CHAPTER

QUALITY CONTROL PROGRAMS

FOR URINARY SEDIMENT
S. Secchiero and G.B. Fogazzi

This chapter describes the Quality Control programs which can be used for urinary
sediment. The purpose of these programs is to obtain an examination of the urinary sediment
of good and reliable quality [1,2]. Internal Quality Control (IQC) and External Quality
Assessment (EQA) Programs integrate each other.

Internal Quality Control

An Internal Quality Control (IQC) for urine microscopy should be done each day the test
is performed and should adhere to the following recommendations [2]:
- All personnel should follow the same documented procedures using the same
equipment, use the same terminology and report results in the same standard format
- Duplicate urine sample examination should be used as a precision check for the
identification of the particles. Alternatively, control solutions containing erythrocytes
or leukocytes, which are commercially available could be used
- In case of disagreement about the presence or quantity of a microscopic element the
examination should be repeated and a shared conclusion should be reached
- Unexpected control results should be identified, and appropriate corrective action
should be taken
- Recent reference texts, atlases, papers or online documents should always be available
for consultation, and experts opinion should be asked for in case of difficult and/or
doubtful findings
In order to fulfil these recommendations, in the laboratory of the Renal Unit of Ospedale
Maggiore-Policlinico, Milano, where one of the authors of this chapter (F.G.B.) works:
-All the procedures and terminology used are standardized and written in detail in a
document which is kept on a shelf over the workbench.

S. Secchiero and G.B. Fogazzi

- The microscope is adjusted according to Khler principle (see Appendix) and phase
contrast is centred every time the examination of the urinary samples is started. In
addition, a regular servicing of the microscope is done once a year by a specialized
technician.
- The exchange of opinions on difficult or doubtful findings is encouraged and regularly
done among the four persons who rotate on urine sediment examination.
- Once or twice a week, some samples, chosen among the most pathologic ones, are
reviewed for a check by the most expert microscopist of the group.
- All special and interesting findings are documented through a digital camera
permanently mounted on the microscope and filed though a dedicated program. in the
computer.
- A specialized library containing several hundreds of scientific papers on various
aspects of the urinary sediment examination and 16 atlases in different languages on
the same subject is kept in shelves close to the microscope for consultation.

External quality control

Medical laboratories have a long tradition in the organisation of external EQA programs,
which started in 1947, when Belk and Sunderman published the results of a clinical chemistry
survey in the US [3].
Today, EQA programs are a key instrument for the improvement of laboratory quality,
and for some disciplines they are an integral part of laboratories overall quality assurance
systems [4]. However, in spite of numerous documents and papers which stress the importance
of designing appropriate EQA schemes [4-10], several laboratorys fields still lack EQA
programs.
EQA surveys on urinalysis are rare [11-13]. Of the few existing programs, some deal with
test strips and quantitative clinical chemistry analytes [12], while others also cover urinary
sediment.
The latter topic is included in the program run by Labquality, a Finnish non-profit EQA
scheme organisation which provides surveys also for Norway, Baltic states and Poland.
Urinary sediment is also included in the program run in Italy by the Centre of Biomedical
Research (CRB), which is an EQA scheme organisation with many programs in different
fields of Laboratory medicine (www.centroricercabiomedica.it).
Interestingly, the College of American Pathologists (CAP) has recently introduced an EQA
program focused on the new aspects of urinary sediment examination which are associated
with the use of automated analyzers (see Chapeter 7).

Features of the Italian EQA Program Urinalysis Performance

The Italian EQA program, called Urinalysis Performance was set up in 2001 by a
promoting Committee which included the representatives of the three Italian societies of

Quality control programs for urinary sediment

Laboratory Medicine and of the Italian Society of Nephrology [14].

This program is the first, and to date the only, Italian project for the standardisation of
urine analysis. It is addressed to Italian central laboratories, both public and private, and to
renal laboratories.
The aims of the program are: the evaluation of the laboratories performances; the training
support to the participants; the improvement of the efficiency and efficacy of urinary sediment
examination.
Urinalysis Performance includes two parts: one on test strips (which is not dealt with in
this chapter), the other on urinary sediment.
The part on urinary sediment is under the guidance and responsibility of one of us (F.G.B.),
who prepares and selects the images and also evaluates the answers of the participants at
each survey.
Today, the program consists in 4 surveys/year.

