivided further into
glomerular and tubular sections. They are
closely packed and form the renal pa-
renchyma (the cortex and the medulla).
Bowman’s capsule
Glomerulus
Renal tubule:
Proximal convoluted tubule
Collecting tube
Distal convoluted tubule
Henle’s loop
Fig. 30: The nephron with its glomerular and tubular sections
82
The Kidneys and the Efferent Urinary Tract
83
Epithelial cells Urine sediment
Fig. 1: Group of pavement epithelium cells (×1000). Fig. 2: Pavement epithelium cells, transitional epitheli-
These are the largest cells encountered in urinary sedi- um cells (urothelial cells) (×450).
ment (30–50 µm).
Fig. 3: Binuclear transitional epithelium cells (×1000). Fig. 4: Group of transitional epithelium cells (×1000).
Urothelial cells measure about 20–30 µm, easily take up Exfoliation of urothelial cells may be indicative of a
water, and are usually the plumpest structures encoun- pathological process in the lower part of the urinary
tered. tract.
Fig. 5: Group of suspicious urothelial cells (×1000). Fig. 6: Group of about 15 urothelial cells (×1000).
In addition to various signs of malignancy the cells
show a dysplastic vacuolated cytoplasm.
84
Urine sediment Tubular epithelium cells
Fig. 7: Epithelial cells probably of tubular origin (×1000). Fig. 8: Three epithelial cells probably of tubular origin
Identification of renal epithelial cells is often difficult. (×1000).
The characteristic cell clustering and the cylindrical
form point to tubular origin.
Fig. 9: Tubular epithelium cells, dysmorphic erythro- Fig. 10: Tubular epithelium cells (×450).
cytes, and a leukocyte (×1000). The occurrence of tubular epithelium cells in large clus-
The cylindrical cells have eccentric nuclei and a weakly ters is unusual.
expressed brush border.
Fig. 11: Degenerating tubular epithelium cells (×1000). Fig. 12: Tubular epithelium cells (“fat granule cells”)
Phagocytosis of considerable amounts of urine consti- (×1000).
tuents leads to cell overloading and degeneration. The As a result of excessive lipid storage these cells are
non-functional epithelial cells are then excreted in clearly larger than other tubular epithelium cells and
urine. point to a severe renal function disturbance.
85
Eumorphic erythrocytes Urine sediment
Fig. 13: Eumorphic erythrocytes, leukocytes (×1000). Fig. 14: Eumorphic biconcave erythrocytes (×1000).
Morphologically normal so-called eumorphic subrenal Eumorphic erythrocytes not showing the cell membrane
erythrocytes show that a disorder of the efferent urinary alterations typical in erythrocytes of renal origin.
tract is present.
Fig. 15: Eumorphic erythrocytes (×400). Fig. 16: Eumorphic erythrocytes, round epithelial cells
(×1000).
Juvenile erythrocytes with typical biconcave form; some
of the cells show a transition to a crenated form.
Fig. 17: Eumorphic erythrocytes (×1000). Fig. 18: Eumorphic erythrocytes (×1000).
Erythrocytes change their form depending on the sur- In alkaline or hypotonic urine erythrocytes swell up and
rounding osmotic pressure gradient. In concentrated undergo haemolysis. The cell-membrane residues are
hypertonic urine they shrink very quickly and appear in called erythrocyte shadows.
a crenated form.
86
Urine sediment Dysmorphic erythrocytes
Fig. 19: Dysmorphic erythrocytes (×1000). Fig. 20: Dysmorphic erythrocytes (×1000).
Erythrocytes that have undergone morphological Morphological abnormalities of the erythrocyte mem-
changes in the kidneys are designated as “dysmorphic.” brane are probably attributable to sustained changes in
pH and osmolality in the tubule system.
Fig. 21: Various kinds of dysmorphic erythrocytes (×1000). Fig. 22: Dysmorphic erythrocytes (×1000).
Erythrocytes of glomerular origin can point to the pres- Erythrocyte shadows of glomerular origin (see Fig. 18,
ence of a very wide range of morphological abnormali- subrenal erythrocyte shadows).
ties.
Fig. 23: Dysmorphic erythrocytes (×1000). Fig. 24: Dysmorphic erythrocyte (×1000).
Erythrocyte shadows of glomerular origin (see Fig. 18, Blue field: interference contrast microscopy; brown
subrenal erythrocyte shadows). field: light-field microscopy.
87
Leukocytes Urine sediment
Fig. 25: Neutrophilic polymorphonuclear granulocytes Fig. 26: Leukocytes, yeast cells (×400).
(×1000). An opportunistic infection with Candida albicans is a
These are easily recognizable by their segmented nuclei relatively frequent finding.
and, when present in large numbers, point to an inflam-
matory disease in the urogenital tract.
Fig. 27: Leukocytes, pavement epithelium cells (×1000). Fig. 28: Leukocytes, erythrocytes, bacteria (×1000).
