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6 - European Urinalysis Guidelines
6 - European Urinalysis Guidelines
net/publication/246167552
Article in Clinica Chimica Acta; International Journal of Clinical Chemistry · July 2000
DOI: 10.1016/S0009-8981(00)00256-4
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for rapid (ordinal scale) examinations (Page 42), document is limited to the most commonly
particle analysis (Page 44) and microbiological requested examinations. Some analytes are
examinations (Page 45). For ordinal-scale discussed in terms of specimen collection only,
examinations they are based on detection and since the precise medical needs and actual
con®rmation limits, as compared with a quan- analytical methods concerned would have
titative reference procedure (Page 53), or made this document too large for everyday
calculation of agreement based on k statistics use. The present recommendations have made
(Page 55). Analytical quality speci®cations for use of some of the existing national guidelines
protein and other quantitative chemical mea- [2 ± 7] as appropriate. Certain recent analytical
surements are summarized based on earlier techniques, such as ¯ow cytometry and nucleic
literature (Page 44). Implementation of elements acid ampli®cation, have widened the perspec-
of a structured quality system (good laboratory tives of information obtainable from urine. The
practice (GLP) with standard operating proce- latest technology is referred to but not described
dures (SOP) as documented in a quality in detail.
manual) is encouraged even in small labora- Target audiences: These guidelines are aimed
tories, based on national co-operation (Page mainly at laboratory professionals in small and
40). general laboratories and at points-of-care. Spe-
These guidelines should impact on the cial features from both clinical chemistry and
validation of local working practices. In addi- microbiology are included in the appropriate
tion, the principles of quality embodied in these sections. The text is divided into a general
guidelines may assist independent authorities section and an appendix containing detailed
charged with accrediting laboratories. methodological descriptions, to make it acces-
sible to clinicians and others not directly
concerned with such detail. Wherever the
1. I N T R O D U C T I O N location, the performance of examinations
must be determined by clinical requirements
1.1. Foreword and this means close co-operation between the
traditional laboratory disciplines and clinicians.
An effective diagnostic strategy from urine
The large number of specimens and the need for
should be based on standard procedures
emergency reports increase the pressure for
for collection, transport and analysis. These
rapid and reliable measurements. At the same
standardized procedures are required to pro-
duce consistent reference intervals and decision time, opportunities for cost-containment must
limits for the harmonized interpretation of be identi®ed. These guidelines will help establish
results. Europe has no consensus standard quali®ed procedures for laboratory examina-
procedures. Standardization is essential not tions in these environments.
only for interpretation of results in individual Process: This document is based on the work
patients, but also for epidemiological studies, of the European Urinalysis Group (EUG),
for determining which populations should be established under the auspices of the European
screened for urinary abnormalities, and for the Confederation of Laboratory Medicine
procedure to be followed when an abnormal (ECLM) in 1997 [8, 9]. The EUG has
result is found [1]. In addition, laboratories collaborated with the Working Party on
want to accredit their urine diagnostics by Urinalysis of the European Society for Clinical
comparing their methods with acceptable refer- Microbiology and Infectious Diseases
ences. These guidelines therefore intend to ®ll (ESCMID) in the preparation of the guidelines.
this gap by summarizing available knowledge The ``European Urinalysis Guidelines'' are
into one consensus practice for urinalysis (or based on both medical needs and available
urine analysis) in Europe. methods and technologies. In collaboration
Selected list of analytes: The terms ``urin- with many experts from most European coun-
alysis'' and ``urine analysis'' are synonymous. tries (see the list below) the present paper
The combination of analytical procedures used attempts to create consensus practice for
in practice is changing and varies in different urinalysis. The EUG wishes to express its
clinical situations. To form a basis, this gratitude to the various sponsors listed in
4 ECLM ± European Urinalysis Group
Section 1.2, without whose help this document Prof. Dr. Walter G. Guder
could not have been produced. Institute for Clinical Chemistry
StaÈdtisches Krankenhaus Bogenhausen
Englschalkinger Strasse 77
D-81925 Munich
1.2. Members of the ECLM-European
Germany
Urinalysis Group and ESCMID Working
Phone: z49 89 9270 2280
Party, Other Contributors and Sponsors
Fax: z49 89 9270 2113
Members of the ECLM ± European Urinalysis E-mail: w.g.guder@lrz-muenchen.de
Group
Dr. Timo Kouri (Chairman)
ESCMID Working Party on Urinalysis
Centre for Laboratory Medicine
Tampere University Hospital Vanya Gant, London, United Kingdom
P.O. Box 2000, FIN-33521 Tampere (Moderator)
Finland Hans Hallander, Stockholm, Sweden
Phone: z358 3 247 5484, Fax: z358 3 247 5554 Francis O'Grady, Nottingham, United
E-mail: Timo.Kouri@tays.® Kingdom
Marc Struelens, Brussels, Belgium
Dr. Giovanni Fogazzi
Divisione di Nefrologia e Dialisi Other contributors
Ospedale Maggiore, IRCCS Amores C, Jaen, Spain
Via Commenda 15, I-20122 Milano Anyszek Tomasz, Krakow, Poland
Italy Arnadottir M, Reykjavik, Iceland
Phone: z39 02 5503 4557 Aspevall O, Huddinge, Sweden
Fax: z39 02 5503 4550 Baerheim A, Bergen, Norway / Gent, Belgium
E-mail: croff1@polic.cilea.it BeÂne M-C, Nancy, France
Blaseio U, Hamburg, Germany
Dr. Vanya Gant Blondiau R, Erembodegem, Belgium
Department of Clinical Microbiology Bondarenko I, St Petersburg, Russia
University College Hospital Colombo JP, Bern, Switzerland
Grafton Way, London WC1E 6DB Delanghe J, Gent, Belgium
United Kingdom Dybkaer R, Copenhagen, Denmark
Phone: z44 171 380 9913 Edel H, Munich, Germany
Fax: z44 171 388 8514 Emanuel V, St Petersburg, Russia
E-mail: v.gant@academic.uclh.nthames.nhs.uk Fang-Kirchner S, Vienna, Austria
Fenili D, Romano di Lombardia, Italy
Dr. Hans Hallander Fernandes B, Toronto, Canada
Swedish Institute for Infectious Disease Control Fuellemann R, Mannheim, Germany
Unit of Quality Assurance Garcia JL, Sevilla, Spain
SE-17182 Solna Gatermann S, Bochum, Germany
Sweden Grubb A, Lund, Sweden
Phone: z46 8 457 2490 Fax: z46 8 3025 66 GyoÈry AZ, Sydney, Australia
E-mail: hans.hallander@smi.ki.se Hesse A, Bonn, Germany
Hoeiby N, Copenhagen, Denmark
Dr. Walter Hofmann HofgaÈrtner W, Oxford, United Kingdom
Institute for Clinical Chemistry Hyltoft-Petersen Per, Odense, Denmark
StaÈdtisches Krankenhaus Bogenhausen Ito K, Yokohama, Japan
Englschalkinger Strasse 77 Itoh Y, Osaka, Japan
D-81925 Munich Ivandic M, Munich, Germany
Germany Kermes K, Tartu, Estonia
Phone: z49 89 9270 2282 Khorovskaya L, St Petersburg, Russia
Fax: z49 89 9270 2113 Kimling H, Mannheim, Germany
E-mail: Hofmann-Sedlmeir@t-online.de Kokot F, Katowice, Poland
European Urinalysis Guidelines 5
(1) Suspicion or follow-up of symptoms or situations suggesting the possibility of urinary tract infection
(2) Suspicion or follow-up of non-infectious renal disease, either primary or secondary to systemic diseases,
such as rheumatic diseases, hypertension, toxaemia of pregnancy, or to the adverse effects of drugs
(3) Suspicion or follow-up of non-infectious post-renal disease
(4) Detection of glycosuria from speci®ed patient groups, e.g., individuals admitted to hospital for various
medical emergencies, or from pregnant women
(5) Follow-up of only selected diabetes mellitus patients, e.g., children at home, to detect morning
glycosuria and ketonuria in addition to blood glucose measurements
(6) Detection or follow-up of selected metabolic states, e.g., vomiting and diarrhoea, acidosis/alkalosis,
ketosis, or recurrent urinary stone formation
a
If understood widely, urine quantities are measured in diagnostics of several endocrine, metabolic and
inherited diseases, pregnancy, drugs of abuse, etc., most of which were not discussed in these guidelines which
focus mainly on diseases of kidneys and urinary tract.
European Urinalysis Guidelines 7
tion of examination procedures and interpreta- compliance and rapid transportation to the
tion is generally underestimated. Suf®cient laboratory can be organized.
detail is seldom documented for urinalysis Second morning urine is a single specimen
specimens. The minimum information is pro- voided 2 ± 4 h after the ®rst morning urine. In
posed in the Appendix (Annex 10.1). contrast to the ®rst morning urine, its composi-
The analysis report may be a structured note tion may be affected by prior ingestion of food
entered directly into the patient's record when and ¯uids and by movement. However, it may
examination is performed at point-of-care. The be more practical for ambulatory patients. To
remote laboratories must use a standardized increase the sensitivities of bacterial culture and
report format with de®ned units, reference particle counting, the quality of the second
intervals and report style (Appendix, Annex morning urine should be improved by allowing
10.1.3). The purpose of a report is to guide the ingestion of only one glass of water (200 mL)
clinician towards rational and evidence-based after 22:00 on the previous evening and
diagnostics and therapeutic management. It extending this abstinence up to the time of
must be technically correct and must provide specimen collection. A bladder incubation time
unambiguous information. exceeding 4 h is possible with this ¯uid restric-
tion. Postural proteinuria cannot, however, be
prevented and should be further investigated by
examining a ®rst morning urine sample if
3. P AT IE NT PR E P AR A T I ON diagnostic problems occur. If these standardized
collection instructions have not been followed,
3.1. De®nitions of urine specimens based on the second morning urine is classed as a
timing ``random'' specimen.
Timed collection of urine is collected at a
The following timed types of urine specimens speci®ed time in relation to another activity,
are described by modifying the de®nitions e.g., therapy, meals, daytime or bed-rest. A 24-h
quoted in textbooks [13 ± 15] and national urine collection contains all portions voided over
guidelines [2 ± 7]. The time of specimen collec- 24 h. A timed 24-h collection can be started at
tion must be recorded both on the examination any time of the day by emptying the bladder
request and on the subsequent report to aid in and noting the time. All urine during the next
the correct interpretation of ®ndings. 24 h is then collected and preserved as appro-
Random urine is a portion of single voided priate for each analyte (see Appendix, Annex
urine without de®ning the volume, time of day 10.3.4).
or detail of patient preparation. This is usually Timed overnight urine is collected by emptying
the unavoidable case in acute situations. the bladder just before going to bed, noting the
Random urine specimens are associated with exact time, and then collecting all urine portions
many false-negative and some false-positive during the bed-rest period. At the end of the
results. period, the last portion is collected, the exact
First morning urine is the specimen voided time recorded and the total volume of overnight
immediately after an overnight bed-rest before urine noted. The specimen or a representative
breakfast and other activities. This is also called aliquot is then sent to the laboratory.
early morning urine. It is recommended that the
early morning urine be voided after an 8-h
period of recumbency, and after not less than 3.2. Patient preparation before specimen
4 h storage time in the urinary bladder (even if collection
the bladder was emptied earlier during the The patient should be told why a urine
night). This has been traditionally recom- specimen requires to be examined and given
mended as the standard specimen for urinalysis, instructions on how it should be collected (see
because it is more concentrated than day urine Section 4.1). Ideally, the instructions should be
and allows time for possible bacterial growth in given both orally and in written form accom-
the urinary bladder. This specimen is most panied by illustrations where possible to ensure
easily collected from hospitalized patients, but uniformity of the collection procedure (see
may be collected even at the patient's home if Appendix, Annex 10.3.1). Because the same
8 ECLM ± European Urinalysis Group
specimen is often used for both microbiological provided by diet (e.g., salt and phosphate),
and chemical measurements, the instructions but increases the excretion of metabolites
should combine both requirements. associated with catabolism, e.g., ketone bodies
and ammonia (16). In detecting glycosuria, a
Transmission of pre-analytical information. carbohydrate meal before the specimen collec-
Adequacy of patient preparation and type and tion improves the clinical sensitivity (postpran-
success of specimen collection can be coded dial urine). In general, fasting before urinalysis
on the label on the sample tube. When avail- is designed to reduce diuresis. The preparation
able, this information should ultimately be of patients for standardized fasting blood
transmitted to the patient records together specimens can be combined with that for
with the results of examinations, e.g., ``quali- urinalysis.
®ed''/``standard'', or ``random''/``non-stand-
ard'' specimen, to increase the reliability of
3.3.2. Exercise and body posture. Wide biologi-
interpretation. Thus, signi®cant deviation from
cal variation in urine composition is related to
``standard'' should be recorded on the request
physical activity and body posture. Exami-
form or label added to the container as
nation of the morning urine and avoidance of
``non-standard''.
strenuous physical exercise minimizes these
in¯uences. Urinary calcium excretion increases
3.3. In¯uence and interference factors more than twofold on immobilization of a
patient by bed-rest (18). Exercise may increase
Biological (in vivo) factors, changing the true
the amount of body constituents excreted by
concentration of a measured component, cause
increasing glomerular ®ltration as a result of
problems in the interpretation of laboratory
increased blood pressure (e.g., appearance or
results, although the measurement process itself
increase in albuminuria or haematuria).
is correct. These are called in¯uence factors
(discussed in detail below).
In addition, there are other factors that 3.3.3. Incubation time in the bladder. To
technically interfere with the analytical demonstrate reliable bacterial growth, classical
method applied (called interference factors, microbiological advice has been to allow bac-
16). The latter are particularly important with teria a log phase of growth by incubating the
non-speci®c analytical methods, e.g., those used urine in the bladder for 4 ± 8 h [19]. Urine is a
in traditional test strip ®elds (see Annex 11.1), good culture medium for many bacteria.
but also in other chemical measurements from Using the classical Griess's examination
urine (17). As a classical example from micro- (applied in the nitrite examination pad on test
biology, the specimen for bacterial culture strips), it has been shown that the ®rst morn-
should be obtained before antimicrobial treat- ing urine specimen is more sensitive in detect-
ment is initiated to allow bacterial growth. ing asymptomatic bacteriuria among pregnant
women than later specimens [20]. In most
3.3.1. Volume rate (diuresis) and fasting. recent guidelines for the evaluation of new
Many urine constituents change in concentra- anti-infective drugs, no incubation times are
tion when the urine volume rate (excretion mentioned [21]. The urgency of micturition
rate of water~diuresis) alters due to variation associated with acute infection will often not
in ¯uid intake, reduction of renal concentrat- permit suf®cient bladder incubation time
ing ability or ingestion of diuretic substances. before voiding, resulting in false-negative cul-
If sensitive screening is needed, a low volume tures. For chemical analyses, no particular
rate (20 ± 50 mL/h) is desirable to produce incubation time is necessary. In studying cell
highly concentrated specimens. This is best and cast morphology, the best results are
achieved in morning urine. Documentation of obtained with a short incubation time of 1 ±
the urine concentration is recommended, e.g., 2 h, provided that a high volume rate does
density (speci®c gravity or weight), osmolality, not lead to false-negative results (rare particles
or a related analyte, which allow calculations are seen more often in concentrated urine spe-
of analyte/reference ratios (see Section 5.4.2). cimens). For patients without urgency or
Starvation decreases urinary constituents acute symptoms, advice concerning bladder
European Urinalysis Guidelines 9
incubation time, and a record of that time, is tegration of diagnostically valuable formed
still recommended to reach the highest sensi- elements.
tivities [22]. Mid-stream urine (or clean-catch urine)
characterizes the middle portion of a voided
3.3.4. Contamination. Urine specimens should specimen. The ®rst portion of urine is not
be collected free of internal and external con- collected, because it is always contaminated by
taminating ¯uids. Sexual intercourse should be commensal urethral ¯ora in both sexes (if not
avoided for 1 day before specimen collection purposely collected, see below). Minimizing
because of the resulting increased amounts of contamination of specimens by commensal
proteins and cells. bacteria is especially important, and requires
Urine from males is usually contaminated detailed patient advice. It is important to
with small amounts of secretory products from wash the introitus around the urethra in
the prostate. Excretion of N-acetyl-b,D-glucos- females, and the glans penis in males with
aminidase, a marker of renal tubular function, water only, before micturition. This reduces
is increased for 3 days after ejaculation [23]. false-positive urine cultures by 20% or more
Seminal ¯uid may contaminate urine after [24]. The use of antiseptics ± and soaps (with
normal ejaculation, but also in diseases asso- variable additives) ± is not recommended as
ciated with retrograde ejaculation to urinary this may affect bacterial viability [25]. The last
bladder. portion is also left over after collecting
Vaginal secretions or menstrual blood may 50 ± 100 mL of urine in the container. Detailed
contaminate urine from females. This may be instructions for mid-stream urine collection are
misleading and can be minimized by tamponing included in the Appendix (Annex 10.3.1).
the vagina when acute symptoms necessitate Technically satisfactory collection of urine
examination of urine. Pregnancy is associated from children and from women especially in
with physiological pyuria. the late stages of pregnancy can be dif®cult. The
use of different sterile devices may help women
to urinate more easily into a collection con-
tainer.
4. COL LECTION OF SPECIMENS, First-void urine characterizes the ®rst portion
P R E S E R V A T I O N A N D TR AN S P OR T of urine voided at the beginning of micturition.
This is the optimal sample for the detection of
Urinalysis may be requested on specimens Chlamydia trachomatis by nucleic acid ampli®-
obtained by voiding (micturition), by catheter- cation. It is NOT suitable for routine micro-
ization, needle puncture, through a postopera- biological culture as urethral organisms usually
tive urostomy, or by using different collection contaminate it.
vessels, such as bags or special receptacles for Single catheter urine is collected after insert-
bed-bound patients. The most commonly ing a sterile catheter into the bladder through
obtained specimen is the mid-stream urine. the urethra (straight or ``in-and-out'' catheter-
Requesting clinical staff must document the ization). For children without urinary control,
method of collection to allow correct inter- this is one of the methods of con®rming or
pretation of results. excluding the presence of urinary tract infection
[26].
Indwelling catheter urine is collected at
4.1. Procedures for urine collection, specimen
replacement or by sterile puncture of an
types
indwelling catheter. Urine analysis specimens
The microbiological requirements usually must not be taken from the collection bag of a
determine the details of any collection permanent indwelling catheter.
method, because urine intended for microbio- Suprapubic aspiration urine is usually col-
logical examination must avoid or minimize: (1) lected by sterile aspiration of urine through the
contamination of specimens by commensal abdominal wall from a distended bladder. The
bacteria, (2) growth of bacteria following bene®t of this technique is that it allows a clear-
specimen collection, (3) damage or death of cut decision on the presence or absence of
diagnostically relevant bacteria, and (4) disin- urinary tract infection [27]. Detailed instruc-
10 ECLM ± European Urinalysis Group
tions are provided in the Appendix (Annex ± identi®cation of any bacteria to low levels
10.3.3). The risk of bladder colonization by (w104 CFB/L)
suprapubic aspiration is lower than that by ± large inocula of urine to ensure accurate
in-and-out catheterization. Miniaturization of plate counts (10 ± 100 mL)
measurement techniques by laboratories may ± report simultaneously relative concentrations
nowadays allow several different examinations at each anatomical site
from the 5 mL of urine obtained typically by ± antibiotic sensitivities of any bacteria grown
the suprapubic aspiration technique.