- Surveys 1 and 3. Each of these surveys shows two urine sediment particles. Each particle
is shown by both bright field and phase contrast microscopy and, when indicated (e.g., crystals
or lipids), also by polarized light (Figure 8.1). The choice of showing the particles by the three
types of microscopy has a twofold motivation: (i) bright field microscopy was, and still is, the
method most widely used in routine practice and (ii) phase contrast microscopy and polarized
light are the method recommended by international guidelines for everyday work (1,2).
For each survey, the participants are asked to identify the particles shown. Moreover, for
one of the two particles (selected by the responsible of the program), they are also asked to
indicate one clinical association, chosen among 4 or 5 possible options.
Over the years, in order to verify whether the program was able to achieve an improvement
in the identification capability of the participants some particles were presented twice by the
means of similar but not identical images.
- Surveys 2 and 4. Each of these surveys present a clinical case. These cases were
introduced because laboratory medicine is moving towards a clinical support service, and
Guidelines and standards emphasise the importance of adding appropriate comments and
interpretation of results to medical reports and their assessment (15-21).
Clinical cases consist in a brief clinical history, which also included some key laboratory
data and four phase contrast microscopy images of particles found in the urine sediment of
the case presented (Figure 8.2). Also for clinical cases the participants are asked to identify
the particles shown and to choose one possible clinical diagnosis among 4 to 5 proposed.
For each survey the answers obtained are then evaluated as correct, incorrect, partially
correct, and no answer, and scored accordingly (5, 3, 0, and -2 respectively). For clinical
association the answer is considered and scored only if the particle (for surveys 1 and 3) or
all four particles (for surveys 2 and 4) are correctly identified.
For each survey, the CRB edits a report for each laboratory, containing the judgement and
the scores obtained. Moreover, a summary of all participants answers is supplied, together
with a comment by the responsible of the program on the images shown, their main clinical
correlates, and the answers supplied by participants.
At the end of each annual cycle, CRB prepares a report summarising the laboratorys
performances and annual score together with an overview of the results obtained by all
laboratories.
Today, the images of each survey are presented in the website of the program (www.
urinalysis.net) and the participants give their answers directly through it.

S. Secchiero and G.B. Fogazzi

Figure 8.1. Survey 2-2003 for the identification of particles. Top: spindle-like uric acid crystals. Bottom: an oval
fat body. For both particles, left, bright field microscopy and, in the inset, polarized light; right, phase contrast
microscopy. Note that for each particle the magnification was indicated and, for, crystals also the urinary pH.

Quality control programs for urinary sediment

Figure 8.2. Survey 2-2007 showing the particles associated with clinical case 1.
Top, left: dysmorphic erythrocytes; right: renal tubular epithelial cells. Bottom, left: an erythrocytic cast; right: a
waxy cast.
The clinical case was presented as follows: a 45-year-old man hospitalised for rapidly progressive renal failure
(S-creatinine 1.2 mg/dL three months before hospitalisation) associated with the appearance of high blood pressure
(160/95 mm/Hg) and urinary abnormalities. Ultrasounds of the urinary system, normal.
Laboratory findings at hospitalisation:
S-creatinine

2.5 mg/dL (n.v. 0.5-1.0)

U-protein/24 hours

1.5 g (n.v. <0.14)

BUN

95 mg/dL (n.v. 15-50)

Urinary output/24 hours

1,700 mL

Possible clinical diagnosis (only one is correct)

