Influence of Vitamin C on Urine Dipstick Test Results

A CASE STUDY PRESENTATION

Submitted by:
Sydney Umayam
Joanne Faith Manayag
Jessie Agub
Edna Jean Martin
Julie Ann Lampitocc

APRIL 2017
 ABSTRACT

A urinalysis is simply an analysis of the urine. It is a very common test that can be
performed in many health-care settings, including doctors' offices, urgent-care facilities,
laboratories, and hospitals.

Urine can be evaluated by its physical appearance (color, cloudiness, odor, clarity), or
macroscopic analysis. It can be also analyzed based on its chemical and molecular properties
or microscopic assessment. It involves the usage of urine dipstick in the determination of
chemical and molecular properties of the urine. Urine dipstick is a narrow plastic strip which
has several squares of different colors attached to it. . The main advantage of dipsticks is that
they are convenient, easy to interpret, and cost-effective that can be analyzed within minutes
of urine collection in the doctor's office or in the emergency room to provide valuable
information but this reagent pad can interpret false negative or false positive reaction as some
agents could alter by reducing or oxidizing the reaction taking place.

Vitamin C is a strong reducing agent found at high levels in various foods, and it may
influence the results of urine strip tests even at an ordinary consumption levels. High
concentrations of vitamin C in urine can cause false decreases in dipstick reactions, with a
variable degree of interference, depending on the analytes and their concentrations. The
utility of a urine strip with a vitamin C indicator is useful to reduce the risk of incorrect
results in regard to diseases that could go unrecognized and considerable costs might be
incurred in the treatment of subsequent complications caused by a misdiagnosis.

As shows that the patient took high dosage of Vitamin C believing it was curative on
what symptoms she was experiencing, the result of her urinalysis was not correlated and
matched to the chemical examination of the dipstick and the microscopic examination, most
especially to the 15-18/hpf counted WBC and 10-13/hpf counted RBC, as a medical
technologist, it is firm that it is not reliable to be releases as a result and interpreted by the
physician. It is advisable to the said situation on the usage of the 11 th pad of dipstick which
was used to determine the presence of Vitamin C in significant interference level that will
determine if the urine specimen is viable in examination, if not, patient would advisable to
repeat the collection voiding or deferring itself from taking medications especially Vitamin
C.
 INTRODUCTION

Urinalysis is one of the essential laboratory test that is simple, inexpensive that can
help in the diagnosis. This could be the key in the detection and management of disorders
such as urinary tract infection, kidney malfunction and diabetes mellitus. It involves he
chemical and physical and microscopic examination or urine via procedures performed in an
expeditious, reliable, accurate and safe manner.

Urinalysis became the mirror of medicine for thousands of years. From a liquid state
through which the physicians could know the body’s inner workings, urine has led to the
beginnings of laboratory medicine and become a powerful tool in obtaining crucial
information for diagnostic purposes. As the time passed, the role of physicians elevated and
the importance of urinalysis became more complex until it is already used to correlate in the
diagnosis of such diseases. Urine is an unstable fluid, and changes its compositions begin to
take as soon as its voided. In the laboratory, urine can be characterized by its physical
appearance which includes the identification of the parameters (specific gravity, protein,
blood, pH, glucose, bilirubin, urobilinogen, ketone, nitrites, and leukocyte esterase’s.
Microscopic examination entails the detection of crystals, cells, casts and microorganism.

As the evolution of laboratory science, urinalysis has become a routine in the check-
ups. From the checking of the physical appreance, concentration and content, abnormality of
result may point to such illness and disorders in excretory system that is responsible in
removing waste and toxin of the body.
 PROBLEM AND DISCUSSION

The presented case study was a female patient arrived at the emergency room with symptoms
of lower back and urinary frequency with burning sensation. She is a firm believer in the
curative power of ascorbic acid. She has tripled her usual dosage in an effort to alleviate her
symptoms; however the symptoms have persisted. She was given a sterile container an asked
to collect amid- stream clean catching urine specimen. Result of her urinalysis is as follows:

Physical Examination
Physical Examination Reference Range
Color Dark Yellow
Clarity Slightly Turbid
Chemical Examination
Specific Gravity 1.015
pH 6.5 4.5-8.0
Protein Trace Negative
Glucose Normal Normal
Bilirubin Negative Negative
Blood Negative Negative
Ketone Negative Negative
Nitrite Negative Negative
Uroblinogen Normal Normal
Leukocyte esterase 1+
Microscopic Examination
WBC 15-18 0-5/HPF
RBC 10-13 0-2/HPF
Epithelial cells Moderate
Bacteria Moderate
Mucus threads Few
Amorphous crystals Few
Hyaline cast 1-2 0-2

Basing on the history and given results above, as the Medical Technologist on duty, will you
report these results?