Bag urine is widely collected from small The lower urinary tract may be the subject of
infants, but carries a high probability of investigation, typically the prostate. For diag-
contamination with skin organisms. The entire nosis of chronic bacterial prostatitis, the Meares
genital region should be washed carefully with and Stamey collection procedure is still recom-
water. A sterile collection bag is applied and the mended: ®rst and mid-stream portions of urine
should be collected, then drops expressed with
urine ¯ow checked frequently. The collection
bag should be in situ for a maximum of 1 h, prostate massage, and the ®nal specimen voided
after which the probability of contamination after prostatic massage [29, 30]; (see Appendix,
increases greatly. Negative culture results reli- Annex 10.3.2).
ably exclude urinary tract infection [26]. Border-
line results need to be re-investigated from a 4.2. Containers
suprapubic aspiration or single catheterized
urine specimen. Sterile sampling of urine is important for
Diapers or nappies are sometimes suggested urine microbiology, but may in¯uence some
as collecting tools for clinical specimens from chemical measurements. Sterility of collection
babies [28]. Despite occasional promising vessels means that the interior of the unopened
results, especially for chemical constituents and unused container is free from interfering
measured by qualitative strip examinations, it microbial contaminants. The European Phar-
is hard to recommend this method due to high macopoeia de®nes sterility as reduction of
variability in the ®bre construction of different bacterial growth to a probability of one
brands and inability to measure the urine survivor in one million, e.g. after irradiation
volumes voided. Morphological and in parti- [31]. Container manufacturers must document
cular microbiological investigations are impos- their product's compliance with the intended
sible with this procedure. clinical use (see Section 4.2.1), rather than
Urostomy specimens (urines from ileal con- following strictly the Pharmacopoeia de®nition
duit) are frequently obtained after bladder only. It is to be remembered that a particle
surgery. Paediatric and adult patients with analyser or a nuclear ampli®cation method will
dilated ureters may be given bilateral ureter- detect even dead bacteria. Furthermore, since
ostomies. Chronic infection and bleeding at the waste is an increasingly important problem
site of the stoma are common. Cleaning the globally, the development of new, environmen-
stoma and discarding the ®rst portion of urine tally safe materials is encouraged for all
obtained through a sterile catheter of suitable disposable containers. Finally, containers
size ensures specimen quality. should comply with the European directive
for in vitro medical devices [32].
women. The container should have a wide The examination tubes used for samples for
base to avoid accidental spillage and should quantitative chemical analysis should keep the
be capped so that it can be transported and specimen intact and the cap should remain
stored without leakage. The container and its closed upon freezing and during centrifugation
cap should be free from interfering substances up to 30006g (relative centrifugal force, RCF).
and should not absorb or change the urine The size, structure and length of the secondary
constituents to be measured. Those parts of container vary depending on the needs of the
the container and its cap which come into diagnostic procedures.
contact with the urine should not contribute
to microbial contamination after specimen col- 4.2.3. Labelling. All specimen containers must
lection. be labelled with a tag that remains adherent
Timed collections: For many chemical con- during refrigeration. The label should include
stituents, quantitative excretion rates are im- a bar code (if used), a code of the exami-
portant. A container designed for a 24-h nation requested, patient identi®cation and
or overnight urine collection should have a requesting unit, as well as details of collection
capacity of 2 ± 3 L. The container should be time, method of collection, and any additional
constructed from materials that prevent (a) pre-analytical information in coded form.
adherence of urine constituents, (b) exposure of Details of any preservative should be shown
urine to direct light, which might alter clinically on a separate label and include any appropri-
signi®cant metabolites, (c) contamination from ate hazard symbol. Labelling should not pre-
the exterior when closed. Stabilizers usually vent a clear view of the specimen. The label
prevent metabolic and other changes of urine must be placed on the container, not on the
constituents. The container should allow for use cap.
of recommended preservatives (Appendix, When body ¯uids are mailed to a distant
Annex 10.3.4). laboratory, additional biohazard labels should
Secondary containers (for basic urinalysis, be added and the packages must comply with
usually examination tubes) should be easily the European standard EN829 (34).
®lled from the primary container without risk of
spillage. The tube should be translucent to
4.3. Preservation and transport
allow a clear view of the sample.
The time elapsing between voiding and
4.2.2. Transport, storage and analytical con- examination of urine is a major obstacle to
tainers. Specimens can be transported in their diagnostic accuracy in most laboratories. Inves-
primary containers or divided into aliquots tigations performed at point-of-care are not
that may range from 1 to 100 mL for chemi- subject to this delay but may suffer from
cal and morphological investigations. For analytical problems. Precise collection times
microbiological analysis, 1 ± 3 mL of urine in must be documented and delays exceeding the
a clean container is suf®cient. For large speci®ed limits should be stated on reports.
laboratories, a standardized vessel with a For many chemical constituents examined with
volume of 3 ± 12 mL is essential for automated test strips no preservatives are needed, provided
analytical systems. the analysis is performed within 24 h and the
Examination tubes for test strip measure- tube has been refrigerated. If the specimen
ment, particle counting or urine culture should contains bacteria and has not been refrigerated,
keep the specimen suitable for analysis at false-positive nitrite or protein results may be
z20³C or at z4³C as speci®ed. obtained using multiple test strips. In practice,
Traditionally, urinalysis tubes have been strip examination should be performed on-site
conical to allow decanting of supernatant when rapid or refrigerated transportation is
after centrifugation. A more accurate sediment not possible. Preservation may be critical,
volume is obtained by suction of the super- since some preservatives interfere with enzy-
natant. Therefore as an alternative to the matic measurements (see Appendix, Annex
conical shape, a round-bottom tube may be 11.1).
considered for easy resuspension of the sedi- For quantitative chemical measurements it is
ment when using standardized equipment. known that several speci®c proteins are unstable
12 ECLM ± European Urinalysis Group
in urine but preservatives can inhibit their for successful preservation without bacterial
degradation [35 ± 37]. The effect of storage inhibition. It is suggested that containers
may be method-dependent, since an earlier containing boric acid should be ®lled to the
radioimmunoassay for albumin did not ®nd indicated line to achieve a correct borate
any effect on storing specimens at ± 20³C for up concentration. The specimen should be exam-
to 6 months [38]. In the present guidelines, ined within 24 ± 48 h of production. It should be
previous data are quoted [3, 39] as modi®ed noted that borate may inhibit growth of
where necessary by technological development Pseudomonas spp.
(Appendix, Annex 10.3.4).
For particle examination the specimen should
be refrigerated if not examined within 1 h,
5. CHEM IST RY E XAMINATIONS
although precipitation of urates and phosphates
will occur in some specimens. If precipitation
5.1. Hierarchy of methods (measurement
disturbs interpretation, a new specimen should
procedures)
be examined atz20³C to avoid their artefactual
generation. The longer the delay, the more In these guidelines, laboratory methods are
likely are elements to lyse, especially when the classi®ed in four levels of performance based on
urinary pH is alkaline and the relative density is accuracy of measurement. This hierarchy was
low (especially true with children, often produ- adapted from earlier de®nitions of method
cing a large diuresis). The WBC counts may be performance in clinical chemistry [47] to help
questionable after 2 ± 4 h, even with refrigera- discussions aimed at better accuracy in
tion [40]. Traditionally, ethanol (50% volume urinalysis.
fraction) is used to preserve the cells but this Level 1: Rapid methods that ideally provide
only partially prevents lysis of red and white the user with a fast, reliable response to an
blood cells. To avoid shrinkage, polyethylene individual patient and easy handling of equip-
glycol (2% mass fraction, low molecular mass ment, usually in primary care laboratories and
such as Carbowax1) may be included in the at points-of-care. These typically include, for
®xative (this is called Saccomanno's ®xative example, urine test strip measurement, simple
[41]). On mixing equal parts of sample and urine microscopy or dip-slide culture. Results
®xative, the particles should then be stable for 2 may be expressed on an ordinal scale.
weeks. Alternative ®xatives also exist [42]. Level 2: Routine or ®eld methods used in
Commercial preservatives, such as formalde- clinical laboratories because of medical need for
hyde-based solutions, buffered boric acid and quantitative or specialized methods, which then
formate-based solutions, and mercuric chloride- require experienced personnel and often a
based tablets are also available. They have centralized site. These are often mechanized or
gained renewed interest following the develop- automated methods. Examples include for
ment of automated systems. Fixatives may example routine identi®cation of several uro-
be adapted after evaluation with the new pathogenic bacterial species, immunochemical
technology. quantitation of numerous urinary proteins, or
Specimens requiring microbiological investiga- advanced urinary particle identi®cation.
tion must be collected in a clean container and Level 3: An intermediate category of ``qua-
examined in the laboratory within 2 h [5, 6]. li®ed comparison methods'' is proposed. The
They should be refrigerated at 4³C without techniques are analytically more accurate and
preservative if delay w2 h is expected. Then precise than Level 2 methods, but are not
they should be examined within 24 h. If delay is applicable for routine use because they may be
unavoidable and refrigeration not possible, too time-consuming or expensive. Level 3 needs
containers pre-®lled with boric acid preservative to be considered and created when no Level 4
alone [43] or in combination with formate or methods exist and methods at Levels 1 or 2
other stabilizing media [44 ± 46], ideally in a need to be evaluated. Sometimes the Level 3
lyophilized form, may be used. Boric acid will methods may be designed ad hoc for evalu-
stabilize white cell number and bacterial ation purposes only. Often, Level 1 may be
concentration in urine held at z20³C for evaluated with Level 2 methods when all the
24 h. Boric acid concentration may be critical pitfalls of the methods of Level 2 are under-
European Urinalysis Guidelines 13
stood. Level 3 methods may be considered as an The odour of normal urine is aromatic of
intermediate stage in reference method devel- undetermined source. Infected urine may be
opment. ammoniacal or fetid. Some metabolic diseases
Level 4: The most analytically accurate have characteristic urine odours (Table III;
methods are called reference and de®nitive from reference 14).
methods (systematically called primary refer-
ence measurement procedures). A de®nitive
5.3. Rapid chemical examinations (Level 1)
method is designed to give the true value of
the measured component [48, 49]. It is ``an Because many urinary tract diseases present
analytical method that has been subjected to acutely, there is a need for rapid diagnostics
thorough investigation and evaluation for frequently at points-of-care. Then, the ®rst
sources of inaccuracy, including non-speci®city. urinalysis is often an ordinal scale (``semi-
The magnitude of the imprecision and bias quantitative'') measurement. Depending on the
(uncertainty) of the de®nitive method is local environment, these may be performed at
compatible with its stated end purpose. The points-of-care or in laboratories in primary to
true value is obtained from a mean value of tertiary care hospitals as part of a more detailed
the measurements'' [50]. Very few de®nitive examination of urine.
methods are available for clinical laboratories
[51]. 5.3.1. Multiple test strips. Multiple test strips
A reference method is de®ned as a ``thor- (dipsticks; of®cially called ``multiproperty''
oughly investigated measurement procedure, strips) have been designed to detect several of
clearly and exactly describing the necessary the following components: leukocytes, bacteria
conditions and procedures, for the measurement (nitrite), erythrocytes, protein (albumin),
of one or more property values that has been glucose, ketone bodies, pH, relative density,
shown to have trueness of measurement and bilirubin, urobilinogen and ascorbic acid.
precision of measurements commensurate with A minimum combination depends on the
its intended use and that can therefore be used intended use; general approaches are suggested
to assess the accuracy of other measurement in Section 8 (Stepwise strategies in urinalysis).
procedures for the same property (-ies), parti- The technology and principles employed in
cularly in permitting the characterization of a test strips have been widely studied. Recently,
reference material'' [48, 52, 53]. The European an interesting British evaluation of multiple
Committee for Standardization (CEN) has also strips from seven companies was published,
described guidelines for the characterization of assessing suitability for point-of-care diagnos-
these procedures [54]. Reference methods tics by visual reading [57].
should be used in the evaluation of trueness The limitations of strip technology are well
of routine methods. For urinalysis and bacterial known [15], but are compiled here in Appendix,
culture, these are usually lacking or are in the Annex 11.1.1. However, any new drug should
process of development. This is why a new be considered as a source of interference. The
lower level (~Level 3) in the hierarchy was need for quality of test-strip measurements is re-
introduced. Level 3 methods may be developed enforced in these guidelines by suggesting new
to Level 4 after adequate descriptions of analytical quality goals (Section 9.2) and
performance. evaluation tools (Annex 11.1).
sensitivity of the strip is about 80 ± 90% at the should be reached. Speci®city at a detection
detection limit of 206106 WBC/L against limit of 206106 WBC/L is about 80 ± 90%.
chamber counting of fresh uncentrifuged speci- Specimens with lysed cells, which are micro-
mens. At 1006106 WBC/L, a sensitivity of 95% scopically classi®ed as negative, are partially
European Urinalysis Guidelines 15
TABLE III. Characteristic odours of metabolic dis- the culture method, depending on the patient
eases. population and the cut-off limit for positive
Odour Disease culture (usually chosen to 108 CFB/L or
105 CFU/mL) [58, 59, 60]. The speci®city of
Sweaty feet Isovaleric acidemia and glutaric this ®eld for bacteria is high (w90%).
acidemia Performance of test strips in detecting
Maple syrup Maple syrup urine disease
Cabbage, hops Methionine malabsorption
bacterial urinary tract infection must be inter-
Mousy Phenylketonuria preted carefully, since the selected cut-off for
Rotting ®sh Trimethylaminuria signi®cant counts in culture (decreased to
Rancid Tyrosinemia 106 CFB/L when patients with acute symptoms
are evaluated), type of specimens and the
studied patient population affect the results
responsible for reduced speci®city. The esterase obtained [61]. The combined positivity ``either
®eld does not detect lymphocytes. Subtilisin of nitrite or leukocyte result positive'' is generally
known activity may be used as a quality control useful [Table IV]. Speci®city of the combination
solution. is reduced compared to the nitrite examination
Bacteria (Nitrite): Nitrite examination is alone, because not all patients with leukocyturia
based on activity of the nitrate reductase that have bacteriuria. The clinical sensitivity of the
is present in most Gram-negative uropathogenic test-strip measurement improves if only patients
rods, such as E. coli (Griess's examination). with pyuria are considered to have infection
Nitrate reductase is, however, lacking from [62 ± 64]. This can be accepted in patients with a
some common uropathogens, e.g. Enterococcus low risk for urinary tract infection only, since
spp. and Staphylococcus spp., and will therefore high-risk patients may have signi®cant bacter-
not be detected whatever their urinary concen- iuria without leukocytes in the urine (see
tration. The positive detection of bacteria Section 8 for strategic approaches).
requires, in addition, nitrate in the patient's Erythrocytes (Pseudoperoxidase): The pres-
diet (vegetables), its excretion into urine and ence of red blood cells (RBCs), haemoglobin or
suf®cient bladder incubation time. The analy- myoglobin in urine is seen either in dotted
tical sensitivity of the method is variably (cells) or homogeneous appearance of colour on
reported as being between 20% and 80% against the reagent pad. The examination relies on
TABLE IV. Performance of multiple test strips in combined detection of bacteriuria (either leukocytes or
nitrite positive).
introduced in test strips to measure albumin/ [89] is particularly reduced in dilute and alkaline
creatinine ratios from patient urines [79]. urines, typically in children with urinary tract
Knowledge on clinically important interferences infection [40]. Casts are also lost in alkaline
has not yet accumulated. urine [90]. Measurements of urine pH are
Glucose: Examinations of urine glucose con- needed for the diagnosis of acid-base distur-
centrations have largely been replaced by bances (such as hypokalaemic alkalosis with
measurements of blood glucose concentration paradoxical aciduria), or when acidi®cation or
[85, 86]. Urine glucose measurements may be alkalinization of urine is associated with speci®c
advocated to check for inappropriate use of diseases (such as renal tubular acidosis, renal
blood examinations, or for those patients stone disease), or during the elimination of
unwilling to use blood sampling in addition to speci®c drugs (e.g. cytotoxic drugs).
laboratory monitoring of glycohaemoglobin Bile pigments: Measurements of urinary
HbA1c concentrations [87]. In less favourable urobilinogen and bilirubin concentrations have
economical situations, urine glucose monitoring lost their clinical signi®cance in the detection of
is better than no monitoring. Since the ®nding liver disease following the introduction of liver
of glycosuria may reveal patients with juvenile enzyme examinations from blood. They may be
or maturity-onset diabetes mellitus, a screening useful, however, in differentiating icteric
policy using test strips continues to be impor- patients or in detecting alcoholic liver disease
tant, especially in acutely ill patients (if blood in non-laboratory environments.
glucose is not used). Routine urine glucose Ascorbic acid: Ascorbic acid (vitamin C)
screening of pregnant women is useful if interferes with the measurement of several
combined with measurements of body mass test-strip analytes (see Appendix, Annex
index (BMI) [88]. The analytical performance of 11.1.1). Because many patients ingest vitamin
glucose screening by test strip is highly satis- C in large quantities (w1 g/day), measurement
factory, partially because in the important acute of ascorbic acid concentration in urine helps in
cases heavy glycosuria exists. identifying those patients with false-negative
Ketone bodies: Ketone bodies (acetoacetate, test-strip results. The other, more direct,
b-hydroxy butyrate and acetone) are excreted approach should be to try to develop test
into urine in diabetic acidosis, during strenuous strips insensitive to interference by ascorbate.
exercise, fasting, during enteric in¯ammations
or periods of vomiting. The chemical reaction 5.3.1.2. Instruments used for multiple strip
used is sensitive to acetoacetate and acetone, examinations. The manufacturer's instructions
but not b-hydroxybutyrate. Ketone bodies need must be strictly followed for optimal results
not be measured as part of general urinalysis, when reading test strips (Appendix, Annex
but serve to classify or treat speci®ed patient 11.1.6). Instruments (rather than the naked
populations, such as patients admitted as eye) are recommended for reading a multiple
emergencies (especially paediatric patients), property strip, whether in the laboratory or at
juvenile-onset diabetics or patients with toxae- point-of-care [91], because observer-related
mia of pregnancy. After institution of insulin major errors occur frequently in practice and
and ¯uid therapy in diabetic hyperglycaemia are not traceable afterwards. It is also clear
and ketosis, tissue b-hydroxybuturate converts that all laboratory examinations, including
back to acetoacetate, leading to transient those performed at point-of-care sites, should
increase in urine acetoacetate excretion despite meet the required quality [92].
an improved clinical situation. Slight ketosis is The selection of different instruments is
detected even after overnight fasting, indicating determined by the local diagnostic require-
an acceptable clinical sensitivity. Unspeci®c ments. Centralized laboratories providing a
reactions occur with the traditional examination 24-h service tend to automate the analysis of
principle (see Appendix, Annex 11.1.1). large numbers of specimens, while point-of-care
pH: Urinary pH varies between 5 and 9. sites show an increasing interest in improving
Concentrated morning urine is usually acidic. the quality of single rapid patient investigations.
Urines from children are often alkaline. Bac- Fully automated test-strip readers are fre-
teria metabolizing urea to ammonia may also quently considered in large laboratories. Auto-
increase the pH of urine. Survival of leukocytes mated urinalysis aims to improve the precision
18 ECLM ± European Urinalysis Group
and accuracy of results at higher level than that 5.4. Quantitative chemical measurements
achieved by visual or semi-automated methods.
For many urine components, a quantitative
Turnaround time, cost containment and safety
result helps in the diagnosis and follow-up of
of the working environment are important
patients. This used to involve timed 24-h or
issues in routine work-¯ow as well. A combina-
other collections of urine with calculated
tion of results from rapid chemical measure-
excretion rates of the analytes. As a practical
ments and automated particle analysis is under
alternative, a reference measurement to adjust
development [93].
for water excretion (osmolality, creatinine or
equivalent) and calculation of analyte/creatinine
5.3.2. Pregnancy examinations. Detection of
or analyte/osmolality ratios has already been
pregnancy is achieved by speci®c measure-
devised for measurements of protein excretion.
ments of human chorionic gonadotropin
This quantitative approach is typically per-
(hCG) secreted by the developing placenta
formed in centralized laboratories (Level 2
[94]. The appearance and rapid increase in the
methods), but may be used in primary care
concentration of hCG up to 10 000 IU/L in
laboratories or even point-of-care sites with
serum and urine during early pregnancy make
methods suitable for Level 1 (e.g., albumin/
it an excellent diagnostic marker. The exami-
creatinine ratio) when the cost/bene®t ratio is
nations are performed from either blood or
favourable. Several analytes measured quantita-
urine specimens. The sensitivity to detect
tively in speci®c clinical situations are listed in
extra-uterine pregnancies is recommended
the Appendix (Annex 10.3.4) in relation to
using blood specimens, while urine is used for
specimen collection. Detailed discussion was
rapid examinations to detect mainly normal
considered to extend these guidelines too much.
pregnancies. Different de®ned sensitivities
should be considered depending on the
intended application, since the sensitivity at 5.4.1. Proteins. Measurement of total protein
25 IU/L is suf®cient to detect pregnancy excretion has been traditionally recommended
already after 3 ± 4 days of implantation [95], for detecting renal disease [97]. In most cases
i.e., before the missed menstrual period. A the urine contains albumin that may be meas-
reduced sensitivity limit of 200 ± 500 IU/L may ured quantitatively or detected by test strip.
be of value if only detection of normal preg- Glomerular nephropathies are characterized
nancies is needed. This will delay the detection by increased excretion of albumin, transferrin
of pregnancy but increase the speci®city of and in the advanced stage by high molecular
obtained results. Detail of measurements is mass proteins such as IgG [98]. It is already
given in the Section 11.3. widely accepted that an early glomerular dis-
ease, such as incipient nephropathy in diabetes
5.3.3. Other rapid examinations. Test strips mellitus, can only be detected with sensitive
with isolated ®elds to show the presence of measurements of (micro)albuminuria (analyti-
glucose and/or ketone bodies, albumin or cal sensitivity down to 5 ± 10 mg/L [10, 99]).
albumin/creatinine ratio only are indicated in Albumin excretion rate is elevated years
screening or follow-up of some de®ned patient before reduction in glomerular ®ltration rate
groups, such as certain patients with diabetes is detected by an increase in serum creatinine
mellitus, pregnant women or renal patients. concentrations [100]. Increased urinary albu-
Pre-eclamptic toxaemia patients should be min is now considered predictive of mortality
screened by blood pressure measurements and morbidity in both non-insulin-dependent
rather than by conventional urinary protein and insulin-dependent diabetes mellitus [101].
measurements [96]. However, proteinuria Albuminuria is the strongest known predictor
assessment is important in treatment decisions of cardiovascular disease in non-insulin-depen-
for pre-eclamptic patients. Rapid detection of dent diabetes mellitus [102]. The detection of
bacteriuria is discussed in detail in Section albuminuria is a risk factor in non-diabetic
7.4. The visual reading of one or two ®elds hypertension [103 ± 105], vascular disease [106]
on a strip is easier than of multiple test strips. and a predictor of heart failure [107]. Albumi-
Rapid examinations for drugs of abuse are nuria also predicts mortality in elderly age in
not included in these guidelines. general [108].
