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URINALYSIS - ASCORBIC ACID

Urinary excretion of ascorbic acid amounts to 20-30 mg daily. Urinary excretion of ascorbic acid depends on daily intake
of vitamin C (an average daily dose is 30-80 mg. !"e stability of ascorbic acid in urine is very lo#$ t"erefore only small
amounts of ascorbic acid are found in 2%-"our urine. !"e level of ascorbic acid in urine is important for its interference #it" t"e
tests for glucose$ blood and bilirubin.
Analyte
Concentrations of ascorbic acid that influence at the result
&' units Conventional units
(lucose ) 283* +mol,- ) .0 mg,dl
/lood ) 2201 +mol,- ) %0 mg,dl
/ilirubin ) 1%20 +mol,- ) 2. mg,dl
'n case of a positive test strip result for ascorbic acid$ t"e analysis s"ould be repeated after 2% "ours$ during #"ic"
period t"e patient s"ould not take vitamin C.
Determination
!"e principle of ascorbic acid determination is based on t"e fact t"at t"e oxidi2ed form of t"ia2ine and oxa2ine is
colorless$ and is converted into a reduced$ colored form #"en coming in contact #it" ascorbic acid. &ome manufacturers (e.g.
3ade-/e"ring "ave developed a met"od of ascorbic acid determination using !illman4s reagent$ based on reagent decoloration.
'n t"e presence of ascorbic acid$ t"e color in t"e test area c"anges from grey-blue to orange. 5pproximately 10 mg,d- or .68
7mol,- ascorbic acid can be detected by a test strip.
Clinical significance
!"e main function of ascorbic acid (vitamin C is its role in t"e synt"esis of collagen$ prevention of tetra"ydrofolate
oxidation$ maintenance of normal ferritin to "emosiderin ratio$ and tyrosine oxidation. 8itamin C deficiency leads to scurvy
syndrome$ presently a very rare condition. 'n vitamin C deficiency$ t"ere is a substantially decreased level or absence of ascorbic
acid in urine. 5scorbic acid is very instable in urine$ t"erefore it must be determined in a fres" urine specimen. !est strip may
yield false decreased or negative results for glucose$ blood$ and bilirubin$ depending on t"e ascorbic acid concentration. 5n
ascorbic acid concentration of 9100 mg: decreases glucose by about ... mmol,-$ and a concentration of only .0 mg:
produces a false negative result at a glucose concentration of %.2-6.* mmol,-.
Effect of drugs
Decreased values:
Ascorbic acid
Increased values:
Azo dye metabolites (pyridium)
Finding
Negative
alse positive
; detergent residues
; "ypoc"lorite
; peroxide
!ositive
alse negative
; especially in ketonuria
; gentisic acid$ p< =.
; reducing agents
actor of conversion (Conv"I) .6.08 (mg,d- 7mol,-
#imit of sensitivity ("I) 28% 7mol,- (. mg,d-
$eference values 1136-1660 7mol,- (20-30 mg,d-
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URINALYSIS - BILIRUBIN
/ilirubin$ urobilinogen$ urobilin$ stercobilinogen and stercobilin are commonly named bile pigmentation. >n"anced
urinary excretion of bilirubin or urobilinogen is called urobilinogenuria or bilirubinuria. /ilirubin is formed in t"e
reticuloendot"elial system as t"e product of "emoglobin degradation. >ryt"rocyte breakdo#n occurs after approximately 120
days of life$ #"ereby "emoglobin is being released. 5 se?uence of reactions in "eme pigments results in t"e formation of
uncon@ugated bilirubin$ #"ic" is #ater-insoluble and cannot be excreted by t"e kidney route. 't binds to albumins in t"e blood
and s"ould be rapidly eliminated as it is "armful to t"e body. !"erefore$ it binds to glucuronic acid in t"e liver to form
con@ugated$ #ater-soluble bilirubin. 5 minor portion of con@ugated bilirubin is rediffused into t"e blood via "epatic lymp"atic
system$ #"ile a ma@ority is secreted from t"e liver via biliary duct$ passing to t"e small intestine. /ilirubin is reduced into
urobilinogen and stercobilinogen by bacterial activities in t"e small intestine$ and is mostly excreted by feces in t"is form. 5
minor part of intestinal urobilinogen returns to t"e liver$ t"en to t"e blood$ and is excreted in t"e urine via t"e kidneys.
/ilirubinuria is t"e usual se?uel of an increased concentration of bilirubin in t"e blood$ due to a reduced bile secretion from t"e
liver (e.g. biliary calculi$ tumors$ etc.. 'n case of a lesion to t"e liver parenc"yma due to increased permeability of t"e cell
membranes$ t"e con@ugated bilirubin reac"es t"e blood$ #"ic" may also result in t"e occurrence of bilirubinemia. 5 bilirubin
concentration of only 3.6 7mol,- can be detected by a test strip. <o#ever$ it is not likely to demonstrate suc" a lo#
concentration of bilirubin in practice. !"e test sensitivity limit for bilirubin is 0 to 1% 7mol,-.
Determination
3etermination of bilirubin by means of test strip is based on t"e bilirubin binding to stable dia2onium salt (2$6-
dic"loroben2ene dia2onium fluoroborate$ /oe"ringerA 2$%-dic"loroaniline dia2onium salt$ 5mes in an acidic medium. 'n t"e
presence of bilirubin$ a reddis"-violet a2odye of t"e intensity proportional to t"e bilirubin concentration develops.
Clinical significance
3etermination of bilirubin in t"e urine is indicated in t"e follo#ing casesB
; intra"epatic and extra"epatic obstructive @aundice
; parenc"ymatous @aundice
; acute and c"ronic "epatitis
; liver cirr"osis
; Cotor4s syndrome and
; 3ubin-Do"nson syndrome
Effect of drugs
Decreased values: Increased values:
; 5scorbic acid
; Cifampin
; 5ceto"examide
; 5cetop"ena2ine
; C"loroprot"ixene
; C"lorproma2ine
; 3apsone
; >t"oxa2ine
; >todolac
; Elup"ena2ine
; 'mipramine
; Fet"yldopa
; Goret"androlone
; Herp"ena2ine
; H"ena2opyridine
; H"enot"ia2ine
; &ulfadimet"oxine
Finding
Negative
alse positive 3rugs producing red urine discoloration (pyridine drugs and senna
!ositive
; 5cute and c"ronic "epatitis
; 3aubin-Do"nson syndrome
; 'ntra"epatic and extra"epatic obstructive @aundice
; -iver cirr"osis
; Harenc"ymatous @aundice
; Cotor4s syndrome
2
alse negative
; 3rugs
; <ig" concentrations of ascorbic acid ()1%20 mmol,-
; Hrolonged sun exposure
actor of conversion (Conv"I) 10.1 ( mg,d- +mol,-
#imit of sensitivity ("I) 0 - 1% +mol,-
$eference values negative (=3.% 7mol,-
URINALYSIS - BLOOD
!"e urine of "ealt"y individuals contains no blood$ except for #omen during menstruation. 'n some diseases$ "o#ever$
blood occurs in t"e urine.
%emoglobinuria and hematuria
!"e term 4presence of blood4 in urine includes "emoglobinuria and "ematuria.
%emoglobinuria
<emoglobinuria is t"e excretion of free hemoglobin$ #"ic" appears in t"e urine in case of intravasal$ intrarenal or urinary
eryt"rocyte destruction. 'n intravasal "emolysis$ "emoglobin passes to t"e urine #"en t"e plasma concentration of free
"emoglobin exceeds 1.0 g,-. !"e urine is clear and red colored. 'n acidic urine$ "emoglobin is found in t"e form of
met"emoglobin and t"e urine is of bro#nis" color$ #"ereas in alkaline urine "emoglobin is found in t"e form of oxy"emoglobin
and t"e urine is reddis". !"e so-called pseudoperoxidase activity of "emoglobin is mostly used for demonstration of "emoglobin
in t"e urine.