In women large numbers of pavement epithelium cells Signs of cytolysis are evident in both erythrocytes and
and granulocytes in the sediment of spontaneous urine leukocytes (alkaline reaction of the urine in bacterial
may be due to a vaginal contamination. infections).
Fig. 29: Leukocytes, urothelial cells (×400). Fig. 30: Leukocytes, triphosphate, bacteria (×400).
Urinary sediment with characteristic signs of an acute Triphosphate crystals are often encountered in infected
or chronic urinary tract infection. alkaline urine, but they can be indicative of obstructed
urine flow.
88
Urine sediment Casts (1)
Fig. 31: Hyaline cast (×400). Fig. 32: Small leukocyte cast (×1000).
Hyaline casts, which can also occur in the urine of Leukocyte casts are pathognomonic for pyelonephritis.
healthy persons, are often overlooked because of their
low refractive index.
Fig. 33: Leukocyte cast (×400). Fig. 34: Erythrocyte cast (×1000).
A prerequisite for the formation of leukocyte casts is Erythrocyte casts are pathognomonic for glomeru-
increased intrarenal excretion of leukocytes in patholo- lonephritis.
gical proteinuria.
Fig. 35: Erythrocyte cast (×1000). Fig. 36: Mixed erythrocyte cast (×1000).
The erythrocytes are partly embedded in a matrix of a Hyaline cast with dysmorphic erythrocytes, tubular
hyaline cast and partly attached to a finely granulated epithelium cells, and granular material on the cast sur-
surface. face.
89
Casts (2) Urine sediment
Fig. 37: Epithelial cast (×400). Fig. 38: Finely granular cylindrical cast (×400).
Epithelial casts occur very rarely in sediment. They con- Granular casts are encountered in nearly all forms of
sist of desquamated tubular epithelium cells bound into specific kidney diseases.
the matrix of a hyaline cast.
Fig. 39: Coarsely granular cast (×400). Fig. 40: Granular cast (×400).
Helically twisted cylindrical cast with coarsely granular Extended granular cylinder with many embedded dys-
material (weakly discernible cell structure). morphic erythrocytes.
Fig. 41: Extended waxy cast (×400). Fig. 42: Waxy cast (×100).
A number of dysmorphic erythrocytes adhere to the Cylindrical waxy casts are always indicative of severe
“waxy” surface of the cast, which is surrounded by ab- chronic kidney diseases (advanced renal failure).
normal sediment structures.
90
Urine sediment Histiocytes, bacteria, carcinoma cells
Fig. 43: Histiocyte (× 1000). Fig. 44: Bacteria on a pavement epithelium cell (×1000).
Histiocytic exhibit substantial variations in size. They Bacteria are often encountered on the surface of large
usually contain numerous vacuoles, granules and other epithelial cells. If neither inflammation sources nor
phagocytic material. protein can be found, the bacteria are usually due to
contamination.
Fig. 45: Group of yeast cells (×1000). Fig. 46: Urothelial carcinoma cells (×1000).
Free-swimming yeast cells are easily confused with ery- In the presence of large groups of urothelial cells there
throcytes or fat droplets. Attention should be paid to is always a suspicion of a tumour in the region of the
branching hyphae and to clumps of budding yeast cells. efferent urinary tract.
Fig. 47: Cells of a poorly differentiated bladder carcino- Fig. 48: Group of urothelial carcinoma cells (×1000).
ma (×1000). Characteristic features of malignancy: complete loss of
Characteristic features of malignancy: anisocytosis and cytoplasm in some cells, aniosocytosis and nuclear
nuclear polymorphism, disturbed nucleus/cytoplasm polymorphism, thick cell nucleus membrane.
ratio, hyperchromatism of the cell nuclei or the cell
walls, multiple nucleoli.
91
Urine Cytology
Normal urothelial cell surrounded by erythrocytes Bladder carcinoma G3, dedifferentiated cells with
large nuclei, vacuoles, and nucleoli
Bladder carcinoma G2, hyperchromatic nuclei, Bladder carcinoma G3, some hyperchromatic nuclei,
numerous nucleoli, destructive changes in the cyto- small cells, multiple nucleoli, hyperchromatism of
plasm, several leukocytes in the surrounding region the nucleus walls
92
Glossary of Specialist Medical Terms
Adiposity Obesity
Apoplexy Stroke
93
Glossary of Specialist Medical Terms
94
Glossary of Specialist Medical Terms
Dilated Expanded
95
Glossary of Specialist Medical Terms
Epithelial cells Cells of the topmost tissue layers; urogenital epithelial cells
are a constituent of urinary sediment
96
Glossary of Specialist Medical Terms
97
Glossary of Specialist Medical Terms
98
Glossary of Specialist Medical Terms
Intoxication Poisoning
99
Glossary of Specialist Medical Terms
100
Glossary of Specialist Medical Terms
101
Glossary of Specialist Medical Terms
102
Glossary of Specialist Medical Terms
Semi-permeable Semi-penetrable
Transient Temporary
103
Glossary of Specialist Medical Terms
Vasoconstrictive Vessel-narrowing
104
Further Reading
105