European Urinalysis Guidelines 19
For detection of tubular disease, a sensitive required for osmolality measurements, very
strategy has also been proposed using measure- few laboratories have applied analyte/osmolal-
ments primarily of a1-microglobulin [109], also ity ratios in their clinical practice [125]. Urine
called protein HC [110, 111]. Tubular dysfunc- osmolality is also related to diet and ingestion
tion can also be detected with other excreted of salts.
markers, e.g., retinol-binding protein (RBP)
[112 ± 115] and enzymes such as N-acetyl-b,D- Relative volumic mass (old terms: relative den-
glucosaminidase (EC 3.2.1.30) originating from sity; speci®c gravity). Relative volumic mass
kidneys [116 ± 118]. The earlier b2-microglobulin (traditional name: relative density [126]) is the
is too labile in acid urine. Enzyme measure- preferred term over speci®c gravity, since the
ments have gained only limited clinical value rede®nition of litre in 1964 to equal 1 cubic
because the interpretation of variably elevated decimetre of water. Since the reference density
excretion rates has been dif®cult among large (reference volumic mass) is the maximum den-
patient populations. For example, in the sity of water at z4³C (r0~0.999972 kg/L),
common paediatric urinary tract infections, there is no practical difference between volu-
elevated excretions of N-acetyl-b,D-glucosami- mic mass and relative volumic mass of urine
nidase, b2-microglobulin or a1-microglobulin within clinical medicine. A more signi®cant
have no additional diagnostic information uncertainty of clinical results is derived from
after measurements of body temperature [119, inaccurate measurement procedures in clinical
120]. This may re¯ect the dynamic metabolic laboratories. Urine relative volumic mass is
states of tubular cells, high regenerative capa- closely related to osmolality [127]. The corre-
city of kidneys as well as their ability to adapt lation between relative volumic mass and
despite the destruction of some nephron seg- osmolality decreases in disease [128] because
ments [121]. Renal tubular enzymes may, relative volumic mass depends on the con-
however, be useful in assessing individuals centration of electrolytes, glucose, phosphate,
exposed to nephrotoxic drugs or heavy metals carbonate and occasionally excreted iodine-
[122]. containing radiocontrast media (after radio-
Clinical speci®city and prognostic signi®cance logical investigations), while osmolality is
in follow-up must generally be assessed to allow dependent on urea, ammonia and electrolytes.
targeted application. A sensitive measurement is
justi®ed with speci®c suspicion of renal disease, Creatinine. Correction of diuresis using urinary
i.e., for patients with chronic diseases associated creatinine concentration to calculate analyte/
with renal complications, such as diabetes or creatinine ratios has gained general acceptance
hypertension, and similar states. Since tubulo- despite certain theoretical problems [10, 11].
interstitial damage may cause end-stage renal Creatinine measurement is easily performed
diseases that have currently remained unnoticed and only minimally affected by protein-
by using mostly screening with albumin strips, a containing diet. Creatinine excretion suffers
revised screening strategy should be considered from inaccuracies related to body weight, age,
for other patient populations as well [123]. gender [129, 130] and renal function, i.e. tubu-
lar secretion in uraemia [131]. Chronic diseases
5.4.2. Quantities of volume rate (diuresis). such as hypo- and hyperthyreoidism may also
Osmolality. Assessment of renal concentrating affect it. Analyte/creatinine ratios should
capacity is classically evaluated in kidney dis- always be measured as part of quantitative
eases. The preferred quantity related to measurements if timed collections overnight or
volume rate (diuresis) is urine osmolality for 24 h are to be avoided.
because it is a solute property [124]. Osmolal-
ity should also be measured when other com- Conductivity. Conductivity is a new parameter
ponents in urine need to be related to variable that is brought to clinical laboratories and
excretion of water in order to estimate excre- intensive care units with novel instruments. It
tion rates. This is essentially true for both is related to osmolality, since both are depen-
renal and lower urinary tract diseases, and dent on concentration of salts in urine. Con-
both formed elements and dissolved chemical ductivity seems to correlate to osmolality
constituents. Because a separate instrument is fairly well, even better than creatinine [69,
20 ECLM ± European Urinalysis Group
128, 132]. However, the exact clinical role of ®nding with unknown clonality. Test strip is
this measurement awaits further clinical usually negative for the light chains.
experience. Size fractionation of urinary proteins on
sodium dodecyl sulphate-acrylamide gel electro-
phoresis [141 ± 143] has been used to classify
5.4.3. Diagnosis and secondary prevention of pre-renal, renal and post-renal proteinuria
renal stone formers. Some quantitative mea- before quantitative measurements of speci®c
surements from urine help in diagnosing and proteins became widely available. Small labora-
classifying patients with a recurring tendency tories may use this examination if a quantitative
to renal stone formation [133]. After analysis result is not needed.
of the stone by X-ray or the infrared method,
quantitative measurements of urine volume,
relative density, pH, calcium, urate, citrate,
oxalate and creatinine are recommended as 6. PA RT IC LE ANA LY SI S
minimum measurements from 24-h collection
[134 ± 136]. Optionally, measurements of urin- 6.1. Clinically signi®cant particles in urine
ary magnesium, inorganic phosphate, ammo- Leukocytes: Granulocytes are the most fre-
nia and cystine are recommended in addition. quent leukocytes detected in the urine of
New technology to detect lithogenicity of patients with urinary tract infection due to
urine has also been proposed based on X-ray common organisms, and may also be seen in
microscopy [137, 138]. Serum (or plasma) con- other conditions such as glomerulonephritis,
centrations of intact parathormone (primary interstititial nephritis and aseptic cystitis. The
hyperparathyreoidism), calcium, urate, inor- appearance of lymphocytes in urine is asso-
ganic phosphate and creatinine are of value, ciated with chronic in¯ammatory conditions,
as well as examination of acid-base homeosta- viral diseases and renal transplant rejection.
sis in blood. Dietary background must be Macrophages (mononuclear phagocytes, histio-
known and understood when interpreting
cytes) appear fairly often in urine of patients
these results. Microscopic analysis of urinary with urinary tract infection. They are also
crystals is discussed under particle analysis suggested to re¯ect, e.g., in¯ammatory activity
(Section 6.1). The German experience suggests of renal disease [144]. Eosinophil granulocytes
the importance of investigations of urolithiasis may occur in several disease states; they are no
patients not responding to non-speci®c treat- longer seen solely as markers of acute inter-
ment, since new stone attacks could be pre- stitial nephritis caused by drugs such as beta-
vented by 46% in the follow-up [139]. lactamic antibiotics [145].
Erythrocytes: Haematuria remains a major
sign of urinary tract and renal diseases. It may
5.5. Electrophoretic examinations
also re¯ect a general bleeding tendency. Hae-
Electrophoretic techniques are essential in maturia for physiological reasons (strenuous
detecting the clonality of serum paraproteins exercise) and vaginal contamination (menstrua-
(M components) and monoclonal immunoglo- tion) should be avoided ± if possible ± during
bulin light chains in urine (Bence Jones careful patient preparation. The appearance of
proteins). Immuno®xation of the urine or RBC in urine re¯ects the origin of bleeding:
serum helps in de®ning the isotype of the dysmorphic erythrocytes (red cells with abnor-
myeloma clone. Some authors recommend mal size or shape) suggest renal disease, whereas
immuno®xation electrophoresis of all specimens RBC with normal morphology usually originate
because of the sensitivity of the method [140]. from the lower urinary tract [146 ± 148]. The
The speci®city must then also be understood morphology of RBC in urine is valuable in
because of the existence of monoclonal gam- evaluation of patients with isolated haematuria,
mopathies of undetermined signi®cance. As an because it can determine if the subsequent
alternative to screening and in monitoring, diagnostic work-up is urological or nephrologi-
turbidimetric quantitation of urinary k or l cal [149]. The examination technique needs
chain excretion is also suggested [111], com- special training and is best performed with
bined with immuno®xation in case of a positive phase contrast microscopy [147]. A subgroup of
European Urinalysis Guidelines 21
of urine microscopy usually provides evidence should be related to the original volume of
of renal damage (right column, usually in che- urine (in litres, L). Counting of native urine
mical laboratories or nephrological units), or avoids the error created by centrifugation. A
speci®es microbes in more detail, e.g. based suf®cient volume is needed to detect rare
on Gram staining characteristics (microbiolo- particles related to renal damage (see Section
gical laboratories). The suggested order of 9.4). Particle concentrations at the low positive
process is that laboratories and nephrological range or upper reference limit in health can vary
units ®rst decide between these two levels and up to 100% owing to the effect of pre-analytical
then de®ne the local detailed procedures to be variables. In regard to this ®gure, a reliable
followed depending on the needs for urine comparison level of enumeration of particles
microscopy, be that in a clinical nephrology has a negligible bias and imprecision to allow
unit or in a general or specialized laboratory. correct classi®cation of patients' results (see
Annex, Section 12.1.1 for further detail).
Automated instruments have improved pre-
6.2. Different techniques of visual microscopy cision by counting many more cells than visual
methods. They may be used for enumerating
6.2.1. Hierarchy of microscopy methods. Refer-
elements for which their method has been
ence method for urine microscopy (Level 4)
validated.
should provide both correct identi®cation of
different particles and their accurate quantities
when measuring urine. Currently, no such 6.2.2.2. Bacteria counting (Slide centrifugation
method exists. Standardization of the method z Gram staining procedure). The slide centri-
used is essential for improving accuracy and fuge method with Gram staining offers the
limit of detection [2, 167, 168], independently highest analytical sensitivity and reproducibil-
of the intended level of ®nal performance. ity in the rapid detection of bacteria in urine,
Special attention should be paid to different although it is not a quantitative method. It
sources of error [169, 170]. The centrifugation can therefore be used in Level 3 comparisons.
step with removal of supernatant is a major When a cut-off value of 108 colony-forming
tool for concentration of the urine specimens, bacteria/litre (CFB/L) in culture is taken, this
but also a major source of errors. method has a sensitivity of 98% and a speci®-
city of 90% against the culture [173]. These
performance ®gures were con®rmed with spe-
6.2.2. Principles of comparison methods (Level 3). ci®c patient populations in later studies, show-
6.2.2.1. Particle counting. Identi®cation: Parti- ing an overall sensitivity of 63% and
cle identi®cation needs an optical method to speci®city of 91% at 106 CFB/L [174]. The
discern formed elements from their ¯uid back- main disadvantage to this robust and consis-
ground and a differentiation method to allocate tent method is that it is very labour-intensive.
these elements into correct classes (Table VI). Details of the method are described further
Bright-®eld microscopy of unstained prepara- under microbiological methods (Appendix,
tions is inadequate for detection of bacteria, Annex 13.5.1).
RBC and hyaline casts, and therefore for
advanced differentiation. For this reason, either
supravital staining [171, 172] or phase-contrast 6.2.3. Routine identi®cation methods for urine
microscopy [56], or both, is recommended. particles (Level 2).
Detection of microbes by Gram staining and Standardized urine sediment under a cover-
other special procedures, such as nucleic acid slip. Standardized centrifuged urine sediment
ampli®cation methods, are needed in the micro- should be investigated under a de®ned size
biology laboratory. Identi®cation of elements coverslip with a known volume of specimen in
such as eosinophils, monocytes or all macro- the view ®eld (Appendix, Annex 12.1.2). This
phages may require speci®c methods as well as is recommended as a routine visual procedure
experienced evaluators. The latter may, how- in examination for kidney-related urine parti-
ever, be beyond the general need of rapid differ- cles for the following reasons:
entiation of urinary particles. (1) The sediment method detects particles
Counting: Concentrations of urinary particles indicating renal damage. With uncentrifuged
24 ECLM ± European Urinalysis Group
specimens, the investigator misses rare elements fuged urine for diagnosis of urinary tract
(most importantly casts and renal tubular infection in young women has also been
epithelial cells) that are clinically signi®cant developed [177]. Uncentrifuged urine may be
but can be concentrated at low-speed centrifu- accepted because bacteria are not concentrated
gation. To allow screening of a large volume, very much at low-speed centrifugation.
i.e. up to 10 ± 20 mL under a coverslip, a low- Reporting at ordinal scale is usually suf®cient.
power (e.g. 6100) magni®cation should always Details of Gram staining are described further
be used in parallel to high-power (usually under microbiology methods (Appendix,
6400) optics. It is understood that centrifu- Annex 13.5.2).
gation methods are never quantitative in
counting RBC and WBC that are variably Chamber counting of uncentrifuged specimens.
lost during centrifugation. The procedure is In some microbiology laboratories, simple
then prone to high uncertainty of certain microscopy is used to improve the detection
particle counts despite standardization. of urinary tract infection only [178, 179].
(2) Differentiation of important formed ele- Chambers were advocated originally to pro-
ments (~ detection of renal damage) is easier vide more precise leukocyte counts than those
through a thin ¯uid layer under a coverslip obtained from sediment preparations, a ®nd-
(40 ± 50 mm) than through the thicker ¯uid layer ing of 10 or more leukocytes 6106/L repre-
of a chamber (usually §100 mm high). A senting signi®cant and abnormal levels of
thicker ¯uid layer may require more focusing leukocyturia [180 ± 182]. Because centrifugation
levels to be examined. results in a variable 20 ± 80% loss of RBC and
WBC [170], no sediment method can be con-
Urine sediment counted in a chamber. Counting sidered as reference for quantitative urinary
concentrated, centrifuged sediments in a cham- particle counting. Analytical sensitivity for
ber has been advocated by some investigators bacteria will be poor at lower concentrations
[168, 175] because of the large counting when compared with bacterial cultures. Perfor-
volume (3.2 mL), which results in a more pre- mance ®gures for bacteriuria for techniques
cise count and possibly a higher sensitivity using uncentrifuged samples of urine are very
compared to uncentrifuged specimens counted variable, depending on the criteria used for
in a chamber. The easier performance of the positivity in culture [183]. They will depend
coverslip method on centrifuged sediment also on operator experience, whether bacilli or
makes this a preferred routine method over cocci are present, and on the degree of inter-
chamber counting despite the lower precision. ference by debris. Sensitivity at the 107 bac-
The reference intervals of chamber counts (the teria/L (104 bacteria/mL) level usually exceeds
number of particles seen in the chamber) in 80%.
health vary because of the different concentra- The major disadvantage of chamber counting
tion factors used in different systems [167, is that it tends to be time-consuming for routine
176]. laboratory practice. Without staining or phase
contrast optics, differentiation of particles is not
Gram staining. Correctly performed, exami- suf®cient for renal elements. The advantage of
nation of urine using a microscope will detect precise, quantitative measurement of elements is
bacteria which are either nutritionally fasti- outweighed by cost as a routine procedure, but
dious and will not easily grow on standard chamber counting is useful as a comparison
media, or which will only grow anaerobically, method in instrument evaluations.
but are nevertheless responsible for urinary
tract infection in a minority of patients. Filtration of urine particles. Filtration of urine
Microbiology laboratories may bene®t from particles on supportive media allows recovery
their capability of interpreting Gram staining of essentially all particles existing in a de®ned
when trying to reduce the total work-¯ow. volume of urine if remaining intact. This prin-
This staining has the added advantage of ciple has been used to improve the sensitivity
immediately ascribing a Gram status to the to detect urine casts using a 3-mm pore size,
infecting organism. A speci®c model incorpor- and starting from 20 ± 100 mL of urine [184].
ating the results of Gram staining of uncentri- Another publication used ®ltering to examine
European Urinalysis Guidelines 25
and small epithelial cells [69] and microcytic examinations for every patient suspected of
(small) erythrocytes [189]. Rational combina- having urinary tract infection. A simple division
tion of automated and visual particle analysis of the patients into usual, uncomplicated cases
with chemical measurement and bacteriological suspected for lower urinary tract infection and
procedures is crucial in the new urinalysis work- special or problematic cases will improve the
¯ow strategy. ef®ciency of clinical laboratory practice.
TABLE XI. Diagnostic performance of different cut-offs for ``signi®cant'' coliform bacteriuria in women with
acute voiding dif®culties (160).
Positive Negative
examined for antimicrobial susceptibility only TABLE XII. Possible causes of low bacterial con-
in exceptional cases (when especially indicated). centrations in mid-stream urine.
This group has been introduced to give more
Early stage of infection
detail for clinical interpretation and to minimize High volume rate (diuresis)
false positives. Urgency symptoms (short bladder incubation time)
Presence of antibiotics in urine
Low pH in urine
7.2.2. Background for limits of clinically signi®-
Slow bacterial growth
cant bacteriuria. Contaminated specimen
7.2.2.1. Unit recommended for expressing bac-
terial concentrations. New technologies for
direct particle counting and development in v107 CFB/L indicated contamination during
standardization of nomenclature ask for a sample collection, whereas bacterial concentra-
rede®nition of the unit used to report bacter- tion in the interval of 107 ± v108 CFB/L was
ial concentrations. The classical ``colony-form- dif®cult to interpret. Despite the fact that the
ing unit/millilitre'' (CFU/mL) has the pitfalls criteria were developed for acute pyeloneph-
that the word ``unit'' should be used as an ritis and asymptomatic bacteriuria in women,
abstraction rather than count of visible things they began to be used generally, even for
such as bacteria, and millilitre is not the stan- symptomatic lower urinary tract infection.
dardized volume to express concentrations. Only the discovery that S. saprophyticus was a
Therefore, bacterial particle concentrations are common cause of seasonal, aggressive cystitis
recommended to be expressed as bacteria/litre in younger women resulted in the cut-off of
(L) in a way similar to cells in body ¯uids. signi®cant growth being lowered to
When grown on agar, the living bacteria §107 CFB/L in these cases.
appear as colonies, corresponding to a stan-
dardized unit colony-forming bacteria/litre 7.2.2.3. Signi®cance of low bacterial concentra-
(CFB/L). Equivalence is given in Table X. tion in urine. Stamm et al. examined 187 sexu-
ally active young women with dysuria and
7.2.2.2. Traditional Kass's criteria. Evaluating urinary urgency [160]. Cultures of mid-stream
urine culture ®ndings has long been domi- urine samples were compared to urine cultures
nated by Kass's criteria for signi®cant bacter- obtained through suprapubic aspiration or
iuria. Kass found that 95% of women with urethral catheterization. ``Coliform'' (the term
pyelonephritis had §108 CFB/L (§105 CFU/ is not de®ned in Stamm's article and most
mL) of one bacterial species in a clean-catch likely refers to Enterobacteriaceae or lactose-
mid-stream urine, and that such a ®nding in positive Enterobacteriaceae) bacteria were iso-
two consecutive mid-stream urine specimens in lated from bladder urine in 98 (52%) women,
asymptomatic women would, with 95% prob- whereas non-coliform bacteria such as S.
ability, give the same result in a third mid- saprophyticus, S. aureus and enterococci were
stream urine specimen [194, 195]. Thus, in cultured in 26 (14%). The women who had
order to diagnose asymptomatic bacteriuria ``coliform'' bacteria in bladder urine were
with reasonable accuracy, §108 CFB/L of the further analysed regarding the number of
same bacterial species was necessary in two CFB/L. If 108 CFB/L mid-stream urine was
mid-stream urine samples obtained within an used as a cut-off for ``signi®cant'' bacteriuria,
interval of a few days. Kass also showed that the sensitivity was 51% and the negative pre-
European Urinalysis Guidelines 29
dictive value was 65% (Table XI). Speci®city gated and reported should vary according to
was high. If, on the other hand, a cut-off of the local case mix and should not interfere
105 CFB/L mid-stream urine was used, the with the needs of speci®c patients.
sensitivity was 95% with a negative predictive
value of 94%, whereas speci®city declined 7.2.3. Laboratory-related decision limits for
from 99% to 85%. Among the 48 who had ``signi®cant'' bacteriuria. The following decision
v108 CFB/L mid-stream urine of ``coliform'' limits for diagnostic laboratory workup are
bacteria, at least one additional bacterial spe- proposed (Table XIII) [7]. They should guide
cies was isolated in 35 cases, i.e. there was the practical process. Consideration has been
mixed ¯ora. given to symptoms, bacteria category, number
Thus, low cut-off of ``coliform'' bacteria in of species isolated, method of specimen collec-
mid-stream urine more accurately predicted tion and gender. One should note the uncer-
bladder infection in symptomatic women than tainty of quantitation when using routine loop
in asymptomatic. The main differences between cultures. A count of 36106 CFB/L (3 colonies
Kass's and Stamm's studies were the prevalence on a plate with a 1 mL loop) is more than
of infection in the patient populations, as well as 106 CFB/L, but reproducibility may be within
the presence of symptoms (dysuria). Thus, the a con®dence interval of 1 ± 106106 CFB/L in
chosen cut-off for ``signi®cant'' bacteriuria should routine work. Few laboratories report one
be adjusted to the population under examination. colony (1 colony with a 1 mL loop ~106 CFB/
Many additional studies support the observa- L). It is obvious that the symptoms and clinical
tion that low bacterial concentrations of E. coli status of patients are important when evaluat-
in particular have diagnostic relevance, even in ing culture results. This implies that consider-
mixed ¯ora [33, 196 ± 205). Findings of E. coli ably greater attention must be paid to the
have been interpreted as the ®rst phase in information given on the request and report
urethritis in an ascending infection. Causes of forms (Appendix, Annex 10.1).