%ematuria
<ematuria is t"e presence of intact erythrocytes in the urine. 5ccording to t"e amount of eryt"rocytes present in t"e urine$
"ematuria is divided into macro- (about 2.00 eryt"rocytes per m- of urine or about 0.. m- blood per 1 - urine and
micro"ematuria (cannot be seen by t"e naked eye and implies ). eryt"rocytes per 7- urine. >very finding of more t"an .
eryt"rocytes per m- urine is considered pat"ologic. 'n #omen$ t"e possible admixture of blood due to menstruation s"ould
al#ays be ruled out. !urbidity and red coloration can occasionally be observed by organoleptic examination of t"e urine
containing eryt"rocytes. !"e urine clears #it" centrifugation$ #"en eryt"rocytes remain in t"e precipitate and are simply
demonstrated by microscopy. !"e most common causes of renal and postrenal "ematuria are urolit"iasis$ tumors of t"e kidneys
and genitourinary tract$ glomerulonep"ritis$ and pyelonep"ritis. !"e 'three-vessel test' is used to determine t"e genitourinary
tract segment from #"ic" t"e "emorr"age causing "ematuria originates. !"e patient is asked to urinate into t"ree vessels (first$
second and t"ird urine flo#. !"e presence of blood is determined in eac" urine specimen and t"e site of "emorr"age is locali2ed
on t"e basis of t"e results t"us obtained.
Determination
3emonstration of "emoglobin by means of test strip is based on t"e same principle as 5dler4s reaction (ben2idine oxidation in
t"e presence of "ydrogen peroxide$ producing a blue-green complex. !"e test strip is impregnated #it" a buffer$ c"romogen
(3$34$.$.4-tetramet"ylben2idine$ o-toluidine and peroxide (organic peroxide - diisopropylben2ene di"ydroperoxideA strontium
peroxide. !"e test is based on t"e peroxidative activity of "emoglobin #"ic" cataly2es indicator oxidation #it" organic peroxide
to t"e blue-green c"romogen$ #"ic" c"anges t"e yello# color of t"e test paper to green. 5 "ig" reaction sensitivity is ac"ieved
by t"e addition of an activator. 3emonstration of "ematuria is based on t"e same principle as t"e demonstration of "emoglobin
by means of test strip. !"e reaction is "ig"ly sensitive. !"e sensitivity limit for intact eryt"rocytes is about . eryt"rocytes per
m- urine. !"e "emoglobin t"us released causes a color reaction in t"e eryt"rocyte surrounding$ #it" green points denoting
eryt"rocytes. 5 "omogeneously green area points to t"e presence of free "emoglobin$ i.e. a great number of "emoly2ed
eryt"rocytes.
Clinical significance
3etermination of blood in t"e urine is indicated in t"e follo#ing casesB
&' %ematuria
!hysiologic excretion of eryt"rocytes ranges up to 3 >,m- urine.
(icrohematuria I normal urine colorA increased eryt"rocyte excretion.
(acrohematuria I red-color urine (visible by t"e naked eyeA corresponding to about 2.00 >,m- urine.
; urolit"iasis (mciro"ematuria is t"e only symptom in t"e early stage of t"e disease
; tumors of t"e genitourinary tract
; glomerulonep"ritis
; pyelonep"ritis
; "emorr"agic diat"esis
1. anticoagulant t"erapy
2. "emop"ilia
3. coagulopat"ies
%. t"rombopat"ies
.. t"rombopenias
; ot"er diseases
3
1. urinary tract diseases (cystitis$ genitourinary tract tuberculosis
2. toxic and "ypoxic lesions and degenerative c"anges of glomerular capillaries
3. papillary necrosis
%. renal and urinary tract trauma
.. renal infarction
6. renal cysts
0. diabetes mellitus
8. lupus eryt"ematosus and ot"er autoimmune diseases #it" renal complications
)' %emoglobinuria and myoglobinuria
; severe "emolytic anemia
; severe intoxication
; severe infectious diseases
; burns
; extreme exertion (e.g.sports training$ myocardial infarction
; muscular lesions
; progressive muscular disease
Effect of drugs
Decreased values: Increased values:
; 5scorbic acid
; /en2t"ia2ide
; 5cetaminop"en
; 5cetanilid
; 5minopyrine
; 5minosalicylic 5cid
; 5mpicillin
; /acitracin
; /romide
; Carbama2epin
; Colc"icine
; Colistin
; Coumarin derivatesB
>tilibiskumacetat$
Eenprokumon$
Eepromaron$
5cenokumarol
; Cuprum
; >tilibiskumacetat$
Eenprokumon$
Eepromaron$
5cenokumarol
; (old salts
; <ipoklorit
; 'fosfamide
; 'ndomet"acin
; 'odide
; Janamycin
; Fandelic 5cid derivates
; Fet"enamine
; Gitric acid
; Kxacillin
; Kxidi2ing agents
; H"enylbuta2one
; &ulfones
; !"ia2ide diuretics
Finding
Negative
alse positive
; alkaline urine (eryt"rocyte "emolysis
; bromides$ copper$ iodides
; myoglobin
; oxidi2ing substances$ e.g. "ypoc"lorite
; peroxidase from microorganisms in genitourinary infection
; red or bro#n pigmentation or urine discoloration
!ositive ; burns
4
; diabetes mellitus
; extreme exertion (e.g. sports training
; genitourinary tract tumors
; glomerulonep"ritis
; "emorr"agic diat"esis
; lupus eryt"ematosus
; muscular in@ury
; myocardial infarction
; progressive muscular disease
; pyelonep"ritis
; renal and urinary tract trauma
; renal cysts
; severe "emolytic anemia
; severe infectious diseases
; severe intoxication
; urinary tract infection
; urolit"iasis
alse negative
; captopril
; formalin
; "ig" amounts of ascorbic acid (in suspected cases$ t"e test s"ould be repeated at least 10 "ours
after t"e last vitamin C intake
; "ig" concentrations of ascorbic acid
; if urine "as not been mixed t"oroug"ly$ t"ese cells "ave dropped to t"e bottom of t"e test tube
; nitrites ()2.2 mmol,-
actor of conversion
(Conv"I)
for "emoglobin 0.0.16 (7g,-,eryt"rocytes,7-
#imit of sensitivity ("I) 1.0-620 7g,- "emoglobin (I.-10 #"ole eryt"rocytes,7-
$eference values negative (up to 3 eryt"rocytes,7- urine
URINALYSIS - LUCOSE
(lucose is normally found in t"e urine. !"e upper level of p"ysiologic glucosuria in t"e first morning urine is about 0.8
mmol,- glucose. !"is concentration is too small to be detectable by test strip. (lucose excretion by urine (glucosuria depends
on glucose concentration in t"e blood and renal function$ i.e. on t"e renal t"res"old a for glucose (serum glucose concentration
8-10 mmol,-. (lucosuria per se is not an evidence of diabetes mellitus$ as it may also ensue from ot"er causes. !"ere are
t"ree types of glucosuriaB
&' Alimentary glucosuria
3iets ric" in carbo"ydrates or intake of great amounts of glucose (e.g. glucose load tests may cause glucosuria also in
"ealt"y individuals$ because t"e serum concentration of glucose in exceeds renal t"res"old over a certain period of time.
)' *lucosuria in diabetic patients
(lucosuria occurs in a ma@ority of diabetic patients. !"e amounts of excreted glucose depend on t"e blood glucose
concentration and renal t"res"old$ #"ic" is "ig"er in diabetic patients t"an in "ealt"y individuals. 3emonstration of glucosuria is
of utmost importance for early recognition$ control$ and self-control of diabetes mellitus.
+' $enal glucosuria
'n individuals #it" impairment of tubular glucose reabsorption$ glucosuria occurs at a normal blood glucose concentration.
(lucosuria fre?uently occurs in pregnancy$ due to t"e reduced kidney function. /eside glucose$ ot"er sugars can also be found in
t"e urine$ e.g. fructose or some pentoses following an abundant fruit meal, or in pregnant women excreting lactose. !"e finding
of t"ese sugars in t"e urine "as no diagnostic relevance$ "o#ever$ a finding of galactose in t"e urine is indicative of a serious
illness in c"ildren. -o# and false-negative results are usually due to "ig" amounts of ascorbic acid in t"e urine$ excreted after
vitamin C intake. 'n suspected cases$ t"e test s"ould be repeated at least 10 "ours after t"e last vitamin C intake.
Determination
3etermination of glucose by means of test strip is based on t"e specific$ cascade-like$ en2ymatic glucose oxidase-
peroxidase reaction. !"e test is en2ymatic and t"erefore specific for glucose$ as ot"er sugars do not interfere #it" t"e reaction.
'n t"e presence of oxygen from t"e atmosp"ere and glucose-oxidase$ t"e glucose is oxidi2ed into gluconolactone. !"us formed
"ydrogen peroxide oxidi2es c"romogen #it" t"e catalytic action of peroxidase. !"en t"e c"romogen is transformed into a bro#n-
colored compound. Color development is not influenced by nonspecific factors$ t"us allo#ing semi?uantitative evaluation of t"e
glucose concentration. Hositive reaction means color c"ange from dark-yello# to bro#n. 'f read beyond t"e given time$ t"e
concentration of glucose can be semi?uantitatively evaluated against color "ues on t"e color scale.