Acute nephritic syndrome

Nephrotic syndrome

Hypovolemic acute renal failure

Acute pyelonephritis

Unilateral hydronephrosis due to ureteric stone

S. Secchiero and G.B. Fogazzi

Results of Urinalysis Performance

The identification of particles. From 2001 to 2007, 84 images were sent, which showed
50 elements of urinary sediment (Table 8.1). The correct identification was the highest for
bihydrated calcium oxalate crystals (100%) and triple phosphate crystals (99.6%), while it
was the lowest for the leukocytic cast (9.2%) and the macrophage (10.9%).
By urinary particle categories, a very high correct identification rate (obtained for each particle
from the sum of correct + partially correct answers) was obtained for micro-organisms and
crystals, followed in decreasing order by cells, lipids, casts and contaminants (Table 8.2).
This part of the program also showed that quite often participants used an inappropriate
terminology to define some particles. This happened especially with renal tubular epithelial
cells, transitional epithelial cells, and squamous epithelial cells which were often defined as
cells from the high, intermediate, or low urinary tract respectively. For other particles such
as erythrocytes and calcium oxalate crystals, the terminology used was often incomplete,
without specification whether the erythrocytes were isomorphic or dysmorphic and calcium
oxalate was mono- or bihydrated.
The particles presented twice. Twenty-four particles were presented twice. For 6 particles
(25.0%) there was a 4.6% to 27.7% (14.6 8.5) decrease in the correct identification rate
when the particle was presented for the second time; for 4 other particles (16.6%) there
were non substantial differences between the first and the second survey (0 to + 0.2%); for
the majority of particles (14 out of 24, 58.3%), the identification rate increased by 2.6% to
77.2% (24.7 19.7). For 11 out of 14 such particles (78.5%), the improvement between the
first and second survey was statistically significant (Table 8.3).
The clinical association. In the cycles from 2001 to 2003, when participants were free to
indicate one association of their choice, a very wide spectrum of answers was supplied, and
the answers were often of difficult interpretation mostly because of the arbitrary and vague
terminology used. Moreover, there was a high rate of no answer (11.8 5.5%, 5-28% per
survey).
Subsequently, with the introduction of multiple-choice answers, the correct clinical
association was indicated by more than 80% of participants for all but one particle (i.e.,
cholesterol crystals). Moreover, there was a substantial decrease of the rate of no answer
(2.5 1.6%, 0.0 to 5.6% per survey) (Table 8.4).
The clinical cases. For the first case presented (Figure 8.2), among 168 laboratories out of
325 which correctly identified all four elements presented (51.7%), the correct diagnosis (acute
nephritic syndrome) was given by 86.9% of participants. For the second clinical case, among
125 laboratories out of 310 which correctly identified all the four elements shown (40.3%), the
correct diagnosis (ureteric stone) was given by 95.2% of participants (Table 8.4).

Quality control programs for urinary sediment

Table 8.1. The particles sent to participants for identification in the period 2001-2007 and

the answers received.
Urinary sediment particle

Answers (%)
Correct

Partially
No
Incorrect
correct
answer

Number of
participants

CELLS (N = 9)
Isomorphic erythrocytes

89.3

2.4

7.9

0.4

291

Dysmorphic erythrocytes

45.2

41.6

13.2

0.0

250

Acanthocytes

52.0

20.8

25.6

1.6

250

Leukocytes

96.9

1.4

1.4

0.3

291

Macrophage

10.6

0.3

83.4

5.7

309

Renal tubular epithelial cells

51.9

1.0

44.0

3.1

291

Deep transitional epithelial cells

45.2

41.6

12.4

0.8

250

Superficial transitional epithelial cells

41.9

14.8

42.3

1.0

291

Squamous epithelial cells

88.1

0.0

11.9

0.0

361

Aggregates of lipid droplets

61.2

29.8

6.1

2.9

245

Oval fat body

55.9

2.4

39.6

2.1

245

Fatty cast

74.7

0.9

24.0

0.4

229

Cholesterol crystals

53.9

1.6

42.9

1.6

245

Hyaline

78.6

0.4

19.7

1.3

234

Hyaline-granular

74.3

0.0

24.8

0.9

234

Finely granular

64.1

1.7

33.8

0.4

234

Coarsely granular

59.9

0.6

38.9

0.6

321

Waxy

88.5

1.3

9.8

0.4

234

Granular-waxy

45.8

22.0

31.4

0.8

361

Erythrocytic

61.1

5.7

33.2

0.0

229

Leukocytic

5.5

3.7

90.8

0.0

327

Containing renal tubular epithelial cells

(RTECs)