low bacterial concentrations in mid-stream The cut-offs for symptomatic urinary tract
urine are given in Table XII. Short bladder infection caused by primary pathogens (E. coli
incubation time (see also Section 3.3.3) is a less and S. saprophyticus, Table IX) are set at
important factor than the lowered cut-offs for §106 CFB/L in mid-stream urine specimens.
signi®cance in symptomatic individuals. On the For secondary pathogens (group II), lower cut-
basis of available information, the cut-offs offs of §107 CFB/L mid-stream urine for
could be set even lower than those proposed women and §106 CFB/L mid-stream urine
in Table XIII, but with the risk of a lower for men are recommended. For men, the risk
speci®city, leading to a decreased predictive of contamination during specimen collection is
value of positive results for clinical urinary tract much smaller, increasing the speci®city of low
infection. The importance of speci®city should bacterial concentrations. For doubtful patho-
be stressed in diagnostic practice. genic bacteria (group III) a cut-off of
§108 CFB/L in mid-stream urine is proposed
7.2.2.4. Mixed cultures. Most acute uncompli- for pure culture in symptomatic patients.
cated urinary tract infections result from one If symptoms are absent, the classical
bacterial species. The isolation of more than criteria apply for asymptomatic bacteriuria:
one organism from a single specimen of urine §108 CFB/L of the same bacterial species (in
must always be interpreted in the light of (a) two consecutive mid-stream urine specimens,
whether one organism is dominant, (b) how or, alternatively, a positive speci®c rapid
the sample was collected (chronic catheteriza- examination and §108 CFB/L mid-stream
tion versus mid-stream specimen), (c) the pres- urine in one sample).
ence of other features suggesting either true When two species are present in mid-stream
infection (presence of WBC) or contamination urine, it is proposed that only these be regarded
(presence of squamous epithelial cells), and in symptomatic patients and that the cut-offs
(d) clinical signs, symptoms and history. True are set at §106 CFB/L for primary pathogens
infection with two species (even three occa- and at §108 CFB/L for secondary pathogens.
sionally) may occur. Policies concerning how When more than two species are isolated from
such mixed growths are subsequently investi- mid-stream urine, only ®ndings of primary
30 ECLM ± European Urinalysis Group
TABLE XIII. Suggested limiting concentrations of bacteria colonies justifying identi®cation and susceptibility
testing in the laboratory.
Symptomsa and Inoculum, Species typeb and number Signi®cant colony concentration
specimens min volume
CFB/L (CFU/mL)
This is obtained only by using a 10-mL loop. This sensitized culture procedure should be specially requested to
avoid inadvertent extra work and costs caused by routine application of a 10-mL loop for all specimens.
e
Suprapubic aspiration specimens should be cultured from a 100 mL inoculum to reach the highest sensitivity,
since w104 CFB/L (101 CFU/mL) and a statistically reliable culture result at 105 CFB/L (102 CFU/mL) may be
signi®cant.
f
Three species are isolated on special request only from symptomatic patients (suspicion of pyelonephritis or
urosepsis). Susceptibility testing from catheter specimens is done only for E. coli and Gram-negative bacteria if
they are present at concentration of 107 CFB/L (104 CFU/mL) per species, or more. For asymptomatic patients, a
higher limit of signi®cant growth (108 CFB/L) is suggested for Gram-negative bacteria.
pathogens are reported. When no primary The reduced cut-offs for ``signi®cant''
pathogens grow, ``mixed culture'' is noted. bacteriuria necessitate cultures performed on
Lower cut-offs are proposed for samples larger volumes of urine. With inoculation of
obtained via suprapubic aspiration, cystoscopy 10 mL, one colony would then correspond to
and single (in-and-out) urethral catheterization. 105 CFB/L. When culturing suprapubic aspira-
Samples from patients with indwelling catheters tion specimens, a 100-mL inoculum is recom-
are handled depending on symptomatology: In mended to approach the sensitivity §104 CFB/
symptomatic patients all isolates are considered L. A statistically reliable positive result (using
for identi®cation and susceptibility testing. In the limit of 10 colonies on a plate) corresponds
asymptomatic individuals the analysis is focused to 106 CFB/L (10 mL inoculum) and 105 CFB/L
on Gram-negative rods. (100 mL inoculum), respectively.
Findings of bacteria belonging to the normal
¯ora of the urethra and genitalia (group IV) are
7.3. Bacterial cultures
reported as specimen contamination. Further
examination should be done only if especially The culture methodology is structured into
indicated after individual evaluation. three levels to satisfy different clinical and
European Urinalysis Guidelines 31
bacteriological needs (see Section 5.1 for general speci®city. Details of the comparison method
de®nitions): Quali®ed comparison methods for bacterial culture are explained in Appendix,
(Level 3; due to the lack of documented Annex 13.1.
reference methods), quantitative ®eld methods
(Level 2) and ordinal scale or rapid methods 7.3.2. Routine cultures on plates. Common
(Level 1). Individual laboratories and their sense is obviously needed in a clinical bacter-
customer clinicians must decide, on the basis iological laboratory to ensure both high clini-
of local patient populations and resources, the cal sensitivity and high speci®city of routine
way in which urine cultures should be organized reports. This may be in¯uenced by the micro-
locally. biology traditions and costs of health care in
different countries. The ideal in terms of
7.3.1. Comparison method for bacterial culture patient preparation, specimen collection and
(Level 3). A quali®ed comparison method transport, and ®nally in the analytical process
(Level 3) is needed to establish traceability of may not be attainable. Previously suggested
local variations in technology. This method signi®cance limits and volumes of inocula
can also be chosen for individual patients or (Table XIII) serve as goals for optimal prac-
patient groups. The indication for more tice. Expert microbiology advice is necessary
extensive culture is usually evaluation of in locations possessing only minimal
results from routine methodology, or from resources.
other examinations suggestive for urinary Inoculum: A 1-mL disposable loop inoculum
tract infection, such as those from rapid is accepted for routine practice although it is
examinations. less than optimal. On special request, higher
Inoculum: Since the cut-off for detection of volumes should be used as recommended.
bacteriuria is reduced, a greater culture inocu- Statistical reliability starts at 107 CFB/L with
lum is necessary. With a precisely pipetted a 1-mL inoculum, but this is also in¯uenced by
10-mL inoculum, a culture result of 106 CFB/L the accuracy of the ¯uid volume in the loop.
is equivalent to 10 colonies on the agar surface, The statistical unreliability of 2 ± 3 colonies
whereas 105 CFB/L equals only 1 colony on a growing on a plate is understood and consid-
plate. At 10 colonies, a minimum imprecision ered when expressing the limits of signi®cant
CV~30% (SD~d10) is due to the uneven growth in Table XIII, but accepted in routine
distribution of bacteria in the urine. For more practice.
critical applications, such as evaluation of a Culture: Quantitative culture should be per-
particle analyser, a more accurate procedure is formed at least on a relatively non-selective agar
needed, e.g., by pipetting 100 mL volumes of plate, such as Cystine-Lactose Electrolyte De®-
serially diluted specimens (see Annex 13.1.). cient (CLED) medium. Alternatives to CLED
Culture: The quantitative culture should be agar also exist [5]. In addition, culture on blood
performed on CLED agar in aerobic, on blood agar is recommended as an optimum approach
agar in anaerobic, and haematin agar in CO2 ([6, 7]; see Appendix, Annex 13.2). Incubation
conditions for 48 h, as opposed to the 24-h for 24 h is suf®cient though not optimal as
incubation of CLED agar in the routine routine. It can be less reliable when fastidious
method. Comparisons with blood agar are organisms cause infection or when mixed
particularly important to describe and follow culture is obtained. Inoculation of four different
the reliability of the routine culture method for specimens on a single plate (``quarter-plate
accreditation of microbiological diagnostic pro- technique'') is prone to contamination and
cedures. The blood agar under anaerobic reading problems. It is, however, understood
conditions is recommended in parallel for the that it appears advantageous particularly in
following reasons: it serves as a quantitative large laboratories with high throughput. Stra-
reference, reveals false-negative results on tegies to reduce the number of non-signi®cant
CLED plates, improves the isolation of bacterial cultures are highly encouraged to
Gram-positive bacteria, assists with the identi- improve the quality of those cultures that are
®cation of isolated species and helps in clearly indicated.
differentiating contaminants from uropatho- The uncertainties of the routine process
genic species, thereby increasing diagnostic should be controlled by the comparison
32 ECLM ± European Urinalysis Group
method (Section 7.3.1). The addition of blood Problems with quantitation: Inoculum on a
agar incubation in a CO2 atmosphere for 1z1 dipslide is not reproducible. Any colony count
days will increase both sensitivity and speci®- is therefore uncertain. At high bacterial
city. Depending on the success of these adjust- concentrations, con¯uent growth necessitates a
ments, the routine process may be considered as subculture for identi®cation. Mixed ¯ora may
a quantitative method (Level 2) or an ordinal also be missed.
scale method only (Level 1). Details of routine To reduce the risk of false interpretation,
culture are included in Appendix, Annex 13.2. dipslide-culturing should be viewed as an
ordinal scale method for bacteriuria, combined
7.3.3. Dipslide cultures. Dipslide cultures can with the possibility of identifying E. coli. It may
be considered suitable for identifying negative be possible to satisfactorily handle up to 90% of
specimens and those with signi®cant growth ambulatory urine cultures requested for sus-
of E. coli at ordinal scale level (Level 1). For pected urinary tract infection with this simpler
reliable results, reading by laboratory profes- rapid procedure. Details of the method are
sionals, or special training to clinical person- described in the Appendix, Annex 13.3.
nel is recommended.
The urine dipslide system has developed from 7.3.4. Enrichment cultures. Enrichment cultures
devices originally designed over 30 years ago from urine using bottled broth media are dis-
[206]. It presently consists of agar media coating couraged because no quantitative results are
both sides of an immersible plastic paddle that obtained. Speci®city is poor due to inevitable
can be dipped in urine at point-of-care, and sent overgrowth of commensal organisms.
to the laboratory in a sealable universal
container. Media usually consist of a relatively 7.3.5. Identi®cation of species. A proposal for
non-selective agar such as CLED on one side identifying species of urinary isolates in routine
and a Gram-negative selective medium such as diagnostics is compiled in the Appendix,
MacConkey on the other. There may also be a Annex 13.4. It is based on the practice where
third section of agar that detects beta-glucur- cultures are performed on CLED and blood
onidase activity by producing brown or black agar. The tabular data suggest at least the mini-
colonies [207]. These devices provide compar- mum criteria for identi®cation of each species.
able results to those obtained using standard
loop inoculation methods [208], and may be 7.3.6. Antimicrobial susceptibility testing. The
useful where delays between the point-of-care goal of susceptibility testing is to allow the
and the laboratory are either unavoidable, clinician to choose the correct antibiotic for
unpredictable, or both, and where no facilities individual urinary tract infections, and to help
for refrigeration are available. In two studies, in investigating the reason for treatment fail-
the selective agar has been shown to have a high ure. The antibiotic sensitivity of pathogenic
sensitivity (95.5%, 92%) and speci®city (97.2%, organisms should usually be examined when
100%) for detecting E. coli in urine [207, 209]. isolated in clinically signi®cant concentrations.
These studies were performed in clinical micro- To reduce the workload in laboratories, it is,
biological laboratories ± and did not evaluate however, suf®cient to rely on the predicted
the interpretation of dipslide cultures by antibiotic sensitivity of individual bacterial spe-
primary health care personnel. cies when community-acquired lower urinary
Problems with species identi®cation: Estimat- tract infection is suspected in low-risk female
ing growth on CLED compared to MacConkey patients, and the information on local resis-
agar in order to differentiate Gram-positive tance in strains is available (then, even bacter-
from Gram-negative bacteria has far too many ial culture may be unnecessary). The antibiotic
sources of error to be useful in practice. For sensitivity patterns of individual species vary
example, enterococci and staphylococci can considerably according to location, patient
grow weakly on MacConkey, fungi grow on case mix and background antibiotic usage.
MacConkey and certain Pseudomonas species
do not grow on MacConkey agar. In addition, Choice of method. Standardized disc diffusion
the dipslide technique does not allow identi®ca- is the frequently used method. Non-
tion of Staphylococcus saprophyticus. standardized disk diffusion, so-called ``direct
European Urinalysis Guidelines 33
7.3.8. Automation of bacterial culture. For Measurement principles. Multiple test strips
large microbiology laboratories, automated including the nitrite ®eld are described in Sec-
urine culture may be an option in addition to tion 5.3.1. Several new technical developments
the methods used for rapid detection of have been suggested [63, 67, 70, 93, 132, 219 ±
potentially positive cultures. Several auto- 222]. These include enzymatic examinations
mated systems exist which satisfy the require- based on adenosine triphosphatase/luciferase,
ments of Level 2 cultures. Advances in catalase or glucose oxidase, ®ltration methods,
technology mean that laboratories, especially advanced microscopy of Gram stained smears
large ones, will be tempted to assess analysers and automated ¯ow cytometry. Some of these
that can replace expensive manual work. methods are well suited to point-of-care test-
Finally, it is recommended that any new auto- ing, but sensitivity and speci®city of procedures
mated technique be assessed against accepta- must be investigated and quoted in relation to
ble Level 3 comparison methods. Evaluation the patient population studied. Others require
should preferably be three-way, where perfor- laboratory-based experience for their perfor-
mance is also compared to the currently used mance, interpretation, or both.
method (usually not Level 3). Urine particle analysis is discussed in Section
6. Bacterial analysis may theoretically adopt
either direct particle counting (of living and
7.4. Bacterial detection by non-culture (rapid)
dead bacteria) or automated rapid culturing of
methods
urine in selected media. Laboratory staff must
There is a need for high performance rapid remember that these analysers may detect
methods for the detection of bacteria in urine. particles and not growth. In microbiology
This applies for the routine laboratory handling evaluation, the arising new view is that some
of large numbers of specimens, for emergency specimens may contain true, aggressive patho-
diagnostics and for detection of asymptomatic gens that do not grow on conventional agar
bacteriuria in selected patients groups, such as plates. There may also be the issue concerning
pregnant women. Development of analytically the presence of antibiotics in the urine that
sensitive and speci®c rapid procedures for inhibit growth. Finally, it should be noted that
detection of bacteria is encouraged both for automated techniques assigning Gram status to
adults and children [217]. organisms were very helpful since they could
Sensitivity view: A high performance high- predict effective antibiotic treatment.
throughput screening procedure with low false-
negative rates (ideally v10%) would identify
true negative specimens and allow signi®cant
reduction in costly and unnecessary urine 8. STEP WISE ST RATEGIES I N
culture. Health care savings would then be U R IN A L Y S I S
achieved even in the face of an appreciable
8.1. Examinations for general patient
false-positive rate. The validation of method
populations
performance for detection of bacteria at con-
centrations less than 108/L (v105/mL) becomes Most of the costs arising from screening
very important. programmes result from the need for con®rma-
Speci®city view: Acutely ill patients need an tion of positive ®ndings. Screening of com-
examination with high speci®city (preferably pletely unselected individuals, i.e. at general
w90%) to demonstrate the presence of bacteria epidemiological level, is discouraged except for
reliably when the clinical presentation is not research purposes. Selected asymptomatic indi-
obvious from symptoms and signs. In these viduals may be investigated if justi®ed by cost/
cases, a positive speci®c result from a rapid bene®t analyses, e.g., pre-school children or
diagnostic procedure supports a correct im- pregnant women [88, 223]. Examinations for
mediate treatment decision, while the rest of the diseases in kidneys and urinary tract can be
cases await results from bacterial cultures [218]. recommended for many clinical populations
A typical question is how does a method cor- (~patients attending health care services in
rectly classify contaminants and debris as hospitals or at ambulatory clinics because of
negatives. their symptoms or diseases), but not for all
European Urinalysis Guidelines 35
patient groups. Use of urine test strips, as well despite a standardized specimen) it may be
as of other laboratory measurements, should appropriate to perform additional investiga-
always be associated with prognostic signi®- tions to detect or isolate organisms with special
cance [224]. The outlined strategy has been growth requirements (Chlamydiae, gonococci,
derived from earlier recommendations [2, 123, Mycobacterium tuberculosis and fungal infec-
225, 226]. tions) by collecting another appropriate specimen
In addition to the minimum properties shown and investigating it accordingly.
(Fig. 2), acute cases generally bene®t from General screening of asymptomatic indivi-
measurements of urinary glucose, ketone bodies duals for bacteriuria should be avoided.
and pH (urine stone formers). The strategy is Bacterial culture is initiated only if the
only an average general approach and not asymptomatic bacteriuria is going to be treated
sensitive to the individual needs of patients. with high probability (Section 8.2.3 for detailed
These strategic proposals are designed to patient groups).
improve the general ef®ciency of urinalysis.
Clinical decisions should be based on direct 8.1.2. Detection of proteinuria. Transient pro-
patient data; laboratory and imaging methods teinuria is a fairly common ®nding among
provide ancillary information only. The recom- acutely ill patients [227] even if detected at the
mendations presented describe some approaches traditional 0.2 g/L albumin level. In these
based on the diagnostic performance of the cases, an occasional positive result may lead
methods available. The term ``®rst visit'' refers to inappropriate investigations. Exclusion of
to the initial diagnostic investigations; the transient proteinuria is accomplished by
follow-up investigations should be based on repeated measurement and review of anamnes-
evaluation of detailed needs. Consultation of a tic data.
nephrologist, clinical specialist for infectious Quantitative speci®c measurements are gen-
diseases, internist, paediatrician or another erally not part of a primary screening process
specialist may be necessary to plan all medically for general patient populations; they are second-
required investigations. A multiple urine exami- line investigations. Total albumin or protein
nation should be performed at point-of-care or quantitation can be requested ± if not already
in the laboratory as locally agreed. the ®rst-line method ± as albumin or total
protein/creatinine ratio (or albumin or protein/
8.1.1. Detection of urinary tract infection. It is osmolality ratio), or as measurement of 24-h
important to clearly differentiate high-risk protein excretion rate. Orthostatic (postural)
patients from low-risk (recurrent female) cysti- proteinuria can be identi®ed by separate day
tis patients when applying any diagnostic stra- and overnight collections. Selected patient
tegies for symptomatic patients suspected for groups do require a sensitive protein determina-
urinary tract infection (see Section 7.1 for tion to detect renal damage already in the ®rst
de®nitions and 8.2 for strategic proposals). line. In addition to albumin and a tubular
Acute cases may also bene®t from a labora- marker protein, immunoglobulin light chain
tory result within 0.5 ± 2.0 h, while a highly determinations may be important (see Section
speci®c result, such as that from bacterial 8.3).
culture, serves to ®nally classify cases even
after 1 ± 2 days. 8.1.3. Detection of haematuria. Exclusion of
Some clinical patients may have general or other coloured substances (red beets, por-
vague symptoms that were not associated with phyria, drugs; Table II, page 14) should
urinary tract infection initially. These cases then always be a ®rst thought. Particle analysis is
appear as unexpected ®ndings. Exclusion of needed to obtain a count of RBC excretion
urinary tract infection at a cut-off of 108 CFB/L from a standardized specimen. Renal elements
is possible from concentrated morning speci- may be seen on urine microscopy. The RBC
mens with a sensitivity of 90% by rapid methods should be assessed for isomorphism, dys-
(see Sections 5.3.1 and 7.4). Urine microscopy morphism and the presence of acanthocytes if
should be performed to detect possible renal no proteinuria is present. This must be per-
involvement if relevant. In cases of so-called formed in a laboratory capable of distinguish-
``sterile pyuria'' (no usual uropathogens grown ing the different types of RBC morphology.