Clinical significance
!"e follo#ing cases point to t"e need of glucose determination in t"e urineB
; adrenal cortical "yperplasia
; Cus"ing4s syndrome
; diabetes mellitus
5
; gigantism
; "yperlipoproteinemia
; "ypertension
; "yperuricemia$ gout
; normal pregnancy
; brain in@ury
; postgastrectomy state
; obesity
; accelerated intestinal glucose absorption
; "ypert"yroidism
Effect of drugs
Decreased values: Increased values:
; 5cetylsalicylic 5cid
; 5mpicillin
; 5scorbic acid
; /ent"ia2ide
; /isacodyl
; /ismut" &ubsalicylate
; Carbama2epine (individual cases
; Carbenicillin
; C"loral <ydrate
; 3ia2epam
; 3igoxin
; 3ipyrone
; Eerrous
; &ulfate
; Elura2epam
; Eurosemide
; <ydro?uinone
; 'nsulin
; -evedopa
; Feralluride
; Fercurial diuretics
; Kxytetracycline
; H"ena2opyridine
; H"enobarbital
; Hrednisone
; Hropoxyp"ene
; &ecobarbital
; !etracycline
; 5ceta2olamide
; 5cetylsalicylic 5cid
; 5minosalicylic 5cid
; 5mpicillin
; 5myl 5lco"ol
; 5scorbic acid (1%.2 mmol,- urine
; 52locillin
; Cep"alot"in
; C"lorot"ia2ide
; C"lorproma2ine
; Corticosteroides
; 3examet"asone
; 3iapamide
; >nalapril
; >p"edrine
; >t"er
; Eura2olidine
; (lucagon
; (lucocorticoides
; (lucose
; <ydroc"lort"ia2ides
; <ydrogen peroxide
; <ypoc"lorite
; 'sonia2id
; -actose
; Feprednisone
; Fet"yclot"ia2ide
; Giacin
; Henicillin
; H"enot"ia2ine
; !etracycline
; !"ia2ides
; !rimeta2ine
Finding
Negative normal finding
alse positive finding
; dirty glass#are
; detergent residues
; in vitro interferences (aminosalicylic acid$ carbama2epine$ corticosteroids$ diuretics$ lead
poisoning
; interferences caused by c"emicals ("ydrogen peroxide$ "ypoc"lorite$ vaginal po#ders
containing glucose$ etc.
!ositive finding
; adrenal cortical "yperplasia
; any case of increased blood glucose concentration$ especially in accelerated intestinal
absorption
; c"ronic infections
; coronary$ cerebral and perip"eral circulatory disorders
; Cus"ing4s syndrome
; diabetes mellitus
; gigantism
; "yperlipoproteinemia
; "ypertension
; "ypert"yroidism
; "yperuricemia$ gout
; normal pregnancy
; obesity
; postgastrectomy state
; renal glucosuria (urine glucose )1.1 mmol,-$ serum glucose normal
alse negative finding
; lo# urine p<
; salicylates
; "ig" vitamin C concentrations
actor of conversion
(Conv"I)
x 0.0...1 ( mg,d- mmol,-
#imit of sensitivity ("I) 2.2 mmol,-
$eference values 0.06 - 0.8% mmol,- (1 - 1. mg,dl
6
(morning urine specimenB 0.3 L 1.1 mmol,- (6 - 20 mg,d-
URINALYSIS - !E"ONES
Jetone bodies include acetone, beta-oxybutyric acid (hydroxybutyrate) and acetoacetic acid. !"ey are formed in t"e
liver if t"e body is deficient in carbo"ydrates and in case of increased lipid decomposition (i.e. #"en t"e process of lipolysis is
more pronounced t"an t"e process of lipogenesis. !"e increased concentration of fatty acids leads to t"e formation of "ig"
amounts of acetoacetyl-Co5$ from #"ic" acetoacetic acid is formed. !"e acetoacetic acid is influenced by "ydroxybutyrate
de"ydrogenase$ producing beta-oxybutyric acid. !"is is a reversible process$ as differentiated from t"e irreversible process of
acetoacetic acid conversion into acetone. !"e occurrence of ketone bodies in t"e blood and urine is kno#n as ,etonemia and
,etonuria$ respectively. !"e accumulation of ketone bodies leads to acidosis$ #"ic" may result in ,etone coma or deat".
5cetone is mostly eliminated by t"e lungs$ and via kidneys along #it" acetoacetic acid. !"e amount of acetoacetic acid is about
10 times greater t"an t"e amount of excreted acetone. 5 urine containing a considerable amount of acetone "as a fruit-like
odor$ #"ile acetoacetic acid and beta-oxybutyric acid are odorless substances. Ketonuria may be a sequel of diabetes,
starvation, low-carbohydrate diet, elevated body temperature, etc.
Determination
3etermination of ketone bodies by means of test strips is based on t"e kno#n principle of -egal4s test. 5cetoacetic acid and
acetone react #it" Ga-nitroprusside (or Ga-nitroferricyanide and glycine in an alkaline medium producing a violet-colored
complex. 5 positive test result manifests as a color c"ange from purple to violet. !"e intensity of t"e violet color is proportional
to t"e concentration of ketone bodies in t"e urine. /eta-"ydroxybutyric acid cannot be demonstrated by t"is reaction. (lucose$
protein$ ascorbic acid$ and urine preservatives (e.g. toluene$ t"ymol$ formalin used in usual concentrations do not interfere #it"
t"e reaction.
Clinical significance
3etermination of ketone bodies in t"e urine is indicated in t"e follo#ing casesB
; diabetes mellitus
; starvation
; vomiting
; diarr"ea
; "ypert"yroidism
; elevated body temperature
; preeclamptic toxemia
Effect of drugs
Decreased values: Increased values:
; 5cetylsalicylic 5cid
; H"ena2opyridine
; 5cetylsalicylic 5cid
; Captopril
; 3imercaprol
; >t"er
; 'fosfamide
; 'nsulin
; -evedopa
; Fesna (Ga-2-mercaptoet"an-sulfonat
; Fetformin
; Fet"yldopa
; G-5cetylcysteine
; Giacin
; Haralde"yde
; Henicillamine
; H"ena2opyridine
; H"enolp"talein
; Hyra2inamide
; &ulfobromp"t"alein
Finding
Negative
alse positive ; /&H
; et"er
; "ig" amounts of p"enylketones
; "ig" concentrations of levodopa metabolites
; "ig" urine specific gravity
7
; insulin
; intensely colored urine
; isopropyl alco"ol
; lo# urine p<
; H&H
!ositive
; diabetes mellitus
; diarr"ea
; elevated body temperature
; "ypert"yroidism
; preeclamptic toxemia
; starvation
; vomiting
alse negative
actor of conversion (Conv"I) 0.1 (mg,d- +mol,-
#imit of sensitivity ("I) 0.. - 1.0 +mol,-
$eference values negative
URINALYSIS - LEU!OCY"ES
-eukocyturia is an increased excretion of leukocytes by urine and a symptom of inflammation of various etiologies$ e.g.
pyelonep"ritis$ glomerulonep"ritis$ p"enacetine nep"ritis$ bacterial infection of t"e lo#er genitourinary tract$ etc. !"e leukocytes
excreted by urine mostly are neutrop"ilic granulocytes. &mall amounts of eosinop"ils can be found in urinary tract allergies$ and
lymp"ocytes can be found in c"ronic inflammation.
Determination
-eukocytes can be demonstrated by microscopy (intact leukocytes and c"emistry (intact and lysed leukocytes. Fore
t"an 10 leukocytes per 7- urine can be determined by means of a test strip. !"e number of leukocytes excreted by urine can be
determined by counting in a c"amber.
5 test strip for leukocyte determination measures t"e activity of esterase from granulocytes. >sterases cataly2e "ydrolysis of
ester substrates$ and t"e reaction product reacts #it" dia2onium salt forming a colored product (5mes uses a derivative of t"e
pyrolic amino acid ester$ and /oe"ringer indoxyl ester as a substrate. !"e color intensity is proportional to leukocyte count.
Fost aut"ors consider 10 to 20 leukocytes per 7- native urine as a suspect finding re?uiring control$ and )20 leukocytes per 7-
urine as a definitely pat"ologic finding.
Clinical significance of a sporadic finding of leukocytes in traces is ?uestionable. <o#ever$ if suc" a finding is recorded on several
consecutive occasions$ it may "ave clinical importance.