38.9

12.7

48.4

0.0

229

Erythrocytic + RTECs

66.4

16.6

16.6

0.4

263

Leukocytic + RTECs

83.2

10.1

6.7

0.0

356

Haemoglobinic

91.0

2.5

6.5

0.0

355

LIPIDS (N = 4)

CASTS (N = 15)

S. Secchiero and G.B. Fogazzi

Table 8.1. Continued

Urinary sediment particle

Answers (%)
Correct

Partially
No
Incorrect
correct
answer

Number of
participants

Hyaline-granular cylindroid

68.0

15.8

16.2

0.0

291

Cylindroid containing erythrocytes

48.5

4.1

47.4

0.0

365

Uric acid

99.2

0.0

0.4

0.4

243

Calcium oxalate monohydrated

66.3

26.7

6.2

0.8

243

Calcium oxalate bihydrated

58.4

41.6

0.0

0.0

243

Triple-phosphate

99.6

0.0

0.4

0.0

243

Calcium phosphate

91.7

0.0

8.3

0.0

265

Calcium phosphate plate

71.0

0.0

27.4

1.6

263

Amorphous urates

86.4

1.1

12.5

0.0

265

Amorphous phosphates

80.4

3.4

16.2

0.0

291

Ammonium biurate

90.1

8.2

0.0

1.7

365

Cystine

94.7

0.0

5.3

0.0

265

Amoxycillin

12.1

50.4

36.0

1.5

355

Indinavir

63.4

0.6

26.1

1.5

344

Ciprofloxacin

25.4

42.8

31.5

0.3

327

Bacteria

97.3

0.9

1.8

0.0

223

Candida

99.1

0.0

0.9

0.0

223

Trichomonas vaginalis

93.3

1.4

5.3

0.0

223

Eggs of Schistosoma haematobium

87.0

3.2

9.4

0.4

223

Starch

50.6

0.4

47.8

1.2

245

Glass fragment

79.5

0.0

17.8

2.7

263

Fibre

91.1

0.7

8.2

0.0

291

Fungal spore (Alternaria)

61.1

29.3

8.3

1.3

324

Pseudocast

22.3

0.4

73.8

3.5

229

CRYSTALS (N = 13)

MICRO-ORGANISMS (N = 4)

CONTAMINANTS (N = 5)

Quality control programs for urinary sediment

Table 8.2. Correct identification rates observed for each of the 6 categories of urinary particles presented during the period 2001-2007.
Particle

Number
presented

Mean sd

Median

Range

Micro-organisms

95.5 4.0

96.4

90.2-99.1

Crystals

13

85.6 14.3

91.7

62.5-100

Cells

71.6 27.6

86.8

10.9-98.3

Lipids

70.1 16.5

66.9

55.5-91.0

Casts

15

69.7 21.4

74.3

9.2-93.5

Contaminants

67.0 29.7

79.5

22.7-91.8

10

S. Secchiero and G.B. Fogazzi

Table 8.3. First and second answers concerning the identification of the particles which were
presented twice.
Urinary sediment particle

Correct + partially correct

identifications (%)
I

II

Change
(%)