36 ECLM ± European Urinalysis Group
An alternative approach is differentiation of and for excluding them from further investiga-
the bleeding site based on urinary IgG/albu- tions for urinary tract infection, whilst it is
min and alpha-2 macroglobulin/albumin ratios understood that such sieving strategies must not
as measured in a centralized laboratory [123]. be applied in high-risk cases.
Urine sediment examination only occasion-
ally offers additional information after a test- 8.2.1. Symptomatic low-risk patients. Low- and
strip measurement in unselected emergencies high-risk patients with respect to urinary tract
[71], but it helps in predicting renal damage if infection were de®ned in Section 7.1. Low-risk
investigated carefully from a standardized patients with suspicion of lower urinary tract
specimen [22]. When the test-strip result is infection can be examined as follows: No
negative for erythrocytes, leukocytes and investigations are needed if the diagnosis is
albumin/protein, sediment microscopy is not clear from the symptomatology. Empirical
generally warranted [228, 229]. Automated treatment can be justi®ed with known local
particle counting possesses higher precision epidemiology of community-acquired infection.
than visual urine sediment examination, but it If the symptoms are not clear, a speci®c
may not detect all signi®cant renal elements examination (speci®city w90 ± 95% for uro-
[69]. pathogens) allows a rapid con®rmation of
A clinical (urological and/or nephrological) bacteriuria and justi®es treatment. Sympto-
consultation is usually needed to search for matic low-risk cases remaining negative with
possible local or systemic diseases causing the speci®c rapid examination (during emer-
haematuria. The presence of a haemorrhagic gency hours) should be treated or investigated
diathesis should not be forgotten. Urothelial by a culture method after obtaining a standar-
and renal cancers often present as unexpected dized morning specimen.
haematuria. On the contrary, prostatic cancer Follow-up of low-risk patients should be
rarely presents with haematuria or proteinuria. organized as follows: if no symptoms re-
Detection and follow-up of prostate cancer is main after treatment, no further examination
undertaken by measurements of serum PSA is needed. If symptoms persist, bacterial
(prostate-speci®c antigen), currently as total culture with antibiotic susceptibility testing is
and free PSA molecules. Screening for bladder warranted.
tumour cell antigens in urine is under develop- Epidemiology of uropathogens: The pre-
ment. Experienced cytopathologists must inter- requisite for treatment of urinary tract infection
pret urothelial tumour cell cytology. without bacterial cultures is an epidemiological
knowledge of uropathogens and their antimi-
crobial susceptibilities within a local commu-
8.2. Detection of urinary tract infection,
nity. This gives valuable information on
speci®c populations
relapsing infections often due to reduced
The suggested sieving strategy to reduce the antibiotic susceptibility of the species. National
number of bacterial cultures in patients sus- and regional efforts to create and maintain
pected for urinary tract infections (UTI) is these data are encouraged.
illustrated in Fig. 3. Cultures of low-risk
patients are not needed [207, 219] with given 8.2.2. Symptomatic high-risk patients. Speci-
precautions. mens from symptomatic high-risk patients
This strategy can be dif®cult to follow exactly should always be cultured for uropathogenic
because of problems with speci®city, such as bacteria both to con®rm the diagnosis and to
contamination and false-positive reactions, and ensure treatment (with the help of antimicro-
sensitivity, because rapid detection methods for bial susceptibility testing). Urgency of micturi-
uropathogenic bacteria are not perfect to date. tion may prevent suf®cient bladder incubation
Despite this, such strategies should help in time, leading frequently to false-negative
reducing traditional cultures markedly, but results ± even with culture methods. Signi®-
should remain sensitive to needs of problematic cant growth may be as low as 105 ± 106 CFB/
or speci®c cases. For example, it may be L (corresponding to 102 ± 103 CFU/mL), occa-
acceptable to use a highly speci®c rapid sionally needing a culture with a 10-mL (or
examination for identifying positive patients even 100-mL) inoculum to reach this sensitivity
38 ECLM ± European Urinalysis Group
reliably. The speci®city of low-count ®ndings Exceptions to be treated may include preg-
should be considered. Local microbiological nant women (a prevalence of about 5% for
consultation is recommended to establish asymptomatic bacteriuria), some patients
rational routine processes. undergoing urogenital surgery (if the indwelling
catheter is going to be used postoperatively) or
8.2.3. Asymptomatic bacteriuria. The need for receiving organ transplant, and many immuno-
investigation of asymptomatic individuals is compromised individuals. During pregnancy,
questionable. Liberal treatment of patients bacteriuria is treated to prevent symptomatic
with asymptomatic bacteriuria by using anti- infection and premature birth [230, 231]. A
microbials results in development of multi- rapid method, reaching analytical sensitivity
resistant strains that replace the less danger- w90 ± 95% at 108 CFB/L (equal to 105 CFU/
ous original species. mL) when compared to bacterial culture is
European Urinalysis Guidelines 39
recommended, with con®rmatory culture of diagnosis is often based on renal imaging and
positive cases. biopsy.
Secondary renal diseases are more common
than primary due to the high prevalence of
diabetes mellitus, hypertension and systemic
8.3. Sensitive detection of renal disease ±
rheumatic diseases. For speci®ed asymptomatic
speci®c populations
patient populations, sensitive screening pro-
Table XIV lists examinations used to detect grammes should be established when improve-
renal disease in patient populations with high- ment in life expectancy or cost containment is
risk for renal damage. The minimum and anticipated. Currently, such a screening pro-
optimum lists refer to economical possibilities gramme is established for incipient diabetic
by different health care service providers. nephropathy by sensitive measurements of
Primary renal disease may present with albuminuria. Renal involvement in hyper-
symptoms. Haematuria and albuminuria, some- tension should be screened at least by measure-
times even leukocyturia may be demonstrated ment of total protein excretion (24-h collection
by sieve measurements; in addition, quantitative or total protein/creatinine ratio) if sensitive
total protein excretion (measured as a 24-h albuminuria measurements are beyond existing
excretion rate, or protein/creatinine ratio of resources. Renal disease secondary to multiple
morning urine) is usually elevated. In tubular myeloma may be detected by ®nding immuno-
disease, defect in urine concentrating capacity globulin light and occasional heavy chains in
may be demonstrated (measured by relative urine in association with glomerular or tubular
density or osmolality). Albuminuria is a major proteinuria.
feature in most glomerular diseases. Monitoring The role of urine particle morphology is to
for side effects from clearly tubulotoxic drugs, con®rm the presence of renal damage (casts,
such as aminoglycoside antibiotics, many cyto- renal tubular cells, dysmorphic red cells)
toxic drugs and some non-steroidal anti-in¯am- because non-renal proteinuria due to, e.g.,
matory drugs is possible with measurements of fever, epileptic seizure or cardiac insuf®ciency
urinary a1-microglobulin, retinol-binding pro- is also frequent. Occasionally, renal elements
tein (RBP) and other markers (see Section may occur in urine due to secondary damage
5.4.1). caused by abdominal or retroperitoneal (surgi-
Measurements of GFR are important in renal cal or gynaecological) disease, or hypotension
disease. Urine creatinine measurement is also due to cardiogenic shock. The analyses of both
needed for calculation of creatinine clearance. urine proteins and formed elements complement
Positive ®ndings from these investigations each other in detection and follow-up of renal
should be followed by more speci®c diagnostic damage. The former are more sensitive but less
procedures. In central hospitals, de®nitive speci®c, while the latter are more speci®c but
less sensitive markers of renal damage.
TABLE XIV. Measurements for sensitive detection
of renal disease in urine.
Minimum measurements 9 . Q U A L I T Y AS S U RA N C E
Urine albumin (20 ± 30 mg/L) and total protein
(quantitative, sensitivity 50 mg/L) 9.1. General principles
Urine microscopy
Optimum quantitative measurements additionally Urinalysis faces many challenges when its
Urine albumin (sensitivity 2 ± 10 mg/L) quality is being de®ned formally. While trace-
Urine a1-microglobulin (sensitivity 2 ± 10 mg/L), ability and description of uncertainties are well
retinol-binding protein, or another tubular marker
protein
established in clinical chemistry and haematol-
Urine creatinine ogy, these concepts are still premature to the
(or another reference quantity for volume rate) semi-quantitative or ordinal scale examinations
Optional urinary proteins in special cases used in urinalysis. For morphological analysis,
Ig, k and l light chains, a2-macroglobulin systematic peer reviews are being used in
Other diagnostic examinations (based on clinical
presentation) cytopathology to reach the highest possible
agreement between observers [232 ± 234). In
40 ECLM ± European Urinalysis Group
microbiology, error in the identity or in a count address systematically all facets of laboratory
obtained from cultured colonies may be dif®cult activity. Accreditation based on such interna-
to set into an acceptable statistical framework. tional standards as EN45001 and ISO/IEC
Quality assurance practices must also encom- Guide 25, or the later ISO17025, should be
pass point-of-care testing [235 ± 237]. Finally, considered for all facets of urinalysis as well.
the increasing costs of health care tend to These guidelines encourage local establishment
challenge the acceptable minimum requirements of quality systems even in small European
[238]. These guidelines are sensitive to such laboratories working under the supervision of
pressures and are designed to propose practical specialized laboratories. Quality systems need
solutions. regional co-operation and support.
Publications already exist at a general level
[239 ± 241] and speci®cally for quantitative
serum chemistry [242]. A Scandinavian group 9.1.2. Quality manual. General principles of
has advised on assessment of analytical quality good laboratory practice apply to all clinical
speci®cations from a theoretical point of view laboratories. The quality system is described
[243]. In urinalysis, the healthy concentrations in the quality manual of a laboratory. The
or excretion rates of many substances or following contents were suggested by a
particles are traditionally reported as ``nega- Scandinavian group [248]. As an example,
tive'' rather than numerically. The performance some speci®c views are reminded for micro-
goals at detection limits must take into account biological investigations as performed in
the large biological variations that occur at low general laboratories under the supervision and
concentrations characteristic for the upper level support of a local microbiology laboratory.
of the reference range in health.
Adherence to the international vocabulary of 9.1.2.1. Description and identity of laboratory
metrological terms (VIM) is encouraged [126, ± In most European countries, national gov-
244 ± 246], although this was not done thor- ernments have designated, by decree, certain
oughly in these guidelines owing to their only microbiology laboratories to investigate infec-
gradual acceptance in routine work. Substance- tions of epidemiological importance. National
based SI units (e.g. mmol/L) should replace regulations may also apply to other microbio-
conventional mass-based (e.g. mg/dl) units in logical examinations, such as cultures from
expressing results. The volume unit litre (L) has urine.
been used throughout this document, including
bacterial colony counts (particle concentra-
tions), as an example of this standardization. 9.1.2.2. Quality policy. (Modi®ed from the
The term accuracy now encompasses both EN45001 suggestion for a policy statement)
precision and trueness of measurements; and, ``The aim of the laboratory is to provide
inversely, inaccurate measurements may be clinically useful information through laboratory
erroneous because of systematic effects (bias) examinations of samples from patients, taking
or random effects (imprecision). into account the allocated resources. The
quality policy is implemented by the following
9.1.1. Quality systems. The concept and prac- means:
tice of Total Quality Management (TQM) is Proper specimen collection, labelling and
now commonplace in many clinical labora- transport
tories. Laboratory practice can be divided into Reliable analytical work
three stages (pre-analytical, analytical and Turnaround time within speci®ed limits
post-analytical) all of which must be quality Results reported in a clear format and
assured in order to obtain reliable chemical supplemented with relevant explanatory infor-
and microbiological results for patient care mation (either together with the result or in a
[247]. separate laboratory handbook)
The essential components of quality systems Appropriate communication is maintained
may be created nationally with reference to with clinical customers to ensure correct
published national guidelines. Organization of integration of laboratory information into
Good Laboratory Practice (GLP) should evaluation of patients''.
European Urinalysis Guidelines 41
9.1.2.3. Staff and education. Training and cer- quality of equipment should be maintained
ti®cation of competence: The necessary educa- and its performance monitored daily. In urine
tional requirements for certi®cation of culture, this includes, e.g., incubators with
specialist competence should be documented. their required temperatures and atmospheres,
Training and certi®cation should be carried and culture plates.
out in consultation with the microbiology
9.1.2.8. Safety and environment. Regular hand-
laboratory. Competence should be updated
ling of biologically hazardous material needs
regularly (e.g., yearly) and after long absences
special attention in routine procedures. The
(e.g., absences for longer than 6 ± 12 months).
details of safety management should be orga-
9.1.2.4. Management and quality assurance. nized and explained.
The documentation and procedures describing The facility must comply with current safety
the quality system in detail must only be legislation.
changed with the authority of the Head of the
9.1.2.9. Research and development. The quality
laboratory or persons nominated to authorize
manual should state how a laboratory is
such changes. These documents must form a
developing its routine programmes. Possible
laboratory manual (with separate appendices),
participation in basic research should be
relevant sections of which are issued to staff.
quoted as well.
When changes are made, all working copies
of the modi®ed document must be updated. 9.1.2.10. Measurement procedures. Reference
The old copies must be stored (one archival materials and methods produced by manufac-
copy) or destroyed (at the working sites). turers must be clearly described to allow audit
Continuous quality improvement is a result and traceability of measurements.
of professional external and internal audits, in Detailed operating procedures for any inves-
addition to development of analytical tech- tigation must be in place, as must instructions
niques. Audits should be arranged on a regular for use of equipment.
basis, e.g., once a year. Level of identi®cation of uropathogenic
The laboratory manager must have access to species must be discussed with the local
advisory documents issued by relevant bodies microbiology laboratory: a small laboratory
including health notices, safety information may decide to report only negative culture
bulletins, health equipment information, health results or to undertake a preliminary typing of
building notes and health equipment notes. positive cultures in agreement with the support-
ing microbiology laboratory.
9.1.2.5. Records, maintenance and archiving.
Reliable microbiological results are often
Final patient records and quality assurance
dependent on detailed adherence to speci®c
data should be archived according to national
procedures. Procedures and interpretation
or institutional regulations, typically 3 ± 15
charts should be followed strictly. The medi-
years, to allow later investigation for clinical,
cally responsible physician or other specialized
epidemiological and, occasionally, for legal
clinical microbiologist, who should be available,
purposes. Laboratories should also keep
must have approved these.
records on their maintenance.
Both commercial kits and media developed in
the laboratory should be veri®ed in a traceable
9.1.2.6. Facilities. Careful planning is needed
manner (standardized procedures and strains
in siting a microbiology laboratory to ensure
obtained from international collections).
stable environments (temperature, atmosphere,
It is important that the number of examina-
humidity, etc.), minimum contamination risks
tions is large enough to maintain the level of
between specimens and safety of personnel.
skill (approximate minimum is about 20 urine
Facilities must be available which are cultures/week).
designed to be safe for the processing and
containment of speci®c pathogens. 9.1.2.11. Request protocols, sample collection
and handling of laboratory samples. Instruc-
9.1.2.7. Equipment and material. In both tions for the receipt and recording of speci-
manual and automated laboratory work the mens must be clear and unambiguous.
42 ECLM ± European Urinalysis Group
Detailed clinical information, including cur- should explain detailed procedures for speci-
rent antimicrobial treatment as well as the real men collection and transport of microbiologi-
time and anatomical localization of the cal investigations, including those for urine
obtained specimen (sample), is crucial for collection. Interpretation of usual culture
interpretation of bacterial cultures. In urine results, antimicrobial susceptibility testing and
cultures, the collection procedure is of similar rapid microbiological methods should also be
importance (see Annex 10.1 for detail). included in the handbook.
Physicians with specialist competence in
9.1.2.12. Veri®cation of results. Data transfer clinical bacteriology should be available for
to individual patient records may be vulnerable clinical consultation.
in manual work with plates. Procedures for
specimen identi®cation, veri®cation of results
and reporting on paper or by electronic data 9.2. Test strips and equivalent rapid
processing systems should be explained. examinations
9.2.1. Trueness of measurements. The ordinal
9.1.2.13. Analytical control. A method must be scale (semi-quantitative) measurements are
set in place for monitoring results, with the usually expressed as categorized data. Perfor-
ability to recognize those where failures have mance can be described as sensitivities and
arisen due to laboratory or human error. speci®cities, i.e., as maximal allowable frac-
External quality assessment (EQA): labora- tions of analytically false-positive (FP) or
tories should participate in external quality false-negative (FN) measurements against best
assessment programmes. The purpose of EQA practical comparison methods. Reference
is to assess how well a laboratory ful®ls the methods, according to a strict de®nition, are
analytical quality speci®cations of bacterial currently unavailable.
culture (Section 9.5.2). It is recommended that evaluation data be
Current results of EQA must be displayed for classi®ed within two limits obtained from the
all to see if they wish and a ®le of all results for comparison method: a detection limit (LD; from
the past few years must be held and available the point where the ordinal scale method starts
for inspection. to give positive results) and a con®rmation limit
Internal quality control (IQC) by recom- (LC; from the point where all ordinal scale
mended strains should con®rm the daily results should be positive). These delineate the
process. ``grey zone''. From experience with test-strip
IQC of even dipslide cultures should be technology, it is recommended that the ratio
organized with the microbiology laboratory. between the concentrations LC/LD~5 (see
Organized submissions of sample cultures Appendix, Annexes 11.1.2 and 11.1.3 for
(dipslides and plates) to the supporting micro- detail). Optimal trueness of measurements is
biology laboratory for veri®cation are also very suggested to be a FP rate v10% at LD and a
useful (see Section 9.5.2 and Annex 13 for FN v5% at LC (compared with the most
detail). accurate, closely related method) (Tables XXIII
& XXIV). In many situations, or with a less
9.1.2.14. Report. The procedures for issuing optimal comparison method, a minimum per-
reports must be clear and unambiguous. formance is acceptable (see Appendix, Annex
Delay in reporting results from bacterial 11.1.1 for principles of measurements). With
cultures should be avoided and must satisfy many comparisons, such as in leukocyte and
the clinical need for treating the patient (see erythrocyte detection, the different principles of
Section 9.5.3). measurement (enzyme activity versus chamber
Reasons for any delay in reporting results counting) must be understood for correct
beyond the agreed limits must be identi®ed, as interpretation. The same applies to comparisons
must the likely clinical impact of such delay. between bacterial culture and rapid chemical
Corrective measures must then be applied. examinations, such as the nitrite or similar
examinations.
9.1.2.15. Co-operation with the clinicians, ward For more than two ordinal scale categories,
staff and patients. Laboratory handbooks agreement should be calculated using k statis-
European Urinalysis Guidelines 43
tics, thus subtracting random agreement from span. Dilutions of control solutions (with buffer
observed data [249, 250] (see Appendix, Annex or pooled human negative urine) help in
11.1.4). The simple k coef®cient is used when following performance at concentrations in
there are only two or three classes. For multiple the low positive range, where few stable control
(4 ± 5) classes, the agreement should be calcu- solutions are available. However, since there is
lated based on weighted k coef®cients. In this a matrix problem in test-strip reading, stable
case the sum of expected disagreement exceeds low positive control solutions would be better
100% because of the squared weighting factors. than daily dilution of high positive control
Thus, the goal must be tighter (Table XV). It is solutions with aqueous buffers.
possible to arti®cially increase the k value by
subdividing the results into six or more classes,
but then the goal for a minimum performance 9.3 Quantitative chemical measurements
should be even higher (0.75 ± 0.8). The quality
These guidelines acknowledge the efforts of
speci®cations are based on common sense: any
the IFCC in creating reference materials for
clinical laboratory examination should classify
clinical chemistry [251]. For most urinary
more than half of the non-random cases
constituents, genuine reference materials and
correctly. Arbitrarily, this is equivalent to k
reference measurement procedures are awaited.
w0.6, although optimally the value should be
Co-operation between manufacturers in prepar-
w0.8 if achievable.
ing calibrators for their quantitative tech-
nologies is greatly appreciated in achieving
9.2.2. Precision. Success in reproducing ordinal comparable concentrations in clinical labora-
scale measurements over time is expressed as tory practice. Recommendations exist for ana-
the fraction of correct results within binomial lytical quality speci®cations for routine
con®dence intervals. It is recommended that quantitative serum chemistry [242]. These
specimens with an original probability of close should be implemented in both internal quality
to 100% for the measured category be used, control [252] and external quality assessment
since the follow-up is then most precise due [253]. The formulae suggested to describe the
to a narrow con®dence interval (see Appendix, maximum allowable total analytical error for
Annex 11.1.5.) As an option, despite the ®nal serum chemistry are quoted in Table XVI. For
ordinal scale output of patient results, a valid reference methods serving serum chemistry, a
continuous signal, e.g. a re¯ectance value maximum of half these errors is proposed [254].
obtained from the measuring device, can be For urine chemistry, these proposals should
followed, allowing a normal calculation of be adjusted to re¯ect the fact that changes in
performance limits. The low positive range pathological states may be in a logarithmic scale
(1z) is more important than the high positive compared to the low or almost negative
range (3z) in rapid examinations. concentrations seen in health. Even if chemical
For good control, reproducibility (day-to-day analytes are excreted in urine in large quantities,
variation) should remain within the binomial they often occur in skewed distributions. Since
con®dence limits in internal quality control. the same measurement is often used for both
Stable control solutions are already available monitoring and diagnostic testing, a combina-
for test-strip reading. Daily implementation tion of quality criteria should be considered.
should then be the rule to allow judgements
on the levels of assays within a reasonable time 9.3.1. Calibration of the measurements. Cali-
bration of urinary total protein is preferably
TABLE XV. Analytical quality speci®cations ex- performed using the CRM 470 (albumin)
pressed as Kappa coef®cients.
standard (see Appendix, Annex 11.2.3). Glu-
Optimum Minimum cose measurements can be calibrated with the
SRM909 material obtained from the National
k coef®cient w0.8 w0.6 Institute of Standards and Technology [255].