Clinical significance
Leuocytes are round cells of a varying si!e, their granular structure being very pronounced in the acidic urine" #n
alaline urine, leuocytes swell up and their contours become indistinct" -eukocyte nuclei can be round or split$ fre?uently
covered #it" granules$ t"us t"ey may occasionally be indiscernible. #n alaline urine, leuocytes are usually grouped in clusters.
'f suc" a urine specimen is stored for a prolonged period of time$ leukocyte nuclei gradually lose t"eir distinct contours$ t"e cells
undergo disintegration and a granular mass$ so-called detritus$ is formed.
-eukocyturia is an increased excretion of leukocytes by urine and t"e main symptom of kidney inflammation (nep"ritis or
bacterial infection of t"e genitourinary tract. Facroscopically visible massive leukocyturia is kno#n as pyuria.
/eside significant bacteriuria$ leukocyturia is one of t"e main symptoms of acute and c"ronic pyelonep"ritis. 'n acute forms of
pyelonep"ritis$ additional symptoms (elevated temperature$ kidney pain$ proteinuria$ eryt"rocyturia usually are also present$
#it" concurrent significant bacteriuria. -eukocyturia is fre?uently t"e only symptom occurring bet#een acute attacks of t"e
disease. -eukocyturia "as a very important role in c"ronic pyelonep"ritis.
Gep"ritis caused by scarlet fever or p"enacetine and glomerulonep"ritis are al#ays accompanied by leukocyturia. -eukocyturia
is a ma@or symptom in inflammatory diseases of t"e urinary tract (pyelitis$ cystitis$ uret"ritis and prostatitis.
-eukocyturia and significant bacteriuria fre?uently but not al#ays develop concurrently. !"erefore$ it is recommended t"at a
positive finding of leukocyturia be al#ays follo#ed by determination of bacterial count in t"e urine" $he reasons for so-called
'abacterial' leuocyturia may include urinary tract infections under treatment, allergic reactions, phenacetine nephritis,
infections with trichomonas, gonococci, mycoplasmas, and mycoses" -eukocyturia may also be caused by glomerulonep"ritis$
intoxication$ tumors and bil"ar2iasis. 'solated leukocyturia is fre?uently t"e only finding pointing to tuberculosis of t"e kidneys
or genitourinary tract.
>ac" case of leukocyturia re?uires t"oroug" examination of urinary sediment$ primarily for leukocyte cylinders (t"ey occur
individually. -eukocyte cylinders are formed by effusion from t"e tubule$ and t"ey demonstrate t"at leukocyturia "as originated
from t"e renal parenc"yma.
Gormal urine specimens yield negative results. Hositive results of )M are clinically significant. 5 sporadic finding of leukocytes in
traces is of a ?uestionable clinical significance. <o#ever$ if suc" a finding is repeatedly found in consecutive specimens$ it may
be clinically important. %ositive findings may occasionally be found in women's urine specimens due to specimen contamination
with vaginal discharge" 'ncreased urine glucose values (8.* mmol,- and "ig" specific gravity may cause false-decreased test
results. !"e presence of cep"alexin$ cep"alot"in$ or "ig" concentrations of oxalic acid may also cause false-decreased results.
!etracyclines may reduce reactivity of t"e reagents in t"e respective test area$ #"ile "ig" concentrations may lead to a false-
negative reaction. Gitrofurantoin produces bro#n discoloration of t"e urine. !"is bro#n discoloration of t"e urine may mask t"e
8
color of reaction in t"e respective test area. 5ny substance producing atypical urine color may mask t"e color of reaction.
-eukocytes can be determined by microscopy or c"emistry tec"ni?ues. !est strip can determine an amount of )10 leukocytes,7-
urine. !"e count of leukocyte excreted by urine can also be determined by counting in a c"amber.
Effect of drugs
Decreased values: Increased values:
; 5scorbic acid
; Cep"alexin
; Cep"alot"in
; !etracycline
; 5llopurinol
; 52at"ioprine
; Cyclosporine 5
; 3antrolerne
; Eenoprofen
; 'ndomet"acin
; 'sotretinoin
; Fet"icillin
; Foxalactam
; Henicillin
Finding
Negative
alse positive
; formalin
; mucus
; parasites
; !ric"omonas
; vaginal disc"arge
!ositive
; genitourinary tract tuberculosis
; glomerulonep"ritis
; infections #it" tric"omonas$ gonococci$ and mycplasmas
; inflammatory diseases of urinary tract (pyelitis$ cystitis$ uret"ritis$ and prostatitis
; intoxication
; mycoses
; nep"ritis due to scarlet fever or p"enacetine
; renal tuberculosis
; tumors
alse negative
; boric acid
; cep"alexin
; cep"alot"in
; "ig" concentrations of oxalic acid
; "ig" concentrations of tetracyclines
; "ig" urine specific gravity
; increased glucose values (8.* mmol,-
; nitrofurantoin
#imit of sensitivity ("I) .-1. cells,7- urine
$eference values =10 leukocytes,7- urine
URINALYSIS - NI"RI"E
!"e most common causes of genitourinary tract infections are &scherichia coli, %roteus, Klebsiella, 'almonella,
enterococci, staphylococci and %seudomonas. 'n t"e urinary bladder$ t"ese bacteria reduce nitrates to nitrites. 5 positive
reaction to nitrites indicates genitourinary tract infection$ and produces discoloration from #"ite t"roug" pink to red. $he first
morning urine should be used for analysis, and testing should be performed within ( hours" ) false negative result is obtained
when the urine contains a low number of bacteria, or when they have been in contact with nitrates for too short a period of
time"
Determination
3etermination of nitrites by means of test strip is based on t"e principle of so-called (riess reaction. 'n an acidic buffer$ t"e
aromatic amine$ sulfanylamine$ reacts #it" nitrite$ producing a dia2onium compound t"at yields an a2o dye #it" 3-"ydroxy-
1$2$3$%-tetra"ydroben2o-("-?uinoline. !"e intensity of t"e red color on t"e respective test strip area is proportional to t"e
concentration of nitrites$ but provides no data on t"e severity of infection.
9
Clinical significance
3etermination of nitrites in t"e urine is indicated in t"e follo#ing casesB
significant bacteriuria associated #it" urinary tract infection
; pyelonep"ritis
; cystitis
; uret"ritis
!"e follo#ing population groups are susceptible to asymptomatic urinary tract infections and c"ronic pyelonep"ritisB
1. pregnant #omen (.:-10:
2. elderly people aged )00 ()20:
3. men #it" early stage of t"e prostatic adenoma
%. urolit"iasis patients (.0:
.. diabetic patients (918:
6. gout patients (96.:
0. patients on long term p"enacetine t"erapy
8. "ypertension patients
*. patients #"o "ave undergone cat"eteri2ation$ cystoscopy or urinary tract surgery
Effect of drugs
Decreased values:
; H"ena2opyridine
Finding
Negative
alse positive
; a2o dye metabolites
; interferences in t"erapy #it" drugs containing p"ena2opyridine
!ositive
; adenoma of t"e prostate
; after cat"eteri2ation$ cystoscopy or urinary tract surgery
; cystitis
; diabetes mellitus
; gout
; "ypertension
; longterm p"enacetine t"erapy
; pyelonep"ritis
; uret"ritis
; urolit"iasis
alse negative
; ascorbic acid concentration exceeding 1%20 mmol,- (2. mg,d- in specimens containing lo#
amounts of nitrites (=13 mmol,- nitrite ion
; fre?uent urination (t"e urine is retained in t"e bladder for too s"ort a period of time
; starvation$ parenteral nutrition$ or lo# vegetable nutrition (nitrates enter t"e body only by food
actor of conversion
(Conv"I)
233.3 (mg,d- +mol,-
#imit of sensitivity ("I) 13-22 7mol,- nitrite ion (0.03 mg,d-
$eference values negative
URINALYSIS # $%
!"e urine of "ealt"y people is usually slig"tly acidic or alkaline. !"e values of urine p< may range from %.% to *.0A
"o#ever$ in "ealt"y individuals it is generally bet#een ("* and +"*. !"e value of urine p< depends on t"e diet$ metabolic
balance$ diseases$ and presence of various drugs. 5n acidic reaction is due to primary p"osp"ates and urates$ and alkaline
reaction to secondary and tertiary p"osp"ates and alkaline carbonates. 5 protein-ric" diet increases urine p<$ because protein
and amino acid decomposition results in t"e formation of numerous acidic p"osp"ate and sulfate salts. 'n vegetable based diet$
t"e urine is alkaline because of organic acids of vegetable origin t"at are converted to <2CK3 and #ater. Urine p< c"anges in
some diseases$ e.g. in infectious diseases #it" elevated body temperature$ or in starvation #"ere urine p< decreases due to
intrinsic protein decomposition$ or in vomiting #"ere urine p< increases due to t"e massive acid loss. 5n alkaline reaction of t"e
urine may also be a conse?uence of urinary tract infection (urine p< 0-8. 'f diurnal urine p< continually ranges bet#een 0 and
8$ it strongly points to a urinary tract infection.