p-value

Waxy cast

89.8

85.2

-4.6

0.123

Deep transitional cells

86.8

80.9

-5.9

0.054

Bilirubinic cast

74.7

60.1

-14.6

<0.001

Uric acid crystals

99.2

82.3

-16.9

<0.001

Hyaline cast

79.0

61.0

-18.0

<0.001

Isomorphic erythrocytes

91.7

64.5

-27.7

<0.001

Calcium oxalate bihydrated crystals

100

100

Leukocytes

98.3

98.4

+0.1

0.924

Candida

99.1

99.3

+0.2

0.762

Triple-phosphate crystals

99.6

99.4

+0.2

0.807

Dysmorphic erythrocytes

86.8

89.4

+2.6

0.359

Egg of Schistosoma haematobium

90.2

93.6

+3.4

0.129

Calcium oxalate monohydrated crystals

93.0

96.6

+3.6

0.066

Fatty cast

75.6

86.4

+10.8

0.001

Finely granular cast

65.8

82.4

+16.6

<0.001

RTECs

52.9

69.6

+16.7

<0.001

Starch

51.0

70.2

+19.2

<0.001

Oval fat body

58.3

83.2

+24.9

<0.001

Erythrocytic cast

66.8

96.3

+29.5

<0.001

RTECs cast

51.6

83.5

+31.9

<0.001

Superficial transitional cells

56.7

89.1

+32.4

<0.001

Macrophage

10.9

44.4

+33.5

<0.001

Cholesterol crystals

55.5

99.7

+44.2

<0.001

Leukocytic cast

9.2

86.4

+77.2

<0.001

CORRECT IDENTIFICATION: DECREASE

CORRECT IDENTIFICATION: UNCHANGED

CORRECT IDENTIFICATIONS: INCREASE

Quality control programs for urinary sediment

11

Table 8.4. Answers concerning the clinical association in the period 2004-2007.
Urinary
sediment
particle

N with
access to
clinical
association

Correct clinical
association
(Chosen among 4
to 5 options)

Dysmorphic
erythrocytes

248

Deep
transitional
cells

Answers (%)
Correct

Incorrect

No
Answer

Glomerular
haematuria

97.6

2.0

0.4

201

Damage to the
deep layers of the
uroepithelium

99.5

0.5

0.0

Macrophage

158

Active
glomerulonephritis

86.7

12.0

1.3

Granular-waxy
cast

165

Renal disease with

deterioration of renal
function

90.3

7.3

2.4

Cast containing
RTECs

269

Acute Renal failure

associated with acute
tubular necrosis

89.2

10.4

0.4

Leukocytic cast

276

Active proliferative
glomerulonephritis

84.0

12.0

4.0

Haemoglobinic
cast

323

Haematuria of renal
origin (glomerular)

83.9

10.5

5.6

Bilirubinic cast

140

Jaundice associated
with increased
conjugated bilirubin

94.3

3.6

2.1

Erythrocytic
cylindroid

345

Haematuria of
glomerular origin

89.9

7.5

2.6

Cholesterol
crystal

317

Severe proteinuria/
Nephrotic syndrome

74.8

21.4

3.8

Calcium oxalate
monohydrated
crystals

212

Crystalluria due to
drugs (e.g., vitamin C,
naftidrofuryl oxalate)

91.9

5.7

2.4

Indinavir
crystals

218

Urolithiasis from
inhibitors of HIV-1
protease (e.g.,
indinavir)

95.9

1.8

2.3

Egg of
Schistosama
haematobium

300

Infection of the urinary

system due to a
parasite

91.0

5.3

3.7

Starch

225

Urine contamination
from environment

92.9

2.7

4.4

12

S. Secchiero and G.B. Fogazzi

Comments to Urinalysis Performance

The EQA programs which also include the examination of the urinary sediment are few.
However, the results obtained by Urinalysis Performance show that there is a great need
for such programs.
In fact, our program demonstrates that only some particles such as micro-organisms and
the most common types of crystals are known to participants. On the contrary, the knowledge
of particles such as renal tubular epithelial cells, and lipids is unsatisfactory, especially if one
considers the clinical implications they have.
Our results also show that EQA programs can improve the skills of the participants, as
shown by the results obtained for particles which were presented twice. In this respect, it is
worth noting that the highest and more significant improvements were obtained for particles
of clinical importance such as the erythrocytic and leukocytic casts, which are a marker of
active glomerular disease.
EQA programs may be a valuable tool also to expand the knowledge about particles which
are known only to specialists. In our program this is clearly demonstrated by the results
obtained with the macrophage, which was almost totally misidentified when it was presented
for the first time, but whose correct identification increased by 33,5% when it was presented
for the second time.
EQA programs may also be used as a tool to improve the knowledge of the clinical
implications of the laboratory tests. The results obtained by our program with the first two
clinical cases presented confirm the validity of this statement.
For all these reasons more EQA programs on urinary sediment should be set up, and the
participation to them should encouraged and sustained, especially bi scientific society of
Laboratory medicine.