(simple) (2 ± 3 classes) There is also a reference method for urine
k coef®cient w0.9 w0.7
(weighted) (4 ± 5 classes) glucose measurements approved by CDC/
FDA/AACC/NRSCL [256]. Calibration of
44 ECLM ± European Urinalysis Group
TABLE XVI. Analytical quality speci®cations for compared to the levels of clinical albuminuria
quantitative routine serum chemistry. or proteinuria that are up to 100-fold (10,000%)
higher in nephrotic syndrome (albumin/creati-
MONITORING (precision is important):
TEMon¦Ksi, where TEMon~total error in moni- nine ratio from 1 to 100 g/mol; total protein
toring, and si~within-subject biological standard from 0.1 up to 10 g/day).
deviation Analytical performance should allow detec-
DIAGNOSTIC TESTING (trueness/total accuracy is tion of microalbuminuria cases and monitoring
important): of diseases based on these ®gures. As an
TEDT¦Jsc, where TEDT~total error in diagnostic approximation, the following performance spe-
testing, and sc~d(si2zsg2)~composite biological ci®cations are proposed for urine proteins
standard deviation; sg~between-subject biological
standard deviation (Table XVII).
In addition to total protein, analytical quality
speci®cations for maximum allowable impreci-
creatinine measurement can be performed sion and deviation (bias) have been calculated
using the SRM914a serum calibrator from the and reported for calcium, creatinine, P-amylase,
same source [257]. phosphate, potassium, sodium, urate and urea
based on 24-h collections of urine [259].
TABLE XVII. Analytical speci®cations for trueness (expressed as relative deviation) and reproducibility
(expressed as imprecision) in quantitative urine chemistry, with special reference to proteinuria.
Optimum Minimum
10-fold difference (from 10 to 1006106 WBC/ uated (EQA schemes). Each site should docu-
L) exists between non-infected and infected ment its personnel training.
urines (see Section 6.2.3). Variation in daily
volume rate (diuresis) also affects particle con- 9.5. Microbiology examinations
centrations easily by a factor of 2 (100%). 9.5.1. Good microbiological laboratory practice.
For trueness, an optimum performance Good Laboratory Practice should be imple-
should have a relative deviation (bias) v30%. mented in all clinical laboratories, including
This is important in particular for evaluation chemistry, microbiology and general labora-
purposes. A minimum performance with a tories. Currently, this is often described in a
relative deviation v50 ± 100% can be accepted local quality manual. Some details of such a
for most routine applications, and in particular quality manual were suggested in Section 9.1.2
at particle concentrations below 36106/L urine. using an example of microbiological investiga-
To achieve these ®gures, one has to count tions as performed in general laboratories
several microlitres of urine from each sample. under the supervision of a local microbiology
In the future, these speci®cations may be laboratory.
replaced by more accurate calculations.
The volumes of counting chambers or other 9.5.2. Analytical quality speci®cations for bac-
similar devices should have an error v10% to terial culture. These speci®cations relate to the
be negligible. The manufacturer should specify microbiological analysis of urine in a Level 2
the volume accuracy for the device. facility. The performance at Level 1 may
Routine sediment examination (ordinal scale require further adjustments, e.g., at points-of-
speci®cations): The generally used standardized care (see Section 7.3 for speci®cations at this
sediment technique essentially provides ordinal level). The given speci®cations do not neces-
scale analysis of urine particles. This can be sarily ful®l the requirements for the Level 3
controlled against counts of uncentrifuged speci®cations (designed as benchmarks for
urine within a chamber or by an instrument. comparative trials and quality control). Varia-
In practice, delays in investigation after tion of exact techniques and technology is
micturition, losses during centrifugation, suc- permissible and indeed necessary at Level 2,
tion of supernatant and inadequate review of
the full coverslip area appear to contribute TABLE XVIII. Maximum allowable false-negative
most to inaccuracy of results, despite a rates in urine microscopy.
standardized procedure. Awareness of the Particle Particle Maximum allowable
many possibilities for systematic error helps type concentration false-negative
in designing the most accurate procedure for (6106/L) rates (%)
routine sediment analysis. Categorized perfor-
mance criteria are tentatively suggested below RBC 10 20
100 5
as an experienced opinion (Table XVIII) that WBC 20 10
can be replaced by more accurate speci®cations 200 5
in the future. Bacteria 10 20
Identi®cation of clinically signi®cant urine 100 5
Casts 10 10
particles should be internally reviewed (peer 50 5
review by staff members) and externally eval-
46 ECLM ± European Urinalysis Group
because of cost and work-¯ow restrictions, the TABLE XIX. Maximum allowable false-negative
rapid performance of emerging technology culture results of uropathogens.
and individual patient case-mix. Colony concentration Allowable false
negative rate
9.5.2.1. Acceptable false-negative rates for
detection by routine culture. Maximum allow- 108/L or more 2%
able false-negative rates are suggested for 107 ± 108/L 5%
detection and identi®cation of established pri- 104 ± 107/L 10%
mary, secondary and doubtful pathogens,
either in pure culture or as part of a mixture,
identi®cation for its own sake. It also represents
as de®ned by organisms in the common, fairly
that which is practically achievable, rather than a
common and uncommon groups (as de®ned in
``wish list'' which would require more resources
Table IX) in Table XIX. These are based on
and time. Individual laboratories must decide
expert opinion.
whether their particular case-mix requires addi-
9.5.2.2. Acceptable routine level of identi®ca- tional investigation beyond the suggested level.
tion. Laboratories working at Level 2 should As an example, isolation of yeast from urine is
be able to isolate ± by culture from clinical more relevant in large centres with signi®cant
samples ± urine organisms at any concentra- transplantation, intensive care and immuno-
tion above those set out in Table XIII, and to suppressed patient activity; the division into
identify the species to the given minimum albicans and non-albicans species relates to
level (Fig. 4). predicted sensitivity to certain antifungal
This is not an exhaustive list of organisms agents. Finally, there is a wide choice of agar
recognized as causing urinary tract infection. media that can be used for isolating these
Instead, this level of identi®cation of species is organisms. A reduction in the number of media
based on a combination of the prevalence and routinely used for urines (such as CLED only)
pathological signi®cance of their isolation, as well may be acceptable. Suggestions for readily
as the relation between the organism group and performable examinations to achieve such iden-
both antibacterial sensitivity and possible resis- ti®cation are given in Appendix, Annex 13.4.
tance acquisition. The list is therefore driven by Many other methods may be equally appropriate
clinical relevance rather than by microbiological and can be found in microbiology textbooks.
9.5.3. Acceptable turnaround times from speci- Point-of-care units and small laboratories
men receipt. The requirement for Level 2 are encouraged to consult with colleagues in
relates to the importance of speed in terms of the larger laboratories before proceeding with
overall cost of patient treatment episodes. It the evaluation of new instruments. Earlier
should be viewed in the context of compli- European recommendations exist for proce-
cated and potentially serious urinary tract dures in instrument evaluation [263]. When
infections. replacing existing techniques with new sys-
The following time limits are suggested for tems at least the following issues must be
relevant uropathogens following receipt of the considered.
specimen (Table XX). These time limits must
incorporate a laboratory information system
Analytical performance.
that allows the clinician easy access to the
Evaluation versus established reference or best
result, either by telephone or, preferably, by
comparison methods
computer interface. The higher minimum per-
Calibration and traceability of devices
centage required re¯ects the clinical priority of
Level of identi®cation (particles, microbes),
antibiotic sensitivity over organism identi®ca-
intended clinical use
tion. It is more important to ensure correct
A statistically signi®cant sample of patients
choice of antimicrobial agent than it is to know
and healthy reference individuals
the name of the organism responsible for
A detailed, pre-planned protocol
infection.
Analytical sensitivity and speci®city of results
(false-positive and false-negative rates and pre-
9.5.4. Microscopy in the microbiology labora- dictive values at different prevalences)
tory. All laboratories wishing to operate at Reliability of quantitation if applicable~
Level 2 must have facilities for microscopy. It linearity of measurement.
is recognized that microscopy is labour-inten-
sive and signi®cantly impacts on overall cost.
Results from particle analysis (visual or auto- Practical performance.
mated) and test-strip examination by general Ease of use and robustness
or chemical laboratories or at point-of-care Ability to self-check and recognize and/or
units may partially replace the need for diagnose faulty performance
microscopy in the microbiology laboratory. Instrument throughput
However, these results should only be used Ease of interfacing with laboratory computers.
to assist in the microbiological evaluation of
cultures. Only experienced evaluators, usually Clinical and economic impact.
in microbiology laboratories, however, should Cost/bene®t assessment including all costs
perform Gram staining. For detailed quality (reagents, manpower, running and mainte-
speci®cations of microscopy, see Section 9.4. nance and indirect costs)
Impact on patient care (if medical decision-
making is altered, impact on outcomes).
9.6. Urinalysis device performance evaluation
Improvements in laboratory technology are Regulations. Any medical device intended for
welcome and lead to better control of disease. in vitro diagnostics should be compatible with
the European directive for such devices [32].
Generally, a minimum sensitivity of 80 ± 90%,
TABLE XX. Acceptable turnaround times in bacter- depending on the patient population and appli-
ial culture.
cation, is considered adequate, while a speci®city
Identi®cation to Level 2 90% within 24 h of 90 ± 95% should be maintained in diagnostic
in pure culture reports. When the instrument or examination is
Identi®cation to Level 2 90% within 48 h used for screening (exclusion of disease), a
in mixed culture sensitivity of 95% with a speci®city of at least
Available antibiotic sensitivity 98% within 48 h
of relevant organism 90% should be the aims when trying to reduce the
total cost of con®rmatory examinations.
48 ECLM ± European Urinalysis Group
APPENDIX (DETAIL OF
Specimen details
MEASUREMENTS AND PROCEDURES) Specimen identi®cation (ID) code (barcode, if
ANNEX 10. TRANSMISSION OF INFOR- used)
MATION AND DETAIL OF PRE- AND
Date and time of voiding (®nal real time)
POST-ANALYTICAL STAGE Collection method (mid-stream urine, single
catheter urine, indwelling catheter urine,
10.1. Essential information in requests and suprapubic aspiration of urine, bag specimen of
reports urine; other)
10.1.1. Specimen identi®cation and patient data. Success in patient preparation and collection
The following boxes structure clinical back- (coded):
ground information for laboratory processes. quali®ed specimen or defective collection
(such as untimed collection, urgency, dif®culties
in technique, etc.; classi®ed by health care
10.1.2. Requesting urinalysis examinations, siev- personnel when known)
ing principle. Stepwise strategies (Section 8)
should be translated into practical requesting Results from rapid examinations (if performed
at point-of-care; such as test strip)
routines. Considerable savings result if a sieve
principle is applied for manual work, e.g. visual
microscopy is performed for specimens positive
with a sieving examination (usually de®ned of repeated lower urinary tract infection and no
®elds of a multiple strip or an automated par- background risk factor), a positive rapid
ticle count) only. In selected cases, however,
examination may be suf®cient to indicate
sensitive protein measurements and even visual
antimicrobial treatment without a need for
microscopy should be requested independently
culture. Patients with no clear-cut urinary tract
of sieving examinations to detect the presence
symptoms (medically justi®ed screening or
of renal damage. Detailed requests help focus
exclusion of urinary tract infection) may also
laboratory activities correctly.
be able to collect standardized morning urine,
Bacterial culture should mostly be requested
from which a rapid examination is able to
independently of results from a rapid exami-
exclude the presence of bacteriuria at 108 CFB/
nation (multiple strip or automated counter) for
symptomatic high-risk patients to avoid false- L level with a sensitivity of 80 ± 90%.
negative cases (this principle may change with The box below should be part of a request to
improved sensitivity of sieving examinations communicate the need for additional proce-
within a laboratory process). For low-risk dures if the sieving examination(s) is (are)
symptomatic patients (females with symptoms performed in the laboratory. The preferred
approach depends on the condition of each
patient or patient group.
Patient identi®cation
Last name, ®rst name
Personal ID code (recommended if available)
Date of birth (if not included in the personal ID
code)
Requesting unit (where patient is being treated) Conditional request for visual microscopy ...
Return address (to whom report should be sent) Detection of albumin/protein, leukocytes or
Responsible physician/nurse (to be contacted if erythrocytes should be followed by visual
consultation is needed) microscopy
Conditional request for bacterial culture ...
Concurrent antimicrobial therapy (bacterial Detection of leukocytes or bacteria by a rapid
culture requested) examination should be followed by a bacterial
culture (treatment of possible bacteriuria is
Additional clinical information (signs, symptoms, anticipated)
tentative diagnosis). No additional examinations with positive results ...
If no information is given, a minimum level (Mark if applicable; may be used if the rapid
of investigation should be applied as agreed examination is suf®cient for a clinical decision,
locally on the basis of patient populations such as in low-risk urinary tract infection or
served. acute cases)
European Urinalysis Guidelines 49
10.1.3. Reports. Reporting results from ordinal particles, CFB/L). The species or genera
scale examinations. Report format: Date, time, grown (depending on the methods of identi®-
technique/instrument and operator ID should cation). Antimicrobial susceptibility results as
be traceable. locally agreed.
Test strip results: In order that the clinician is The bacterial culture report or laboratory
aware of the uncertainty of the measurement, handbook should state the method of culture,
ordinal scale reporting is recommended (nega- since the level of precision varies accordingly
tive, 1z, 2z or 3z). (from dipslide to accurate cultures with 1 ±
It is recommended that the range of arbitrary 100 mL inocula; grown for 24 ± 48 h).
concentrations corresponding to the assigned
categories is always made available for the 10.2. Role of computers in transmission of
clinical interpreter either with the report or, information
more practically, in the laboratory handbook.
A range is more informative than a single The need for increased ef®ciency goes in
arbitrary concentration, e.g., for protein 1z parallel with automation and computerized data
(0.2 ± 1.0 g/L) is preferred over 1z(0.3 g/L). To transmission. Speci®c needs of urinalysis usually
avoid continual confusion, it would be of great create additional work to satisfy the transmis-
help if all manufacturers were to adopt the same sion of medically relevant information. Details
arbitrary categories for rapid examinations of of requests and reports are compiled in Section
the same type. As a minimum, speci®ed 10.1. In addition, the following issues should be
analytical sensitivity limits for positivity considered.
should be identical.
Standardization. National coding of laboratory
Reporting results from particle analysis. The examinations is highly recommended. Addi-
method should be stated in the report or in tional codes are needed to Supplement urina-
the laboratory handbook (standardized sedi- lysis requests (Section 10.1). Morphological
ment; standardized chamber counting; auto- and microbiological reports need special
mated analysis). coding, but also space for free-form report-
Morphological detail should be reported at a ing (occasional written notes on individual
basic or advanced level (see Section 6.1). Units results). Units of quantities and formats of
and quantities must be de®ned: particle counts/ reports must be standardized.
high power ®eld (HPF, 6400 usually) are used
for sediments examined under coverslips; count- Request speci®cations. Conditional requests
ing chambers have de®ned volumes (e.g. 1 mL). (Section 10.1.2) and selections of correct pro-
Even with HPF units, a calculation of particles/ cedures (such as shown in Table XIII for dif-
litre (L) of original urine must be provided for ferent options for bacterial culture) need
the clinician. Recommended unit for publica- decision rules in the on-line programmes when
tions is particles/L. computerized; rapid results must be trans-
Particle counts should be given as averages mitted to other working sites to organize
per unit volume (HPF or L), not as ranges seen work-lists for microscopy or bacterial culture.
in different view®elds. Only micro-organisms Algorithms applied in these decisions may be
and clumps of cells are uncountable by visual simpli®ed from the given guidelines as agreed
methods and may be reported in ordinal scale locally.
from ``negative'' to ``3z''.
Evaluation and reporting. Serial work-¯ow
Reporting microbiological results Gram staining should be easy and accessible when working
Oil immersion ®eld (OIF) is used for Gram with microscopes or reading culture plates.
staining. The report may be formatted in Computer-assisted interpretation and graphic
ordinal scale from ``negative'' to ``3z'' if display of daily results are encouraged where
quantities are used. possible.
Bacterial cultures. Quantity of growth (recom- Internal quality control (IQC). Internal quality
mended unit for particles: 10x colony-forming control data should be accessible for responsi-
50 ECLM ± European Urinalysis Group
ble operators in both individual and cumula- means of understanding by individuals unfami-
tive form; this means collection of separate liar with the native language (illustrations
®les. IQC data are expected to be stored for enclosed). Professional ``hands on'' assistance
long periods (up to 15 years) in most quality is often needed for small children and elderly
systems. people.
Connection to laboratory and hospital informa- 10.3.1. Collection of mid-stream urine specimen
tion systems. A computerized urinalysis labora- (patient instructions)
tory should have a standardized interface with Females: Wash your hands with soap and
the general laboratory information system and water or a towelette. Dry-wipe them. Have
hospital administrative system, including the clean collection container beside you.
patients' medical records. Medical information Avoid touching the inside with your ®ngers.
on patients will be increasingly available with While sitting on the toilet, wash your outer
electronic patient records. Access to crucial genital organs, including the opening where
parts of this information should be permitted the urine comes out, with a hand shower or
based on laboratory user ID and patient IDs with lukewarm water and wet paper towels
of investigated samples, as agreed locally. (or a sterile towelette) without using any dis-
infectants. Dry-wipe. When urinating, let the
Orientation towards a real time process. It is ®rst portion pass into the toilet (bedpan). Col-
not possible to know the precise time or suc- lect the mid-portion in the container. Allow
cess of quali®ed urine collection in advance; any excess urine to pass again into the toilet.
sometimes even the method of collection may After urination, dry-wipe the outer surface of
change. Thus, the possible preliminary compu- the container, secure the lid or transfer the urine to
terized request must be completed after the tube(s) provided, and write or check your
obtaining the specimen for such post- name and the date and time when you produced
collection detail. the specimen on the label on the container. Then
Computer transmissions should have a neg- proceed as advised locally. If any problems occur,
ligible effect on turnaround times of emergency please consult the clinical attendant (see illustra-
reports. Comparison with an earlier result of tions 1a and 2a, pages 91 and 93).
the same patient should be possible. Males: Wash your hands with soap and water
Safety of data: Back-up procedures must be or a towelette. Dry-wipe them. Have the clean
organized to allow replacement when erroneous collection container beside you. Avoid touching
transmissions occur or ®les become corrupted in the inside with your ®ngers. Uncover the
repeated use. urethral opening by withdrawing the foreskin
Quality control data should be easily acces- if necessary. Wash the end of your penis,
sible for the reviewer of patients' results. including the opening where the urine comes
out, with a hand shower or with lukewarm
water and paper towels (or sterile towelette)
10.3. Collection of urine specimens
without using any disinfectants. Dry-wipe.
Nurses or laboratory personnel usually When urinating (either standing or sitting), let
instruct patients how to obtain an adequate the ®rst portion pass into the toilet (bedpan).
urine specimen. Health care personnel must ®rst Collect the mid-portion in the container. Allow
understand the minimum requirements of any excess urine to pass again into the toilet.
standardized specimen collection. Since the After urination, dry-wipe the outer surface of
compliance of the patient or his/her parents is the container, secure the lid or transfer the urine
usually needed to obtain an adequate specimen, to the tube(s) provided, and write or check your
both oral and written guidance, often with name and the date and time when you produced
illustrations, is necessary. Each institution is the specimen on the container label, then
encouraged to modify the text given below to proceed as advised locally. If any problems
make their local practice as ef®cient as possible. occur, please consult the clinical attendant (see
Pictures showing the basic procedures for illustrations 1b and 2b, pages 92 and 94).
females, males and children should be used Children (capable of controlled micturition):
and can be freely copied; these may be the only After appropriate explanation, reasonably ade-
European Urinalysis Guidelines 51
quate mid-stream specimens can be collected 7. Bend forward and hold the sterile specimen
from children old enough to sit on a potty container (C) to catch the prostate secretion
chair. This can be achieved by placing the while the physician massages the prostate.
collection container in the potty chair (see Several drops are needed.
illustration 3, page 95). Older children may 8. If no secretion is visible during massage, the
follow the same advice as given to adults. physician collects a specimen with a 10 mL
After producing the sample, dry-wipe the loop from urethral ori®ce for direct culture.
outer surface of the container, secure the lid or 9. After prostatic massage, try to urinate an
transfer the urine to the tube(s) provided, and additional 10 ± 15 mL into the container (D).
write or check the child's name and the date The containers A ± D should be sent for
and time when the specimen was produced on bacterial culture. If possible, particle analysis
the container label, then proceed as advised is also of diagnostic value after inoculation of
locally. If any problems occur, please consult the plates.
the clinical attendant.