Determination
/y measuring urine p<$ t"e activity of "ydrogen ions is determined. Urine p< is exclusively measured in fres" urine$ because
urine turns alkaline #"ile stored$ and a result t"us obtained "as no diagnostic value. Urine p< can be measured by means of
10
indicator slip$ test strip or p< meter. 5 test strip usually contains a combination of t#o indicators$ met"ylene blue and
bromot"ymol blue (covering a p< range of .-*. !"e color of t"e indicator c"anges #it" p< value$ from orange t"roug" yello#
and green to blue.
Clinical significance
Decreased values (acidic urine)
; diabetic acidosis
; de"ydration
; diarr"ea
; drug t"erapy (e.g. ammonium c"loride$ ascorbic acid$ met"ionine$ mandelic acid
Increased values (al,aline urine)
; c"ronic renal failure
; genitourinary infection
; tubular acidosis
; salicylate intoxication
; pylorus obstruction
; presence of bacteria possessing urease en2yme
Effect of drugs
Decreased values: Increased values:
; 5mmonium C"loride
; 5scorbic acid
; C"ollestyramine
; Corticotropin
; 3ia2oxide
; Fet"enamine
; Fet"ionine
; Fetola2one
; Giacin
; 5ceta2olamide
; 5ldesteron
; 5miloride
; 5mp"otericin /
; Carbenoxolone
; Cimetidine
; Citrates
; 'fosfamide
; Fafenide
; Giacinamide
; Harat"yroid >xtract
; Canitidine
; &odium bicarbonate
; !riamterene
Finding
Normal values: . - 6
alse increased values: ; urine becomes alkaline #it" prolonged storage values
Decreased values:
; de"ydration
; diabetic acidosis
; diarr"ea
; drugs (ammonium c"loride$ ascorbic acid$ met"ionine$ mandelic acid
increased values:
; c"ronic renal failure
; presence of bacteria
; pylorus obstruction
; tubular acidosis
alse decreased values:
actor of conversion (Conv"I) 1
$eference values usually .-6 (may range from %.. to 8
URINALYSIS - &RO"EIN
Hroteinuria is t"e occurrence of protein in t"e urine$ usually conse?uential to a renal parenc"yma lesion. 5 normal
kidney prevents t"e loss of protein by tubular resorption. 't "as been found t"at a very small amount of protein is excreted by
primary urine$ and undergoes tubular reabsorption$ so t"at final urine contains very lo# amounts of protein t"at cannot be
demonstrated by routine examinations (test strip. 'n normal individuals$ urinary excretion of protein amounts to up to 1.0 mg
protein daily. 3ue to limited permeability of t"e renal glomerular membrane$ t"ese proteins are of a lo# molecular mass (mostly
albumins.
!hysiologic proteinuria is al#ays transient and occurs conse?uentially to p"ysical exertion$ sport activities$ follo#ing intake of
protein-ric" food$ after exposure to lo# temperature$ and in late pregnancy.
11
5ccording to t"e site of onset$ pat"ologic proteinurias are classified as follo#sB
&' prerenal proteinurias
)' renal proteinurias
a) glomerular proteinuria
b) tubular proteinuria
+' postrenal proteinurias
&' !rerenal proteinurias develop as a conse?uence of a process occurring 4before4 t"e kidney. Hroteins of a lo# molecular
mass t"at are not reabsorbed in t"e tubules$ e.g. /ence-Dones protein$ pass to t"e urine. !"is type of proteinuria also occurs in
some "eart diseases #it" circulation disorders$ some liver diseases$ and #it" elevated body temperature.
)' $enal proteinurias occur due to increased tubular permeability or lesion. !"ese proteinurias are usually permanent.
+' !ostrenal proteinurias develop conse?uentially to inflammatory processes of t"e lo#er genitourinary tract (urinary bladder$
urinary duct$ prostate or vagina.
Krt"ostatic proteinuria is a se?uel of elevated renal intravenous pressure. 't occurs in c"ildren and young individuals$
only #"ile #alking or standing$ and disappearing on lying do#n and at rest. !"e so-called ort"ostatic test is performed to
demonstrate ort"ostatic proteinuria. Hrotein concentration in 2%-"our urine usually is belo# 1000 mg,-$ #"ereas in individual
specimens it may range bet#een .00 and 1000 mg,-. Krt"ostatic proteinuria is not considered a disease$ "o#ever$ t"ese
individuals s"ould be follo#ed up because studies "ave s"o#n t"at 3.: of cases of ort"ostatic proteinuria progress to
permanent proteinuria.
Determination
!"e met"ods of protein demonstration by means of test strip are based on t"e principle so-called indicator protein error.
!"e test strip area for protein determination in urine contains a buffer and indicator (bromop"enyl blue or
tetrabromop"enolp"t"aleinet"ylene ester. 5t p< 3.0$ t"e indicator is yello# and in t"e non-ioni2ed form. !"e color of t"e
ioni2ed form of t"e indicator at t"e same p< c"anges to lig"t-green t"roug" blue. N"en t"e test strip is immersed in t"e urine
containing protein$ t"e protein is bound to t"e indicator anion groups via -G<2 groups$ #"ereby t"e concentration of t"e
indicator non-ioni2ed molecules is decreased$ and t"e ratio of ioni2ed and non-ioni2ed form of t"e indicator is c"anged. 5s t"e
color of t"e indicator depends on t"e ratio bet#een ioni2ed and non-ioni2ed form of t"e indicator$ t"e color of t"e indicator #ill
c"ange from yello#-green to blue in t"e presence of protein alt"oug" p< "as remained unc"anged (p< 3.0. !"e indicator is
"ig"ly sensitive to lo#-molecular albumin$ #"ic" is excreted in glomerular lesions$ and less sensitive to ot"er proteins (e.g.
globulins$ /ence-Dones protein$ !amm-<orsfall protein.
Clinical significance
3emonstration of proteinuria #it" microscopic examination of urinary sediment is one of t"e most important procedures for t"e
recognition and differential diagnosis of kidney disease. 'n kidney diseases$ proteinuria is a common and nonspecific symptom.
't need not al#ays be an evidence of renal disease$ but may also point to diseases of t"e genitourinary tract. !"erefore$ a
positive finding of protein in t"e urine s"ould al#ays be follo#ed by additional differential diagnosis tests.