References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]

Kouri T., Fogazzi G.B., Gant V. et al. European Urinalysis Guidelines. Scand J Clin Lab Invest 2000;
60 (Suppl 231): 39-47.
Nccls. Urinalysis and collection, transportation, and preservation of urine specimens. Approved
guideline. Second edition 2001; GP 16-A2: 6,14.
Belk W.P., Sunderman P.W. A survey of the accuracy of chemical analyses in clinical laboratories.
Am J Clin Pathol 1947; 17: 853-96.
Libeer J.C. Role of external quality assurance schemes in assessing and improving quality in medical
laboratories. Clin Chim Acta 2001; 309: 173-7.
International Federation of Clinical Chemistry (IFCC) fundamentals for External Quality Assessment
(EQA). Guidelines on improving analytical quality by establishing and managing EQA schemes.
Example from basic clinical chemistry using limited resources. July 1996.
Libeer J.C., Baadenhuijsen H., Fraser G.C. et al. Characterization and classification of Externals
Quality Assessment Schemes (EQA) according to objectives such as evaluation of method and
participant bias and standard deviation. Eur J Clin Chem Clin Biochem 1996; 34: 665-78.
Nccls. Using Proficiency Testing (PT) to improve the clinical laboratory. Approved guideline
(GP27-A). Wayne, Pennsylvania: NCCLS, 1999; 19: August N. 15.
Ilac. Guidelines for the requirements for the competence of providers of proficiency schemes. ILAC;
ILAC-G13; 2000.
Ifcc/Emd/C-AqQ. Guidelines for the requirements for the competence of EQAP organizers in medical
laboratories, version 3. IFCC; 2002.

Quality control programs for urinary sediment

13

[10] Sciacovelli L., Zardo L., Secchiero S. et al. External quality assessment schemes: need for recognised

requirements. Clin Chim Acta 2001; 309:183-99.

[11] Takubo T., Tatsumi N. Quality control in urinalysis. Southeast Asian J Trop Med Public Health 1999;

30 (Suppl 3): 136-48.

[12] Boisson R.C., Eynard J.C., Crozier M. et al. French experience about quality assessment of

quantitative urinary analysis. Chim Clin Acta 2000;297:285-95.

[13] Guder W.G., Boisson R.C., Fogazzi G.B. et al. External quality assessment of urine analysis in
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]

Europe. Results of a round table discussion during the Symposium From uroscopy to molecular
analysis, Seeon, Germany, September 18-20, 1999. Clin Chim Acta 2000; 297: 275-84.
Fogazzi G.B. Urinalysis Performance Programma di Valutazione Esterna di Qualit sul sedimento
urinario. Anno 2001-2003. Pisa: Pacini, 2006.
The Royal College of Pathologists. Guidelines for the provision of interpretative comments on
biomediacal reports. Bull R Coll Pathol 1998; 104: 25.
Vasikaran S.D., Penberthy L., Gill J. et al. Review of a pilot quality-assessment program for
interpretative comments. Ann Clin Biochem 2002; 39: 250-60.
Sciacovelli L., Zardo L., Secchiero S. et al. Interpretative comments and reference ranges in EQA
programs as a tool for improving laboratory appropriateness and effectiveness. Clin Chim Acta 2003;
333: 209-19.
Mun Lim E.E., Sikaris K.A., Gill J. et al. Quality assessment of interpretative commenting in clinical
chemistry. Clin Chem 2004; 50: 632-7.
Clinical Pathology Accreditation (Uk). Standards for the medical laboratory. Scheffield, UK: CPA,
Version 1; 2001 January.
International Standard Iso/Fdis 15189. Medical laboratories-particular requirement for quality and
competence. Final draft, 2002.
Sciacovelli L., Zardo L., Secchiero Set al. Risk management in laboratory medicine: quality
assurance programs and professional competence. Clin Chem Lab Med 2007; 45: 756-65.