10.3.3. Collection of suprapubic aspiration spe-
10.3.2. Collection of sequential urine specimens cimen. From infants and toddlers able to con-
for diagnosis of chronic bacterial prostatitis and trol their urination, a container inserted into a
related disorders (Meares and Stamey pro- potty chair helps get a mid-stream specimen
cedure). For diagnosis of prostatitis, sequen- (see illustration 3, page 95). If not, suprapubic
tial collection of ®rst and middle portions of aspiration (or catheter specimen) should be
a single-voided specimen is of diagnostic attempted when the diagnosis or exclusion of
value, as well as drops expressed with prostate urinary tract infection is crucial and a bag
massage and urine after prostatic massage specimen does not work (see illustration 4,
[27]. The results are better if the patient has page 96).
not ejaculated at least for 3 days before the
collection of specimen. The given instructions 10.3.4. Timed collection of urine. A 24-h urine
are to be followed with the assistance of the sample is the most common example of a
physician performing the examination. timed collection. Patient instructions must be
provided. Different preservatives to be used in
Patient instructions timed collections are listed in Table XXI. The
1. Half an hour before specimen collection, table was compiled for analytes requested
drink 400 mL of water (or juice). The from outpatients. Based on preservatives listed
examination starts when you want to in the NCCLS Urinalysis Guidelines [3], new
void. analytes have been added. Moreover, technical
2. Label four sterile collection vessels (A ± D) development in measurements and changes in
and remove the closures from them. Avoid the body ¯uid have been taken into account
touching the inside of the vessels or closures. (serum measurements replacing urine assays),
3. Wash your hands with soap and water or a as well as European experience in preservation
towelette. Dry-wipe them. of the analytes [39, 264].
4. Take the clean collection container with you.
Uncover the urethral opening by withdraw- Patient instructions: 24-h collection of urine. As
ing the foreskin. Wash the end of your penis, part of your medical examination you have
including the opening where the urine comes been asked to collect a timed urine sample
out, with a hand shower or with lukewarm because the doctor wants to know the exact
water and paper towels (or sterile towelette) amount of (the examined substance) excreted
without using any disinfectants. Dry-wipe. into your urine. You have been asked to col-
5. Urinate 10 ± 15 mL into the ®rst container lect for a 24-h period. If you are not in hospi-
(A) in a standing position. tal, select a day when you expect to be able
6. Urinate 100 ± 200 mL into the toilet use the toilet where you keep the collection
(bedpan). Without interrupting the stream, container throughout the continuous collection
urinate 10 ± 15 mL into the second container period. READ THESE INSTRUCTIONS
(B). Allow any excess urine to pass again CAREFULLY BEFORE YOU START THE
into the toilet. COLLECTION.
52 ECLM ± European Urinalysis Group
TABLE XXI. Preservatives for single and timed urine collections (maximum documented stable time is
expressed, when known, with the following abbreviations: h~hours, d~days, w~weeks, mo~months,
y~years). The table assumes non-infected urine (bacteriuria may dramatically affect the preservation of some
analytes). Usually, about 1% ®nal concentration is used.
A~acetic acid is not obligatory, E~EDTA addition in laboratory is helpful, L~lead-free container,
S~protect from sunlight; No~not recommended. *~explained in Notes for each line.
Your collection may need preservatives for on to it. Check or write your name, personal
reliable analysis. Your local advisor will tell you identi®cation number and detailed collection
how to deal with these. Preservatives are usually date and times on the label.
added to the collection container before the If any questions arise, please contact your
start or immediately after the ®rst voided clinical attendant.
portion.
Write down the date and time when you start
the collection (you can choose when to start). ANNEX 11. DETAIL OF
Empty your bladder and discard that sample. C H E M I S T R Y EX A M I N A T I O N S
All voided urine after this start is to be
collected in the container. 11.1. Detail of multiple test strips
Exactly 24 hours after starting the collection, 11.1.1. Analytical principles. See Table XXII.
empty your bladder and add this to the 11.1.2. Calculation of trueness in ordinal scale:
collection container. Close the container tightly, grey zone. The trueness of ordinal scale mea-
dry-wipe and place the label provided on the surements is expressed by de®ning detection
container. Write or check the details of your limits (LD) and con®rmation limits (LC) from
collection times and your personal identi®cation comparison measurements. They delineate a
data. Store and transport the container to the grey zone. Below the detection limit, a strip
laboratory as advised. examination should remain negative, while
If only a portion of the 24-hour specimen was above the con®rmation limit, it should be
requested, mix the complete collection thor- positive. At the grey zone, a gradual tran-
oughly before pouring a small sample into the sition from negative to positive results should
small container you have been given. Dry-wipe occur. The ratio between concentrations LC/
the small container and place the label provided LD is recommended to be ~5.
54 ECLM ± European Urinalysis Group
TABLE XXII. Detection principles and their limitations for multiple strips (modi®ed from references 14 and
15).
*Bacteria are detected on the basis of nitrate reductase present in most Gram-negative uropathogenic rods,
such as E. coli (Griess's test). Nitrate reductase is lacking from some common uropathogens, i.e. Gram-positive
bacteria, such as Staphylococcus saprophyticus and Enterococcus spp.
European Urinalysis Guidelines 55
TABLE XXIII. Example data for estimation of trueness of test strip examinations.
TABLE XXIV. Analytical quality speci®cations for trueness of test strip examinations.
TABLE XXV. Suggested detection and con®rmation limits for multiple test strips.
TABLE XXVI. Analytical quality speci®cations suggested for sensitive albumin (rapid) examinations.
been published earlier [250]. A more detailed 11.1.5. Estimation of repeatability. Ordinal
explanation is given elsewhere [266]. scale data are amenable to binomial statistics.
Table XXVII gives selected 95% binomial
k~(P(o)2P(e))/(12P(e))
con®dence limits to the observed proportion
~12(Q(o)/Q(e)) of results for those readers who do not have
where P(o)~observed probability of agree- statistical tables or computer programmes at
ment, P(e)~expected probability of agree- their bench. It shows that a specimen that lies
ment by chance; Q(o)~observed within a certain concentration category (e.g.
disagreement~1 ± P(o) and Q(e)~expected 1z) at a probability of 95% or more is a
disagreement by chance~1 ± P(e). better control than another with a lower (even
In a 262 table, a sensitivity of 90% and as low as 50%) original probability, because
speci®city of 90% against the comparison the higher original probability has a narrower
method result in a k~0.8. k~0.8 means that con®dence interval.
the non-random agreement~P(o) ± P(e) was
obtained with the examined method in 80% out
of all expected disagreement by chance~ 11.1.6. Quali®ed procedures for test-strip
Q(e)~1 ± P(e). reading
A sensitivity of 80% and speci®city of 80%
result in k~0.6. A zero value means no
deviation from a random distribution (equiva- 11.1.6.1. Visual reading. Quali®ed test strip
lent to sensitivity of 50% and speci®city of measurement is summarised in a tabular form
50%). k coef®cient varies between ± 1 (complete both for visual reading (11.1.6.1) and instru-
disagreement) and z1 (complete agreement). mental reading (11.1.6.2).
European Urinalysis Guidelines 57
Identi®cation of specimen Label the specimen Compare label with the working list if
analysing several specimens at once
Homogeneous specimen Mix immediately before dipping Even colour
Temperature of the specimen z20³C Allow to stand for 15 ± 30 min before
analysis
Quality of strips Date still acceptable Expiration date
Environment Suf®cient light Arti®cial light is an adequate substitute
for daylight to allow easy reading
Calm space for working Allow no other activity during the
procedure
Dipping Follow manufacturer's guidance Observation by trainer
Timing Use a timer showing seconds Not possible afterwards
Reading Compare with the colours on the Train before actual patient analysis
packing vial
Internal quality control Control solutions measured daily Follow-up charts maintained
if analysis is done daily
External quality control Participation expected, organized Reports available
with local supporting laboratory
Storage of strips No physical problems associated Outlook of the strips (bent, wet, etc.),
with storage closed vials
Reporting Use the prede®ned units. Fill in Train before actual patient analysis
the patient record or working
list immediately
Identi®cation of specimen Label the specimen Compare label with the working list
if analysing several specimens at once
Homogeneous specimen Mix immediately before dipping Even colour
Temperature of the specimen z20³C Allow to stand for 15 ± 30 min before
analysis
Quality of strips Date still acceptable Expiration date
Protocol for instrumental Protocol written locally after Written protocol available
measurement training
Internal quality control Control solutions measured Follow-up charts maintained
daily
External quality control Participation expected, organized Reports available
with national or foreign EQAS
provider or within smaller groups
Maintenance Instrument manual followed Documentation of service and repairs
Calibration of the instrument Methods described mainly by the Documentation by the manufacturer,
and methods, changes of reagents manufacturer. In vitro medical changes of strip lots recorded
devices directive by the European
Council
58 ECLM ± European Urinalysis Group
No. of resultsb 50% 60% 70% 75% 80% 85% 90% 95%
11.2. Detail of quantitative urine measurements 11.2.3. Detail of quantitative measurement pro-
cedures
11.2.1. Health-associated reference intervals of
Total protein
urine proteins. The health-associated upper ref-
Principles of measurement
erence limits shown for excreted urine proteins
derive from references 109 and 111 (Table Benzethonium chloride [272] and trichloroacetic
XXVIII). These point estimates have wide con- acid precipitation [273], dye binding methods
®dence intervals owing to skewed distributions with Brome-phenol blue [274], Coomassie
of values as shown in the latter reference. brilliant blue [275], Ponceau red [276] and
pyrogallol-red [277], nephelometry and turbidi-
metry have been suggested. All these methods
11.2.2. Diagnostic classi®cations based on pro- can be automated, in contrast to the biuret
teinuria. Sensitive detection and differentiation examination [278]. Determination of total
of prerenal, glomerular, tubular and postrenal protein is a compromise because no procedure
proteinuria is now available with a low detec- detects all the proteins in urine.
tion limit by means of speci®c protein mea-
surements [267, 268]. Algorithms have also
been developed to classify patients based on
these measurements using two-dimensional Calibration. Calibration of total protein con-
reference areas [269] (Fig. 5). centration can be performed with a reference
Other diagnostic classi®cations have been sample of diluted serum. The use of albumin
created from different protein to protein con- solution is preferable and more reproducible,
centration ratios in urine [80, 123, 270, 271] however. CRM 470 standard is available as a
(Table XXIX). primary calibrator [279].
TABLE XXVIII. Upper 95% reference limits (URL) for protein-creatinine ratios in urines from healthy indivi-
duals. SI units are favoured over conventional units.
Protein Type of specimen Upper 95% reference limit Upper 95% reference limit
(g/mol creatinine; SI unit) (mg/g creatinine;
conventional unit)
FIG. 5. Differentiation of (1) primary glomerulopathies, (2) secondary glomerulopathies and (3) tubulo-
interstitial nephropathies by speci®c protein measurements. The shaded area represents the health-associated
values.
Prediction limit for incipient diabetic nephropa- Reference interval from healthy individuals
thy. An albumin excretion rate of w20 mg/min and interpretation. Creatinine in urine:
(traditionally cited unit), which corresponds to 7 ± 20 mmol/day (0.8 ± 2.2 g/day). Creatinine
an approximate albumin/creatinine w4 g/mol excretion rate depends on muscle mass. Crea-
(30 mg/g in conventional units), will predict tinine is almost entirely ®ltered by the glomer-
incipient diabetic nephropathy [10]. uli and only traces are secreted by the
tubules. The fraction of tubular secretion
Interpretation. Albumin/creatinine ratios decrease increases, however, with reduced glomerular
slightly with age [283]. The albumin/creatinine ®ltration rate. High protein meals and intense
ratio is also slightly higher in women physical exercise lead to increased urinary
than in men because of lower creatinine creatinine concentrations.
excretion in women. Upper normal limit in
pregnancy is 30 mg/day (24-h collection) [281].
Osmolality
The average intra-individual coef®cient of varia-
Principles of measurement
tion of albumin excretion from day to day is
approximately 20 ± 30% [109], and even larger Osmometry follows directly the de®nition of
for diabetic patients [258]. Diagnostic decisions osmolality: it is based on either of the two
should therefore not be based on a single mea- colligative properties, a decrease in freezing
surement, especially if the result is equivocal. point or an increase in the evaporation point of
solutions.
a1-microglobulin (protein HC)
Principles of measurement Interpretation. Urea, ammonia and mono-
Nephelometry, turbidimetry, RIA and ELISA valent ions are mostly responsible for urine
with polyclonal antibodies are commonly used. osmolality. With the maximum antidiuresis
the urine reaches an osmolality of about
Calibration. Measurement of a1-microglobulin 1200 mOsm/kg H2O. Maximal diuresis may
or protein HC concentration has not been result in an osmolality as low as 50 mOsm/kg
H2O [127]. The concentrated morning urine
standardized yet. An international calibrator
is highly desirable. after an overnight restriction of ¯uid intake
reaches an osmolality of at least 700 mOsm/kg
Interpretation. The within-subject coef®cient of H2O in healthy individuals. In chronic renal
variation from day to day is 20% on average failure, the urine remains isotonic within the
[109]. a1-microglobulin (30 ± 33 kDa) is pro- range 300 ± 350 mOsm/kg H2O.
duced in the liver and lymphocytes. This glyco-
protein appears in serum in free (50%), albumin Relative volumic mass (old terms: relative den-
bound (v10%) and IgA-bound forms (40%). sity; speci®c gravity). Calibration. Relative
Only the free form is ®ltered and reabsorbed in volumic mass measurement can be calibrated
the proximal tubule to 99.8%. Increased concen- in practice by measuring volumic masses (den-
trations in the urine are found in tubulo-intersti- sities) of pooled human urine, i.e., by weigh-
tial dysfunction or in nephropathies. ing out accurately known volumes of pooled
human urine. In this way, refractometers and
Creatinine related instruments can be adjusted using a
Principles of measurement calibrated balance.
Methods based on the Jaffe reaction [284]
should be replaced with more speci®c enzymatic Principles of measurement. Measuring princi-
methods [285]. Reference measurement pro- ples include urinometry, refractometry, oscillo-
cedure is based on isotope dilution mass metry and test strips. These have been
spectrometry [286]. reviewed extensively [127]. It is to be noted
that there are marked differences in the accu-
Calibration. A known reference material for racy of these methods [287].
serum creatinine is SRM 914a [257]. Weighed
out creatinine solution may serve as an Reference interval and interpretation. Relative
approximate estimate. volumic mass is primarily a function of glu-
European Urinalysis Guidelines 61
total number of ®elds to be counted depends Their multilobular nucleus and cytoplasmic
on the concentration of particles: lower num- granules make them readily identi®able. In
bers require more ®elds to reach statistical dye-binding methods, living granulocytes do
reliability). not always allow dyes to enter the cell. In
Sternheimer staining, nuclei and inclusions
12.1.3. Morphologic criteria for urinary sedi- usually stain bright blue, while cytoplasm
ment ®ndings (Level 2). Recent atlases show- remains reddish or brownish. Granulocytes
ing detailed morphology of urinary elements may aggregate to form clumps. They also lyse
for reference purposes must be consulted until easily when the osmolality is low or when the
enough experience is accumulated [15, 41, 56, pH is high [89]. Eosinophils need special stains
288, 290 ± 292]. for their detection (Hansel's stain [145]).
Macrophages (histiocytes) are often seen in
association with in¯ammation. They show thin
12.1.3.1. Detailed characteristics. Erythrocytes. pink granular cytoplasm, often ®lled with red
The size and haemoglobin content of erythro- blood cell remnants and other vacuoles, and
cytes can vary according to the osmolality of bluish nuclei with unevenly distributed chroma-
urine (the lower the osmolality the larger the tin on Sternheimer staining.
cell and the lower the haemoglobin content). Lymphocytes have smooth nuclei that almost
``Ghost erythrocytes'' that have lost their hae- ®ll the cell. In Sternheimer staining, they are
moglobin content can be missed if bright ®eld usually dark blue. Cytoplasm is scarce and
microscopy is used alone. At low osmolality without granules.
values, erythrocytes can even lyse. Erythro- Tubular epithelial cells. Different types of
cytes usually have a diameter of 4 ± 7 mm. The tubular cells line the different segments of the
appearance can vary according to the source renal tubules. As a consequence, several types
of haematuria: isomorphic erythrocytes usually of tubular cells can be found in the urine, which
indicate a post-renal bleeding, while dys- differ in size and shape. Tubular cells are
morphic erythrocytes indicate glomerular mononucleated with granular cytoplasm and
disease (see below). are larger than leukocytes. Most nuclei are
Dysmorphic red cells. Phase-contrast micro- round to ovoid. They have an average diameter
scopy is mandatory. Report the total number of of about 13 mm, and probably come from the
erythrocytes/HPF and the percentage of dys- proximal segments of the tubules. Less fre-
morphic red cells. Fassett et al. (1982) originally quently, rectangular, polygonal or even colum-
proposed that a fraction of 80% dysmorphic RBC nar cells can be seen, which originate from
or higher indicates renal bleeding [147]. A fraction distal tubules or collecting ducts. In Sternhei-
of 80% isomorphic (normal) RBC indicates post- mer staining, tubular cells usually have dense,
renal bleeding. In the middle, there are mixed granular red cytoplasm that may contain lipid
cases. It is recommended that the fraction of droplets in patients with severe proteinuria, and
acanthocytes be reported as well, because they are a blue or purple nucleus. A practical way to
readily identi®ed by the blebs on the cell surface learn the morphology of tubular cells is to look
and a presence of 5% or more acanthocytes is for these cells within casts: epithelial cells within
indicative for renal bleeding (see also Section 6.1). casts are by de®nition tubular epithelial cells.
The morphological appearances of dysmorphic Transitional epithelial (urothelial) cells. Divi-
red cells, especially acanthocytes, can be studied sion of urothelial cells into super®cial and
from the available publications. The correct deeper cells has been described recently [293].
evaluation of abnormal RBC morphology may Super®cial urothelial cells are usually round
depend on pH and osmolality of the urine, which is to oval mononucleated cells with a mean
why morning specimens are recommended if diameter of about 30 mm, and a pale halo
possible [151]; acanthocyte formation does not around the nucleus. Occasionally they can be
occur in vitro with the same frequency as other bi- or multinucleated. These cells are a frequent
dysmorphic shapes [150]. Special training of the ®nding in patients with urinary tract infection
investigator is needed. and urological disorders.
Leukocytes. Polymorphonuclear granulocytes Deep urothelial cells are smaller than super-
are the most frequent leukocytes found in urine. ®cial cells (mean diameter about 17 mm). They
European Urinalysis Guidelines 65
may exhibit various shapes, but they have Owing to degenerative phenomena, it is often
mostly a club-like or an ovoid appearance, a dif®cult to say whether the cells within the casts are
central or peripheral nucleus and thin granular tubular rather than leukocytes. In such cases the
cytoplasm. Usually they are found in associ- correct de®nition should be ``cellular cast'' only.
ation with urothelial carcinoma, ureteric stones Haemoglobin and myoglobin casts. These are
or hydronephrosis. These cells stain darker than brownish in colour with a granular surface. More
super®cial urothelial cells. Atypical forms of frequently, haemoglobin casts derive from ery-
urothelial cells can also be found in association throcyte casts. Therefore, they too indicate renal
with the rapid techniques of cellular preparation parenchymal bleeding. However, haemoglobin
used in routine urinalysis [172, 288]. Their casts may also be due to haemoglobinuria caused
interpretation should be undertaken in specia- by intravascular haemolysis. Myoglobin casts
lized cytological laboratories. may be seen in the urine of patients with renal
Squamous epithelial cells. Squamous epithelial failure caused by crush syndrome.
cells are the commonest cells of the urine. They Bilirubin casts stain yellow-brown due to
have a polygonal shape, a central nucleus and water-soluble (conjugated) bilirubin excreted
an average diameter of about 55 mm. Squamous into urine. Urinary bilirubin may be used in
cells derive from urethra and vagina, and are differentiation of icteric patients if serum
usually markers of contamination of urine measurements are lacking.
during specimen collection. Bacterial and yeast casts. These are rare.