't "as been s"o#n t"at not only albumins (albuminuria$ but also t"e follo#ing proteins are excreted by urineB
1. plasma proteins and t"eir fragments
2. proteins originating from t"e kidneys
3. proteins originating from t"e prostate and vagina
%. tissue proteins
.. "ormones
6. tumor markers
0. proteins found in t"e urine after bacterial or viral infection
!roteinuria:
&' !hysiologic proteinuria
; p"ysical activity
; essential ort"ostatic proteinuria
; pregnancy
; in some #omen$ in t"e premenstrual period
)' !athologic proteinuria
; Hrerenal proteinuria
a acute infections
b liver diseases
c "eart diseases
d partial renal venous t"rombosis
e febrile states
f sei2ures
g severe anemia and leukemia
" trauma
i tumors exerting pressure upon renal veins (abdominal tumors
; Cenal protenuria
a acute and c"ronic nep"ritis
b eclampsia
12
c drugs and toxins (mercury c"loride$ lead$ uranium$ cadmium
d nep"roses
e pyelitis
f pyelonep"ritis
; Hostrenal proteinuria
a diseases of t"e urinary duct$ urinary bladder$ urinary tube and prostate
Effect of drugs
Decreased values: Increased values:
; 5tenolol
; Captopril
; Cyclosporine 5
; >nalapril
; 'nterferon-O-2
; Hrednisolone
; Puinapril
; &alicylates
; &ulfinpyrasone
; &ulfonamides
; 5cetaminop"en
; 5cetanilid
; 5ceta2olamide
; 5minop"yline
; 5minopirin
; 5minosalicylic acid
; 5ntimony compounds
; 5rsen compounds
; /acitracin
; /icarbonates
; /ismut" triglycollamate
; Carbon tetrac"loride
; >t"osuximide
; >t"oxa2ine
; (entamycin
; (old salts
; (riseofulvin
; 'sonia2id
; Janamycin
; Fercuric c"loride
; Fet"enamine
; Fet"suximide
; Geomycin
; Govobiocin
; Henicillamine
; Henicillin
; H"ena2opyridine
; H"enolp"talein
; Puaternary ammonium compounds
; Cadiopa?ue contrast media
; &alicylates
; &odium bicarbonate
; &ulfinpyrasone
; &ulfonamides
; &ulfones
; !"eop"ylline sodium
; !"iosemicarba2ones
; !"ymol
; !olbutamide
; 8itamin 3
Finding
Negative
alse positive
; bicarbonates
; c"lor"exidine
; in vitro interferences
; p"ena2opyridine (false-red color
; polyvinylpyrrolidone infusion
; urine container contamination (antiseptics and disinfectants containing ?uaternary
ammonium salts
; very alkaline urine
!ositive ; acute and c"ronic nep"ritis
; acute infections
; diseases of t"e urinary duct$ urinary bladder$ urinary tube and prostate
; drugs and toxins (mercury c"loride$ lead$ uranium$ cadmium
; eclampsia
; essential ort"ostatic proteinuria
13
; febrile states
; "eart diseases
; in some #omen$ in t"e premenstrual period
; liver diseases
; nep"roses
; partial renal venous t"rombosis
; p"ysical activity
; pregnancy
; pyelitis
; pyelonep"ritis
; sei2ures
; severe anemias and leukemias
; severe s"ock (stress
; trauma
; tumors exerting pressure upon renal veins (abdominal tumors
alse negative
actor of conversion
(Conv"I)
10 (mg,d- mg,-
#imit of sensitivity ("I) 1.0 L 200 mg,- (1. - 20 mg,d-
$eference values = 1.0mg,2% "ours
URINALYSIS - S&ECIFIC RA'I"Y
3etermination of urine specific gravity "as a great diagnostic value for evaluation of t"e concentration capacity of t"e
kidneys. &pecific gravity of t"e urine depends on urine volume and urinary concentration of dissolved substances. !"e normal
values of urine specific gravity range from ,"-,* to ,"-.*, #"ic" is a relative ratio bet#een urine density and #ater density$
t"us it is a dimensionless number. 5s t"e kidneys are capable of diluting or concentrating t"e urine$ as needed$ the values of
urine specific gravity may range from ,"--. to ,"-(-" 3uring t"e day$ t"e kidneys eliminate about 60 g of solid substance from
t"e body.
Determination
!"e principle of urine specific gravity measurement by means of test strip is based on t"e c"ange in polyelectrolyte
solution (poly-(met"ylvinyl et"er,maleic acid pJa$ causing c"ange in t"e indicator color. !"e an"ydride group of t"e
polyelectrolyte solution undergoes "ydrolysis on test strip immersion in t"e urine$ #"ereby active carboxyl groups are formed.
!"e "ig" concentrations of GaM and JM from t"e urine release "ydrogen ions from t"e polymer. !"us released protons (<M
decrease t"e solution p<$ #"ereby t"e color of t"e bromot"ymol-blue indicator c"anges from blue to yello#. !"e concentration
of ions is determined in t"is #ay$ #"ereas nonionic substances dissolved in t"e urine are not involved (e.g. glucose$ protein. 'n
t"is case$ t"e measurement of specific gravity does not depend on glucose concentration and temperature. <o#ever$ at p<
values greater t"an 0.0$ a correction by M0.00. (one "ue area is re?uired. &pecific gravity is indirectly determined by
comparing t"e color c"ange #it" t"e given scale. <ig" amounts of drugs and contrast media may produce false-increased
values. 'n suc" cases$ no correction of t"e value of urine specific gravity is possible.
Clinical significance
'ncreased values of urine specific gravity are found inB
; glomerulonep"ritis
; uncontrolled diabetes mellitus
; obstructive uropat"y
; proteinuria.
3ecreased values of urine specific gravity are found inB
; tubular disease
; c"ronic renal insufficiency
; malignant "ypertension
; diabetes insipidus
Effect of drugs
Decreased values: Increased values:
; Carbenoxolone ; 5lbumin
14
; Colistin
; -it"ium
; Fet"oxyflurane
; 3extran
; 3itri2oic 5cid
; (lucose
; 'sotretinoin
; Cadiopa?ue contrast media
Finding
Normal values: 1.01. - 1.02.
Decreased values:
; 3iabetes insipidus
; glomerulonep"ritis (not in acute form
; pyelonep"ritis (not in acute form
; severe kidney damage
alse increased values:
; c"lor"exidine
; "ig" amounts of bivalent cations (e.g. Ca
MM

; "ig" amounts of protein


; presence of contrast media in t"e urine
Increased values:
; glomerulonep"ritis
; loss of "ig" amounts of #ater (de"ydration$ fever$ vomiting$ diarr"ea
; obstructive uropat"y
; proteinuria
; uncontrolled diabetes mellitus
alse decreased values: ; strongly alkaline urine
actor of conversion (Conv"I) 1
$eference values 1.01. - 1.02.
URINALYSIS - UROBILINOEN
!"e amount of urobilinogen in t"e urine depends on t"e diurnal r"yt"m of urobilinogen metabolism$ food intake$ and
"epatic bile output. 'f t"e amount of urobilinogen produced is greater$ it passes to t"e blood and is excreted by t"e kidneys. 'n
liver diseases$ urinary excretion of urobilinogen is also increased due to t"e liver function impairment. Urobilinogen is not found
in t"e urine in case of decreased bile production by "epatocytes$ obstruction of bile output to t"e intestine$ and failure of t"e
intestinal bilirubin reduction.
Determination
3etermination of urobilinogen is performed exclusively in fres" urine. 'f t"e urine is left at room temperature$ urobilinogen is
oxidi2ed to urobilin. 'f t"e determination of urobilinogen cannot be performed in fres" urine$ it is recommended to determine
urobilin. !"e test strip area for urobilinogen determination is impregnated #it" p-dimet"ylaminoben2oalde"yde and acidic buffer
or dia2onium salt of p-met"oxyben2oldia2onium tetrafluoroborate. 5 test strip impregnated #it" dia2onium salt of p-
met"oxyben2oldia2onium tetrafluoroborate is specific and it does not react #it" ot"er substances producing positive >"rlic"
reaction. !"e intensity of red a2o dye is proportional to t"e concentration of urobilinogen in t"e urine.
Clinical significance
5n increased excretion of urobilinogen by urine occurs due toB
1. overloading of t"e liver functional capacity
; increased "emoglobin decompositionB
; "emolytic anemia
; intravasal "emolysis (transfusion$ poisoning$ infectious diseases
; pernicious anemia
; polycyt"emia rubra vera
; increased intestinal production of urobilinogen in constipation$ enterocolitis$ ileus$ en"anced digestive processes
; increased urobilinogen production and resorption in biliary duct insufficiency (e.g. c"olangitis
2. decreased liver functional capacity
; viral "epatitis
; c"ronic "epatitis and liver cirr"osis
; toxic "epatic lesions (poisoning #it" mus"rooms$ organic solvents$ drugs$ etc.