Above the history of the patient, discrepancy was found causing the pre-analytical and
analytical be involved reason that it should not be reported instantly. Vitamin C or Ascorbic
Acid could cause false-negative in the reaction pad affecting glucose, blood, bilirubin, and
nitrite and leukocyte esterase.

The analytes affected and the level of ascorbic acid that is needed before interference
occurs is described in the following table with the amount or level of presence of Ascorbic
Acid in the urine that can interfere each analyte in the reaction pad of the urine strip:

Analyte Interference Level

Bilirubin >25 mg/dL
Glucose >50 mg/dL
Nitrite >25 mg/dL
Leukocytes Unspecified
Blood 9 mg/dL
Urobilinogen Unspecified
Brunzel, Nancy A. (2016). Fundamentals of Urine and Body Fluid Analysis. (4th Edition). Retrieved from
goo.gl/GM0FXB.

Ascorbic acid is a strong reducing substance because of its ene-diol group. As

a hydrogen donator, ascorbic acid readily oxidizes to dehydroascorbic acid, a colorless
compound. Reagent strip tests that use hydrogen peroxide or a dia-zonium salt are subject to
ascorbic acid interference. Whether these compounds are impregnated in the reaction pad or
are produced by a first reaction, they are removed by ascorbic, which prevents the intended
reaction. As a result, colorless dehydroascorbic acid is produced, no positive color change is
observed, and a false-negative or a falsely low result is obtained. (Brunzel, Nancy A. (2016))
Ascorbic is known to be a strong oxidizer and can be sensitive in the alteration of the
color reaction of the strip. The reagent strip tests are vulnerable as for in test for the presence
of blood as it reacts with H2O2 on reaction pad decreasing reaction resulting to wrong color
developed; in bilirubin, ascorbic reacts with diazonium salt on reagent pad; in glucose, it
reacts with H202 produced by first reaction and in nitrite, it reacts with diazonium salt
produced by first reaction; in leukocyte esterases, it also reacts diazonium salt resulting to
false negative. However because of reagent strip variations, some brands overlays
pigmentation to the strip to prevent or hydrolyze the reaction of vitamin C in prevention of
alteration in the development of color pad.

Usually, the presence of ascorbic acid in urine most often is suspected when
microscopic examination reveals increased numbers of red blood cells but the reagent strip
test for blood is negative. The effect of ascorbic acid on decreasing glucose reagent strip is
less obvious and may be suspected only when ketones are positive and glucose negative, or
when a discrepancy exists between the copper reduction test and the reagent strip test for
glucose. Ascorbic acid remains a source of false-negative or decreased chemical test results
when some brands of reagent strips are used, thus highlighting the importance of reading the
product inserts provided by each reagent strip manufacturer.

CONCLUSION

In the said discrepancy above, the result should not be reported and released.
Correlation plays a big part on the determination of the discrepancy of the specimen.
Microscopic examination was differ to the possible result of the urine strip as it showed that
the presence of 15-18/hpf WBC, 10-13/hpf RBC and moderate level of bacteria.

From a clinical perspective, when ascorbate is present in the urine a clinician may
need to question the urinalysis results for the analytes listed above or repeat the test
altogether once the ascorbate has been voided from the patient’s bladder. However,
determining whether or not ascorbate is present in the urine and at what concentration is
nearly impossible to do unless the ascorbate level is tested concurrently with the urinalysis
test itself. Even more difficult is determining how quickly ascorbic acid is voided from the
bladder since each person’s metabolism occurs at different rates. Some experts recommend
that if inhibiting quantities of ascorbic acid are found or suspected to be present, or if
discrepant results are observed, that a urine specimen voided at least 10 hours after the last
administration of vitamin C should be retested. This could conclude the use of 11 th pad of the
urine strips that could determine the high levels of ascorbic acid, which is source of
interference in the urine, to know if the urine is viable for testing and releasing of the result as
a source for diagnosis of patients

Early symptoms of the diseases could go unrecognized and considerable costs might be
incurred in the treatment of subsequent complications caused by a misdiagnosis. These parts
need the role of a medical technologist to correlate the results between the chemical reaction
of the urine strips and microscopic examination of the said specimen