Casts. Casts are elongated elements with a However, they may be seen in immuno-
cylindrical shape that varies due to bending, compromised patients with bacterial or fungal
wrinkling and irregular edges. The main types infection affecting the kidneys.
of casts are described below. Lipids are usually seen as isolated or clumped
Hyaline casts. These have a matrix with low droplets (either free or within cells and casts), or
refractive index and are best identi®ed by phase as oval fat bodies (round-shaped particles
contrast microscope. They are found in both containing packed lipid droplets), fatty casts
renal parenchymal diseases and in normal or cholesterol crystals (see below). Lipids are
subjects. identi®ed because of their refractility and their
Granular casts. These can contain either ®ne ability to polarize light.
or coarse granules. They are not usually found
in normal subjects and when present suggest the Crystals. Uric acid. Lozenges, barrels or
presence of renal disease. rosettes with a typical amber colour and bire-
Waxy casts. These are usually large, with fringence under polarized light.
clear-cut edges or indented borders, and are Calcium oxalate dihydrate. Typically bipyr-
refractile. Waxy casts have a homogeneous amidal. They can appear also in aggregates.
appearance, just like wax. They are found in Only large crystals show birefringence.
patients with renal insuf®ciency or failure. Calcium oxalate monohydrate. Ovoid, dumb-
Fatty casts. These contain lipid particles. bell or biconcave discs, always brightly bire-
Fatty casts are typical of patients with heavy fringent.
proteinuria associated with lipoproteinuria. Calcium phosphate. Prisms, needles or rosettes
Cellular casts. According to the cells con- that polarize light. When occurring in plates,
tained, cellular casts are classi®ed as: calcium phosphate is not birefringent.
± Erythrocyte casts (which always indicate Triple phosphate. Transparent birefringent
bleeding from the renal parenchyma) prisms, usually with a ``cof®n lid'' appearance.
± Leukocyte (usually Granulocyte) casts Amorphous urates and phosphates. Granular
(which may indicate acute pyelonephritis, particles, often in clumps. Urates are found in
acute interstitial nephritis or proliferative glo- acid urine, phosphates in alkaline urine. Urates
merulonephritides) polarize light while phosphates do not.
± Tubular epithelial cell casts (which are Cystine. Thin, hexagonal, birefringent plates
found for example in patients with acute with irregular sides. They can be isolated, heaped
tubular necrosis, acute interstitial nephritis, upon one another, or in clumps and rosettes. They
acute cellular rejection of grafted kidney and can be seen at low pH (v6) and usually after an
glomerular disorders). overnight incubation at z4³C.
66 ECLM ± European Urinalysis Group
Leucine. Oily-looking spheres with concentric establish the optimal intended diagnostic use
striations. for a given instrument. Based on the technical
Tyrosine. Thin needles, often aggregated in principles used, advice on specimen collection
bundles or rosettes. and storage is essential to obtain reliable results
Cholesterol. Transparent thin plates with and avoid artefacts. Lists of known interfer-
sharp edges and corners. These are associated ences should be made generally available as
with heavy proteinuria. soon as they are discovered during evaluations
Crystals of drugs. Sulphadiazine (crystals with and in clinical practice.
the appearance of ``sheaves of wheat''), triam- Customers should work out standard operat-
terene, acyclovir (birefringent and needle- ing procedures with the help of manufacturers.
shaped crystals), indinavir (plate or star-like These should include descriptions of regular
crystals [294] and vitamin C [56, 163]. working, combinations of different analyses
Microbes. Bacteria may be seen on routine from the same urine, quality assessment proto-
microscopy; rods are particularly visible with cols and measures to be taken in the event of
phase contrast microscopy. Cocci may be instrument alarms or error messages. Specimens
confused with salt precipitation. not amenable to automated analysis should be
Fungi. Cells of Candida spp. appear as ovoid listed, as well as the standardized alternative
or roundish elements not absorbing stain. They manual methods.
also appear as hyphi. Budding is the most
typical morphological feature. On most occa-
sions they are due to contamination from the
12.3. Health-associated upper reference limits
vagina, although they may represent true
of particles in morning urine
infection in the chronically debilitated or
immunosuppressed patient. Healthy reference intervals depend heavily on
Protozoa. Trichomonas vaginalis, when alive, preanalytical as well as analytical standardiza-
is easily identi®ed owing to the motility of the tion and delay of examination. Table XXXIII
¯agella and the rapid and irregular movements cites some of the 98% and 95% upper reference
of the body. When dead it is similar to limits found in the earlier literature [170, 185,
leukocytes. In most cases it is in the urine as 295 ± 297]. Comprehensive detail necessary to
a consequence of genital contamination. evaluate the results has not been published. The
Parasites. The diagnosis of parasitic infesta- ®gures are concentrations rather than excretion
tion by Schistosoma haematobium relies on the rates, as originally proposed by Addis [298];
observation of the eggs in the urine. These lysis of cells unfortunately diminishes the
measure about 140650 mm and are spindle- validity of excretion rates based on 12-h
shaped with a round anterior and a conical collections. Adjustment to volume rate (diur-
posterior end tapering into a delicate terminal esis) should be considered.
spine. They may be seen to hatch if the urine is Rough estimates for arbitrary (non-para-
dilute enough. metric) 95% upper reference limits in morning
Details of urinary particles are tabulated for urine without centrifugation: leukocytes and
easier reference in routine practice in Tables erythrocytes v10 x 106/L.
XXXI and XXXII. NOTE 1. Owing to the procedural uncertain-
ties these upper limits are given as arbitrary
inequality ®gures only. Female specimens are
more vulnerable than male specimens for pre-
12.2. Automated particle analysis
analytical errors, as shown by the Stansfeld &
Manufacturers of urine particle analysers Webb study. In addition, erythrocytes may be
should describe in detail the differentiation dif®cult to see without phase contrast optics
capability of their instrument, including sensi- and proper 6400 magni®cation [295]. For best
tivity and speci®city data against a manual clinical comparability, concentrated ®rst (or
comparison method, such as chamber counting, low-diuresis second) morning urine should be
sediment morphology or bacterial culture. collected as a washed mid-stream collection and
General as well as speci®c patient populations investigated according to an identical procedure
should be targeted in the evaluations to that is applied to the patients as well. About
European Urinalysis Guidelines 67
TABLE XXXI. Differentiation of urine cells by phase contrast optics or supravital staining.
Prostatic epithelial cells cannot be differentiated from transitional epithelial cells by this method; prostatic
particles may be seen occasionally.
The intensity of staining varies and is dependent on the length of exposure to the stain as well as unknown
factors related to the specimen. The ratio of blue to red is also affected by the batch of stain used in preparing the
stain mixture.
TABLE XXXII. Differentiation of other urine particles (phase contrast or supravital staining).
Microbes:
Bacteria
rods Dark, often in chains
cocci Dark, isolated, in pairs, chains or clusters
Yeasts Nucleus often visible, budding; do not stain well; also as branching hyphi (pseudomyceliae)
Casts:
Cellular casts Cells (erythrocytes, leukocytes, tubular cells) packed and/or plunged in the cast matrix
Microbial casts Granular appearance; rods may appear clearly discernible
Hyaline cast Low refractive index, may occur as darkly blue, compact or ®brillar, occasionally
convoluted
Granular cast Granules of various size and colour, usually red
Waxy cast Refractile, with hard and indented edges; colour red rather than blue
Fatty cast Lipid droplets can be isolated, in clumps, or packed; occasionally protruding cholesterol
spicules
Pigmented cast Haemoglobin and myoglobin (red-brown), bilirubin (yellow-orange-brown)
68 ECLM ± European Urinalysis Group
TABLE XXXIII. Health-associated upper reference limits (URL) of urine leukocyte (WBC) and erythrocyte
(RBC) concentrations in uncentrifuged specimens.
half of the erythrocytes and leukocytes are lost lower cell counts due to the higher cell numbers
during centrifugation (when preparing urine counted. It seems likely that new more precise
sediments). health-associated reference intervals will be
NOTE 2. With statistically reliable total created based on re-assessed procedures and
numbers of individuals, selection criteria of new technology [132, 175, 300].
reference individuals or calculations may have
been defective, leading to non-standardized
ANNEX 13. DETAIL OF MICROBIOLOGY
results. Because of the skewed distributions,
EXAMINATIONS
parametric calculations may be misleading if the
skewness is not corrected properly. Exact
13.1. Suggested comparison method for
percentile estimates are in any case imprecise,
bacterial culture of urine (Level 3)
and a marked grey zone should be considered
(expressed as a con®dence interval of the Substrates.
percentile estimate). CLED (Cysteine-Lactose Electrolyte-De®cient)
NOTE 3. Concentrations of erythrocytes and agar plate
leukocytes in urines of newborn individuals are Blood agar
most likely higher than those given above. Haematin agar
NOTE 4. Diagnostic decision limits differ For more accurate identi®cation of yeasts,
from the given upper healthy reference limits. special methods are required.
For example, the probability of infection in a Control strains, see Table XXXV.
non-standardized specimen increases when the
amount of granulocytes (leukocytes) rises from Inoculation. Alternative A:
10 to 100 6 106/L [180, 265]. Ten microlitres of urine is inoculated with a
Automated methods show higher precision at micropipette in the middle of a haematin agar
European Urinalysis Guidelines 69
Volume of inoculum No. of colonies Colony count in urine Colony count in urine
on plate (CFB/L) (CFU/mL)
1 mL 1 106 103
10 107 104
100 108 105
10 mL 1 105 102
10 106 103
100 107 104
100 mL 1 104 101
10 105 102
100 106 103
plate and a blood agar plate. In addition, 1 mL a neutral buffer; 100 mL of each dilution is
is inoculated on to CLED agar with a plastic or inoculated by means of a Drygalski spatulum
platinum loop. When performing cultures on and a rotating platform (1 or 10 mL may not be
suprapubic aspiration urine, a large 100-mL precise enough volumes for normal pipettes).
amount of inoculum is recommended on blood The colonies on the plates from at least three
and haematin agar. Different amounts of dilutions are counted. The original concentra-
inoculum lead to different interpretations of tion is calculated as the mean concentration
quantitative growth for each colony count from the dilutions. (Scheme 1)
observed (Table XXXIV). In order to raise the accuracy of the estimate
The inoculum is spread with a platinum or for mean bacterial concentration the number of
plastic loop by streaking back and forth replicates can be increased, e.g., for disinfectant
through the drop a few times (Phase 1; Fig. examinations the same sample should be
6). Finally, several streaks are made very close analysed in 10 ± 20 replicates. The counts
to each other and perpendicular to the ®rst line follow Poisson distribution.
(Phase 2; Fig. 6). Quantitation is performed on
plates inoculated by a micropipette. Plates not Incubation times. The following incubation
used for quantitation can be divided for two temperatures, atmospheres and times are
different specimens. recommended for best identi®cation of species
Alternative B: and quantitative comparisons:
When a more accurate quantitative result
than that obtained by the method in alternative CLED agar 35 ± 37³C, aerobic 1z1 day
A is necessary, the following procedure is Blood agar 35 ± 37³C, anaerobic 2 days
recommended. The sample is diluted 1:10 with Haematin agar 35 ± 37³C, 5% CO2 1z1 day
FIG. 6. Inoculation of a culture plate. (limitations of computer graphics must be understood in the inter-
pretation of these drawings).
70 ECLM ± European Urinalysis Group
enterococci. S. saprophyticus can also be identi- 6. Incubate the dipslide at 35 ± 37³C overnight
®ed using certain products. Aerobic incubation (for 18 ± 24 h).
at 35 ± 37³C is recommended for all products 7. If interpretation cannot be made on the
[5, 6, 303 ± 307]. following morning, for example because of a
Urine samples showing the presence of yeast weekend, proceed as follows: Place the
on microscopy can be inoculated on chromo- dipslide as usual in the incubator and take
genic yeast culture medium such as Chrom it out when leaving. Store it at z20³C and
Agar, which allows a direct presumptive interpret it on Monday morning. Culturing
identi®cation of Candida albicans C. tropicalis at z20³C for 2 ± 3 days is comparable to
and C. krusei. culturing at 37³C for 24 h.
8. Store the original urine specimen in the
refrigerator. If the dipslide is sent to
13.3. Dipslide cultures the bacteriological laboratory for sus-
ceptibility testing or evaluation, the analysis
Equipment will be more reliable if the original speci-
Incubator 35 ± 37³C (note: thermometer for men can be sent as well. Urine specimens
temperature control) should be under refrigeration when trans-
Comparison chart for interpretation ported.
Dipslides
Interpretation of results
Procedure Colony concentration. The bacterial concentra-
tion is interpreted on the green side (CLED
1. Check the expiry date of the dipslide. agar) of the dipslide, since this does not con-
2. Label the dipslide. Open the dipslide without tain antibacterial agents. Bacterial growth may
touching the agar surfaces. Verify that the consist of large or very small colonies. High
agar surfaces are even and shiny and that the bacterial concentration appears as merging
corners and edges are not dried or shrunken. colonies. Interpretation is simpli®ed if only
Any condensation in the tube must be 75% of the dipslide is immersed. By doing so,
poured out. a clean surface will be left for comparison. A
3. Dip the slide in the urine specimen once, magnifying glass (126) also helps in the inter-
moistening 75% of the agar surfaces. If the pretation because small bacteria colonies
amount of urine is inadequate, the agar are differentiated better, for example, from
surfaces can be moistened by pouring the crystals.
urine over them once. Note: Do not forget to state the volume unit
4. Let the excess urine drip off. Place the lower of the concentration (L or mL as used).
edge of the dipslide on clean, absorbent
paper. Mixed ¯ora. Note different appearances of
5. Screw the dipslide back together. Make sure bacterial colonies; for example, different sizes,
that the lid is tightly closed. colours or shapes. The presence of several
72 ECLM ± European Urinalysis Group
Evaluation of growth
growth on MacConkey agar. For details and ter. Other isolates can be reported as ``Gram-
extensive species identi®cation, see handbooks negative rod, non-Enterobacteriaceae''.
for Enterobacteriaceae.
Pseudomonas aeruginosa. Minimum criteria:
Minimum criteria: ``4 ± examination'': Lac-
tose, Voges ± Proskauer (VP), ONPG, indole 1. Characteristic odour and appearance (green-
examination with p-dimethylaminocinnamalde- brown pigment, strawberry or ``fruity''
hyde (DMACA); alternatively, tube exami- odour) can be directly reported; Kovacs
nation with p-dimetylaminobenzaldelyde oxidase-positive.
according to Kovacs or Ehrlich. 2. ADH-positive, growth at 42³C.
A. Lactose-positive growth on CLED When non-glucose fermenting Gram-negative
1. Colony appearance suggests E. coli: rods are examined for decarboxylase, it is
. Perform indole examination from blood appropriate to have both positive and negative
agar. controls because of the dif®culty of interpreting
. Positive indole ~ E. coli, negative indole the examination results. P. aeruginosa is ADH-
~ Gram-negative rod Enterobacteriaceae: per- positive and LDC-negative.
form VP.
positive VP, negative indole ~ Klebsiella/ Stenotrophomonas maltophilia. Minimum cri-
Enterobacter. teria: Typical colony appearance after 2 days,
negative VP, negative indole ~ Gram-nega- non-fermentative, oxidase-negative, DNase-
tive rod Enterobacteriaceae. positive.
2. Colony appearance suggests Klebsiella/ . Characteristic appearance, ammonia odour
Enterobacter: when grown on blood agar.
. Perform VP, indole examination. . Microscopy: Gram-negative, narrow rods.
. positive VP, positive/negative indole ~
Klebsiella/Enterobacter. Acinetobacter. Minimum criteria: Typical
. negative VP, negative indole ~ Gram- colony appearance, non-fermentative, oxidase-
negative rod Enterobacteriaceae. negative.
. negative VP, positive indole ~ E. coli. . DNase-negative, microscopy, Gram-
3. Positive beta-glucuronidase ~ E. coli. negative coccoid rod.
B. Lactose-negative growth on CLED:
Yeast. Minimum criteria: Typical colony
1. Swarming on blood agar:
appearance, microscopy: fungi.
. Perform indole only.
. Negative indole ~ Proteus mirabilis. . Convex, dry colonies with even edges (after
. Positive indole ~ Proteus vulgaris. longer incubation times, sometimes star-
2. Additional lactose-negative: shaped), yeast odour in heavy growth.
. negative VP, positive ONPG, positive . Microscopy: Gram-positive, large, oval
indole ~ E. coli. cells, sometimes with budding.
. negative VP and ONPG, perform extended . Positive serum examination ~ C. albicans.
biochemistry. . Negative serum examination ~ unspeci®ed
. other combinations should be identi®ed for yeast.
species. Further typing is justi®ed when Cryptococcus
3. Positive beta-glucuronidase ~ E. coli. neoformans or other clinically relevant yeast
infections are suspected.
Procedure:
TABLE XXXVII. Suggested grading system for bacteria detected by the slide centrifuge method.
Grade Negat 1z 2z 3z
TABLE XXXIX. Suggested system for grading urine in microtitre tray method.
Grade Negat 1z 2z 3z
2. Allow the formed elements to settle for a in one representative ®eld after establishing
minimum of 5 min. that elements are evenly distributed across
3. Place the plate on the microscope and the well bottom.
examine the bottom of the well using a 5. Note the presence of bacteria, and estimate
620 objective and medium light intensity to the High Power Field (HPF) area that is
maximize detection of bacteria. covered by them in accordance with Table
4. Note the presence of leukocytes and red cells XXXIX.
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European Urinalysis Guidelines 87
INDEX
Electrophoresis 20 Lipids
Eosinophil granulocytes criteria 65
signi®cance 20 signi®cance 22
Epithelial cells 21 Lymphocytes
Erythrocytes criteria 64
criteria 64 signi®cance 20
detection by test strips 15 Macrophages
in particle analysis 20 criteria 64
signi®cance 20 signi®cance 20
Esterase 13 Meares and Stamey procedure
Exercise 8 detail 51
First morning urine 7 MEDICAL NEEDS 6
First-void urine 9 Microbes
Glucose, detection by test strips 17 as detected by microscopy 22
Good Laboratory Practice microbiological classi®cation 26
in microbiology 45 morphologic criteria 66
in quality systems 40 uropathogenicity 27
Gram staining Microbiology examinations
detail 75 detail 68
general 24 MICROBIOLOGY EXAMINATIONS 26
Haematuria See also Erythrocytes Microscopy See also Particle analysis
strategies 35 detail 61
Hierarchy of methods different techniques 23
bacterial culture 30 in microbiology, detail 74
general 12 microtitre tray method 25
microscopy 23 procedure for routine work 62
Identi®cation of bacteria rapid methods 25
detail, Level 2, 72 Microtitre tray method 25
Immuno®xation 20 detail 76
Incubation time, in the bladder 8 Mid-stream urine
Indications de®nition 9
for bacterial culture 27 specimen collection 50
for microbiology investigations 26 Mixed culture 29
for urinalysis 6 Morphologic criteria for urine particles 64
Indwelling catheter urine 9 Nitrite 15
In¯uence and interference factors 8 Non-standardised urine sediment 25
Information Odour
preanalytical 8 general 13
request and report detail 48 metabolic diseases 15
role of computers 49 Osmolality
Instruments measurement detail 60
automated bacterial culture 34 signi®cance 19
evaluation 47 Particle analysis
for multiple test strips 17 clinical signi®cance 20
particle analysis 25 criteria for ®ndings 64
Kappa coef®cient 55 detail 61
Kass's criteria 28 operating procedures for automated analysis
Ketone bodies 17 66
Label 11 standardized sediment procedure 62
Leukocytes upper reference limits 66
criteria 64 PARTICLE ANALYSIS 20
detection based on esterase 13 Particles
signi®cance 20 counting after ®ltration 24
European Urinalysis Guidelines 89
FIG. 1. Collection of mid-stream urine by females (1a) and males (1b) by washing genital organs with a
shower. (Published with the permission of Tampere University Hospital.).
European Urinalysis Guidelines 93
94 ECLM ± European Urinalysis Group
FIG. 2. Collection of mid-stream urine by females (2a) and males (2b) by washing genital organs with a
towelette. (Published with the permission of Tampere University Hospital.).
European Urinalysis Guidelines 95
FIG. 3. Collection of mid-stream urine specimen when using a potty chair. (Published with the permission of
Tampere University Hospital.).
96 ECLM ± European Urinalysis Group
FIG. 4. Specimen collection by suprapubic aspiration. (Published with the permission of Tampere University
Hospital.) Aseptic measures should be taken to avoid skin contamination. Specimen collection and washing
tools should be prepared ahead, including a 5 (210) mL syringe used for aspiration. It is possible to wait up
to 2 h for the bladder to ®ll. However, the urgency symptoms may lead to loss of the specimen by sponta-
neous voiding if not followed carefully. Dehydrated febrile children should take in ¯uid to the extent needed
to start diuresis. Anaesthetic skin cream containing lidocain or prilocain is recommended before the puncture.
The bladder is punctured by simultaneous aspiration. The site is chosen to avoid both periosteal damage
(1 cm distant from the symphyseal region) and intestinal contamination. Aliquots of urine to different labora-
tory tests need a local agreement. For bacterial culture, 0.5 ± 2 mL is usually suf®cient for inoculation.