; liver stasis (e.g. in myocardial infarction or cardiac insufficiency
; liver "ypoxia
; liver tumors$ depending on turmor si2e and locali2ation
; partial biliary duct obstruction$ depending on t"e grade of liver parenc"ymatous lesion
3. liver stasis
15
; liver cirr"osis #it" portal "ypertension
; portal venous t"rombosis
; "epatic venous occlusion
Effect of drugs
Decreased values: Increased values:
; 52o dye metabolites (pyridium
; C"loeamp"enicol large dose
; Eormalin
; 5minosalicylic acid
; 5ntipyrine
; /&H
; C"lorop"yl
; C"loroproma2ine
; Eormalin
; Henicillin
; H"ena2opyridine
; H"enot"ia2ines
; &ulfadia2ine
; &ulfamet"oxa2ole
; &ulfanilamide
; &ulfisoxa2ole
Finding
Negative
alse positive
; aminosalicylic acid
; antipyridine
; /&H
; drugs leading to red discoloration of t"e urine$ e.g. p"ena2opyridine
; p-aminoben2oic acid
; sulfonamides
!ositive
; acidosis
; diabetes mellitus
; diarr"ea
; fever
; "ypert"yroidism
; preeclamptic toxemia
; starvation
; vomiting
alse negative
; c"loramp"enicol ("ig" doses
; formalde"yde concentration )00 mmol,-
; formalin as preservative
; t"erapy #it" "examet"ylenetetraamine
; urine exposed to sunlig"t
actor of conversion (Conv"I) 16.* (mg,d- 7mol,-
#imit of sensitivity ("I) 3 7mol,- (about 0.2 >"rlic" units,d-
$eference values 3-16 7mol,- - upper limit 10 7mol,- (1 mg,d-
Conse(uences of ina$$ro$riate urine s$ecimen storage
Until analysis$ urine s"ould be protected from direct sunlig"t$ t"us avoiding t"e possibility of erroneous results due to
subse?uent urine c"anges. 'n case of prolonged urine storage beyond t"e above mentioned time limits$ t"e follo#ing c"anges
developB
bilirubin - decreased due to sun exposure
color - c"anged due to oxidation or metabolite reduction
bacterial count - increased
cell and cylinder count - decreased due to disintegration$ especially in a diluted or alkaline specimen
glucose - decreased due to glycolysis and bacterial utili2ation
16
,etones - decreased due to volatili2ation
nitrites - increased due to bacterial reduction of nitrates
p% - increased because of urea decomposition to ammonia due to t"e bacterial urease activities
turbidity - increased due to bacterial gro#t" and possible deposition of amorp"ous salts
urobilinogen - decreased due to oxidation to urobilin
OVERVIEW
IN"RODUC"ION
Urine analysis is considered to be t"e oldest clinical c"emistry test. 5t present$ it still remains one of t"e basic tests regardless
of t"e disease involved. Currently$ c"emical testing of urine is usually performed by use of a test strip. !"e routine urine
examination includes test strip screening$ follo#ed by microscopic examination of urinary sediment if necessary. Kt"er tests are
performed #"ere applicable.
Urine sam$ling
5 midstream urine specimen collected after t"oroug" "ygiene of external genitals is an optimal sample. 5ppropriate urine
sampling and preparation are of utmost importance for t"e c"emical and microscopic urine tests to produce reliable results.
!"erefore$ t"e containers used for urine collection must be t"oroug"ly clean and time of analysis strictly defined (#it"in 1-2
"ours from urine sampling.
Urine specimen can be obtained byB
1. spontaneous urination$
2. spontaneous urination - midstream urine specimen$
3. cat"eteri2ation$ and
%. percutaneous and suprapubic urinary bladder aspiration.
")$es of urine s$ecimen
5 "ealt"y adult excretes about 1.00 m- of urine daily. !"e overall amount of urine excreted during 2% "ours s"ould preferably
be obtained for urinalysis$ be it ?uantitative or ?ualitative. <o#ever$ t"is mode of urine collection is ?uite ?uestionable$ because
not all people comply #it" t"e instructions and may not present total 2%-"our urine for examination. Urine is collected into clean
containers in t"ree #aysB
1. random specimen (individual specimen$
2. diurnal or nocturnal specimen collected over a certain period of time$ and
3. 2%-"our urine.
$andom specimen
!"is type of urine specimen can be obtained at any time of t"e day$ "o#ever$ t"e first morning urine is recommended as it is
most concentrated and approximates t"e composition of 2%-"our urine. !"e p"ysicoc"emical examination of urine is performed
on fres" urine #it"out t"e addition of preservative.
Diurnal or nocturnal urine specimen or urine specimen collected over a certain period of time
!"e urine collected in t"is #ay is used for urinalysis in some disorders$ e.g. alimentary glycosuria$ proteinuria$ etc. !"e mode of
urine collection$ storage and preservation depends on t"e tests to be performed.
)-.hour urine
Eor ?uantitative assays$ 2%-"our urine specimens s"ould be carefully collected and preferably refrigerated. Certain preservatives
s"ould be added if c"emically instable compounds are to be determined. !"e type of preservative depends on t"e analyte to be
17
determined. 10: solution of t"ymol in isopropanol (. ml for 2%-"our urine is most commonly used as preservative.
Eor routine urine examination$ it is recommended to use t"e first morning urine obtained at least 8 "ours from t"e last void. Eor
urinalysis by means of test strip$ any random urine specimen can be used$ "o#ever$ t"e time of urine sampling s"ould be
considered on result interpretation.
Containers
!"e containers used for urine collection must be made from a material non-reactive #it" urine constituents. !"ey must "ave a
#ide neck (at least % cm in diameter$ and be .0 ml in si2e$ preferably disposable. !"e container used for urine collection must
be t"oroug"ly clean. 'n case of urine specimen transportation$ t"e containers must be provided #it" appropriate caps and labels
containing t"e follo#ing dataB
; patient4s first and last name$
; date and time of urine sampling$ and
; sample storage before transportation to laboratory (in a refrigerator at M2 QC to M8 QC or at room temperature.
Storage of urine s$ecimen
!"e analysis of a urine specimen s"ould be carried out as soon as possible after urine sampling$ due to rapid autolytic c"anges
of t"e formed elements (cells$ cylinders and propagation of bacteria. !"erefore$ urine specimens s"ould not be stored at room
temperature for more t"an 2 "ours (according to some sources$ not more t"an 30 minutes. 't is recommended for urine
specimen to be stored at M2 QC to M8 QC$ "o#ever$ t"e time of storage s"ould be maximally reduced.
'f stored in a refrigerator$ urinalysis s"ould be carried out #it"in % "ours from urine sampling.
Conse(uences of ina$$ro$riate urine s$ecimen storage
Until analysis$ urine s"ould be protected from direct sunlig"t$ t"us avoiding t"e possibility of erroneous results due to
subse?uent urine c"anges. 'n case of prolonged urine storage beyond t"e above mentioned time limits$ t"e follo#ing c"anges
developB
bilirubin - decreased due to sun exposure
color - c"anged due to oxidation or metabolite reduction
bacterial count - increased
cell and cylinder count - decreased due to disintegration$ especially in a diluted or alkaline specimen
glucose - decreased due to glycolysis and bacterial utili2ation
,etones - decreased due to volatili2ation
nitrites - increased due to bacterial reduction of nitrates
p% - increased because of urea decomposition to ammonia due to t"e bacterial urease activities
turbidity - increased due to bacterial gro#t" and possible deposition of amorp"ous salts
urobilinogen - decreased due to oxidation to urobilin
&rocedure of urine sam$ling - urine collection
1. Urine specimen
Forning urine (midstream
2. Hatient preparation
; !"e patient is given a urine container$ labeled #it" t"e patient4s name
; !"e patient is instructed on "o# to perform urine samplingB
a "and #as" #it" soap
b #as"ing external genitals #it" soap
c genitals "ygiene
(en:
1. Uncircumcised men s"ould be #arned to pull t"e preputium to expose t"e external ureteral orifice.
2. !"e glans s"ould be cleaned #it" a clean (sterile to#el$ from t"e ureteral orifice out#ard.
/omen:
!"e ureteral orifice and surrounding area s"ould be cleaned #it" a clean (sterile to#el.
d t"e first void s"ould be allo#ed to pass into t"e lavatory (1$
e t"e midstream urine is voided into t"e urine container (2$
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f t"en t"e remaining urine is voided into t"e lavatory (3$
g t"e container is closed and urine specimen immediately delivered to t"e laboratory.
"est stri$ - general information
!est strips are used to analy2e urine p< and specific gravity$ and to demonstrate t"e presence of glucose$ bilirubin$ ketones
(acetoacetic acid$ blood$ protein$ urobilinogen$ nitrites$ leukocytes and ascorbic acid in urine (depending on t"e type of test
strip used. !est strips are used for rapid and reliable demonstration and semi?uantitative determination of particular analytes in
urine by ?uite a simple procedure.
N"ile #orking in a medical bioc"emistry laboratory in 8ienna in 1*20s$ Erit2 Eeigl began to t"ink about a more rapid testing for
certain urine compounds by filter paper impregnation #it" particular reagents. &ome 20 years elapsed from t"e idea to its
implementation. 'n 1*3.$ a report on rapid urinalysis by test strips appeared in t"e @ournal of t"e -eip2ig 5cademy of &ciences.
<o#ever$ Eeigl4s invention found routine application years later$ #"en industry manufacture of strips for rapid urine testing
started. Eirst strips #ere intended for a single parameter$ e.g. glucose$ albumins$ ketones$ etc. !"en$ 5mes started t"e
manufacture of test strips for simultaneous determination of a number of analytes$ e.g. <ema-combistix for protein$ glucose$ p<
and acetone. !"e s"ortcoming of t"ese first test strips #as t"eir instability due to t"e reagent susceptibility to t"e effect of
moisture (#it" filter paper as a medium. -ater on$ filter paper as a carrier #as substituted by inert plastic strips #it" reagent-
impregnated paper slips (6x6 mm slips of filter paper pasted on.
Currently used test strips are made of plastic foil #it" reagent paper (impregnated reagents at particular areas. 5 special layer
to absorb excess fluid is placed underneat" t"e reagent paper. 5 t"in nylon mes" is stretc"ed over t"e absorbent layer and
reagent paper$ fixing t"em to t"e foil and at t"e same time protecting t"em from any undesirable contact and contamination.
!"e strip allo#s t"e reagent paper (6x6 mm to be uniformly perfused #it" urine #"ile t"e reaction is proceeding steadily$
toget"er #it" removal of excess urine. !"e principles of reagent reactions in dry state for testing particular analytes in urine are
identical to t"ose performed in t"e test tube. 5 specific c"emical reaction for determination of an analyte concentration is
combined #it" an indicator or con@ugated reagent to produce a color of varying intensity proportional to t"e tested analyte
concentration.
!"e first test strips #ere manufactured in 1*.0 for diagnostic purpose$ i.e. for t"e detection and follo#-up of diabetes mellitus.
!"ese test strips contained reagents for demonstration of glucose in urine (Clinistix$ 5mesA &-(lucotest$ /oe"ringer-Fann"eim.
Ceagents for ot"er tests #ere t"en gradually added onto t"e test strip. 5t present$ 11 different urine parameters can be
?ualitatively or semi?uantitatively determined by manual evaluation or automaticallyB
1. p<
2. glucose
3. protein
%. nitrites
.. urobilinogen
6. ketones
0. bilirubin
8. blood
*. leukocytes
10. specific gravity
11. ascorbic acid
!est strips "ave been continuously developed$ e.g. ne# reagents to prevent interferences "ave been added to t"e layers #it"
basic reagents (for instance$ an iodate-impregnated layer oxidi2ing ascorbic acid in urine$ t"us preventing t"e potentially
interfering effect$ is being added onto t"e test strip for determination of blood in urine.
!est strips allo# rapid and reliable demonstration and semi?uantitative determination of particular analytes in urine. !"e use of
test strips "as a number of advantagesB
; simple use$
; constant reagent composition$
; specificity for particular parameters$ and
; long-term stability.
3isadvantages of t"e use of test strips includeB
; inade?uate sensitivity for some analytes (e.g. albumin$
; susceptibility to interferences$ and
; semi?uantitative results.
!"e test strip pack and vial are labeled #it" t"e type of analyte determined at eac" individual test strip area. !est strip areas are
ready for use immediately upon being taken out from t"e vial. !est strips can be read manually$ #it"out any additional
laboratory e?uipment$ or on automated urine test strip readers of a number of manufacturers (e.g. Clinitec$ Fiditron$ Capimat
''$ etc..
"est stri$ and its use
!"e manufacturer4s instructions provided in eac" pack s"ould al#ays be strictly follo#ed$ because t"e procedure may vary #it"
different manufacturers.
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Urine test strips can be used forB
1. routine examination$
2. monitoring of t"erapy and possible relapse$
3. self-monitoring$ and
%. systematic examinations.
&' $outine e0amination
Complete c"emical urinalysis by means of a test strip covering t"e follo#ing parameters is t"e most rational procedure for daily
routine examination of urine in a general practice or "ospital settingB
; nitrites
; p<
; protein
; glucose
; ketones
; urobilinogen
; bilirubin
; blood
; leukocytes
; ascorbic acid
; specific gravity
>arly symptoms of t"e follo#ing large groups of diseases can be detected by a single urine test stripB
; carbo"ydrate metabolism disorders$
; kidney and genitourinary tract diseases (e.g. calculi$ tumors$ glomerulonep"ritis$ pyelonep"ritis$ etc.$ and
; "emolytic and liver diseases.
)' (onitoring of therapy and possible reccurrence
a' Diabetes mellitus
Eor t"erapy monitoring$ special test strips for t"is indication are used.
!"e follo#ing tests are performed in diabetes mellitusB
; glucose
; ketones.
!"ese tests #ill reveal metabolic c"anges or dietary errors.
b' 1idney and genitourinary tract diseases
!"e follo#ing tests are performedB
; nitrites
; p<
; protein
; blood
; leukocytes
c' 2ile pigment demonstration
!"e follo#ing tests are performedB
; urobilinogen
; bilirubin
+' "elf.monitoring
!est strips can be given to patients$ as recommended by t"e p"ysician. !"is especially "olds for diabetic self-monitoring (glucose
and ketones.
-' "ystematic e0aminations
Urine test strips are used forB
; general screening in systematic examinations$
; general or target screening in epidemiologic studies$
; early detection of pat"ologic conditions$ and
; t"erapy monitoring.
"est stri$ sensiti*it)
3est strip evaluation
!#o criteria are essential for t"e evaluation of test strip usabilityB
; test strip sensitivity and
; test strip specificity
3he level of sensitivity is a very important criterion for test strip evaluation. !"e level of sensitivity is t"e concentration of a
substance at #"ic" at least *0 of 100 different specimens are positive.
20
!"e level of sensitivity is t"e smallest concentration of a substance t"at can be detected by t"e test strip.
3etection limit of particular tests is so lo# t"at even very small c"anges in urine composition cause c"anges in t"e color of test
paper slips$ yielding positive reaction.
!"e limits of detection differ bot" for particular analytes and for test strips from different manufacturers.
"est stri$ s$ecificit)
3est strip specificity is t"e c"aracteristic of c"emical reaction to react exclusively #it" t"e analyte #"ose concentration is to
be determined. 'f no ot"er substances interfere #it" t"e reaction$ t"e c"emical reaction is considered "ig"ly specific.
; (lucose
5 "ig"ly specific test$ because only glucose reacts #it" t"e glucose oxidase en2yme.
; Hrotein
!"e reaction is specific for albumins #it"in p< range of .-*. !"e test is less sensitive for ot"er proteins (e.g. /ence-Dones
protein$ mucoproteins suc" as !amm-<orsfall protein.
; Jetones
5 "ig"ly specific reaction for acetoacetic acid and acetone.
; Urobilinogen
5 "ig"ly specific reaction. Go interferences from porp"obilinogen$ indican$ or p-aminosulfosalicylic acid.
; /ilirubin
&pecific reaction in a fres" urine specimen.
; <emoglobin
&pecific reaction for "emoglobin and myoglobin. >pit"elial cells$ leukocytes$ and spermato2oids do not interefere #it" t"e
reaction.
; Gitrites
!"e reaction depends exclusively on nitrites (p< .-*.
; -eukocytes
!"e esterase from granulocytes and "istiocytes is specific. >pit"elial cells and spermato2oa do not interfere #it" t"e reaction.
"est stri$ storage
!est strips are packed in an aluminum or plastic box. >ac" box is provided #it" a moisture absorbing desiccant (inorganic silicate
gel or silica gel. Nit" appropriate storage (M% QC to 30 QC and usage (t"e box must be closed immediately upon taking a strip
out of it$ t"e test strips remain stable until t"e expiry date specified on t"e pack.
/or,ing procedure
!est strips are kept at room temperature in original aluminum boxes. 'f t"e box #it" test strips "as been stored in a refrigerator$
t"e strip must be accommodated to room temperature.
!"e box #it" t"e strips must be kept closed all t"e time.
Urine tests performed #it" test strips are very simple.
3etermination is performed in a fres"ly obtained$ uncentrifuged urine specimen.
3est strip immersion in urine
!"e test strip is briefly (maximally 1 second immersed in t"e urine so as to #et all test areas.
$emoval of e0cess urine
Upon taking t"e test strip out of t"e urine$ excess urine can be removed by #iping t"e strip edge along t"e container brim.
<o#ever$ it is recommended to lean t"e lo#er side of t"e strip against a filter paper or cell-tissue.
$eading
Kn visual (manual reading$ time "as to be measured because t"e duration of a particular reaction differs bet#een test strips of
different manufacturers. Ceading is performed #it"in 30 and 120 seconds (depending on test strip type and manufacturer.
5fter t"e time period strictly defined by t"e manufacturer$ t"e color produced by t"e reaction is compared #it" t"e color of t"e
respective area on t"e reading scale.
Color c"anges appearing only along t"e margins of test areas$ or developing after more t"an 2 minutes "ave no diagnostic
value.
5utomated test strip readers read t"e result #it"in t"e strictly defined time set according to t"e manufacturer4s instructions.
't is recommended to use automated test strip readers. 'f it is not possible$ a stop-#atc" s"ould be used on manual reading.
; 'f some drugs are suspected to influence positive test results$ t"e test s"ould be repeated upon t"erapy completion.
; Urine assay s"ould be performed #it"in % "ours.
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