Chapter 6 | Chemical Examination of Urine 1
SUMMARY 621 Clinical Significance
of Urine Specific Gravity
Monitoring patient hydration and dehydration Loss
of renal tubular concentrating ability Diabetes
insipidus
Determination of unsatisfactory specimens due to low
concentration
SUMMARY 622 Urine Specific Gravity
Reagent Strip
Reagents Multistix: Poly (methyl vinyl ether/maleic
anhydride) bromothymol blue
Chemstrip: Ethylene glycol diaminoethyl
ether tetra-acetic acid, bromothymol
blue
Sensitivity 1.000–1.030
Interference False positive: High concentrations of
protein
False negative: Highly alkaline urines
(greater than 6.5)
media and plasma expanders that are included in physical
measurements of specific gravity. This difference must be
con- sidered when comparing specific gravity results
obtained by a different method. Elevated concentrations of
protein slightly increase the readings as a result of protein
anions.
Specimens with a pH of 6.5 or higher have decreased
read- ings caused by interference with the bromothymol blue
indi- cator (the blue-green readings associated with an
alkaline pH correspond to a low reading for specific gravity).
Therefore, manufacturers recommend adding 0.005 to
specific gravity readings when the pH is 6.5 or higher. The
correction is per- formed by automated strip readers.
Study Questions
1. Leaving excess urine on the reagent strip after removing
it from the specimen will:
A. Cause runover between reagent pads
B. Alter the color of the specimen
C. Cause reagents to leach from the pads
D. Not affect the chemical reactions
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References
1. Chemstrip 10UA product Insert, Roche Diagnostics, Indianapo-
lis, IN, 2004.
2. Multistix Reagent Strips Product Insert. Siemens
Healthcare Diagnostics, Inc., Tarrytown, NY 2010-2017.
3. Clinical and Laboratory Standards Institute. Urinalysis;
Approved Guideline-Third Edition. CLSI document GP16-
A3. Clinical and Laboratory Standards Institute, Wayne, PA,
2009, CLSI.
4. Bleyer, AJ, Kmoch, S: Tamm Horsfall glycoprotein and
Uromodulin: It is all about the Tubules! Clin J Am Soc
Nephrol. 2016 Jan 7; 11 (1): 6-8. Doi: 10.2215/CJN.12201115.
Web
site: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702239/.
Published December 18, 2015. Accessed May 6, 2019.
5. Pugia, MJ, and Lott, JA: New developments in urinalysis
strip tests for proteins. In Bayer Encyclopedia of Urinalysis.
Bayer Diagnostics, Elkhart, IN, 2002.
6. Bhuwnesh, A, et al: Microalbumin screening by reagent
strip predicts cardiovascular risk in hypertension. J
Hypertens 14: 223–228, 1992.
7. Bianchi, S, et al: Microalbuminurea in essential
hypertension. J Nephrol 10(4):216–219, 1997.
8. Clinitek Microalbumin Reagent Strip Product Insert.
Bayer Diagnostics, Elkhart, IN, 2006.
9. Multistix Pro Reagent Strips Product Insert. Siemens
Healthcare Diagnostics, Inc. Tarrytown, NY, 2008.
10. Benedict, SR: A reagent for the detection of reducing
sugars. J Biol Chem 5:485–487, 1909.
11. College of American Pathologists. CAP Today, Q&A
Column 9/16. https://www.captodayonline.com/qa-column-
0916/. Accessed May 6, 2019.
12. Lane R, and Phillips, M: Rhabdomyolysis has many causes
including statins and may be fatal. Brit J Med 327:115–
116, 2003.
13. Hager, CB, and Free, AH: Urine urobilinogen as a component
of routine urinalysis. Am J Med Technol 36(5):227–233,
1970.
14. Wise, KA, Sagert, LA, and Grammens, GL: Urine leukocyte
es- terase and nitrite tests as an aid to predict urine culture
results. Lab Med 15(3):186–187, 1984.
2. Failure to mix a specimen before inserting the
reagent strip will primarily affect the:
A. Glucose reading
B. Blood reading
C. Leukocyte reading
D. Both B and C
2 Part Two | Urinalysis

3. Testing a refrigerated specimen that has not warmed 10. Indicate the source of the following proteinurias by
to room temperature will adversely affect: placing a 1 for prerenal, 2 for renal, or 3 for postrenal in
A. Enzymatic reactions front of the condition.
B. Dye-binding reactions A. Microalbuminuria
C. The sodium nitroprusside reaction B. Acute-phase reactants
D. Diazo reactions C. Preeclampsia
4. The reagent strip reaction that requires the longest D. Vaginal inflammation
reaction time is the: E. Multiple myeloma
A. Bilirubin F. Orthostatic proteinuria
B. pH G. Prostatitis
C. Leukocyte esterase 11. The principle of the protein error of indicators reaction
D. Glucose is that:
5. Quality control of reagent strips is performed: A. Protein keeps the pH of the urine constant
A. Using positive and negative controls B. Albumin accepts hydrogen ions from the indicator
B. When results are questionable C. The indicator accepts hydrogen ions from albumin
C. Per laboratory policy D. Albumin changes the pH of the urine
D. All of the above 12. All of the following will cause false-positive
protein values on a reagent strip except:
6. All of the following are important to protect the
integrity of reagent strips except: A. Microalbuminuria
A. Removing the desiccant from the bottle B. Highly buffered alkaline urines
B. Storing in an opaque bottle C. Delay in removing the reagent strip from
the specimen
C. Storing at room temperature
D. Contamination by quaternary ammonium
D. Resealing the bottle after removing a strip
compounds
7. The principle of the reagent strip test for pH is the:
13. A patient with a 2+ protein reading in the afternoon is
A. Protein error of indicators asked to submit a first morning specimen. The second
B. Greiss reaction specimen has a negative protein reading. This patient
C. Dissociation of a polyelectrolyte is:
D. Double indicator reaction A. Positive for orthostatic proteinuria
B. Negative for orthostatic proteinuria
8. A urine specimen with a pH of 9.0:
C. Positive for Bence Jones protein
A. Indicates metabolic acidosis
D. Negative for clinical proteinuria
B. Should be re-collected
C. May contain calcium oxalate crystals 14. Testing for microalbuminuria is valuable for early
detec- tion of kidney disease and monitoring patients
D. Is seen after drinking cranberry juice with:
9. In the laboratory, a primary consideration A. Hypertension
associated with pH is: B. Diabetes mellitus
A. Identifying urinary crystals
C. Cardiovascular disease risk
B. Monitoring vegetarian diets D. All of the above
C. Determining specimen acceptability
15. The primary chemical on the reagent strip in the Micral-
D. Both A and C Test for microalbumin binds to:
A. Protein
B. Antihuman albumin antibody
C. Conjugated enzyme
D. Galactoside
 Chapter 6 | Chemical Examination of Urine 3

16. All of the following are true for the ImmunoDip test 23. The principle of the reagent strip tests for glucose is the:
for microalbumin except:
A. Peroxidase activity of glucose
A. Unbound antibody migrates farther than bound
B. Glucose oxidase reaction
antibody
C. Double sequential enzyme reaction
B. Blue latex particles are coated with
antihuman albumin antibody D. Dye-binding of glucose and chromogen
C. Bound antibody migrates farther than unbound 24. All of the following may produce false-negative
antibody glucose reactions except:
D. It utilizes an immunochromographic principle A. Detergent contamination
17. The principle of the protein-high pad on the Multistix B. Ascorbic acid
Pro reagent strip is the: C. Unpreserved specimens
A. Diazo reaction D. Low urine temperature
B. Enzymatic dye-binding reaction 25. The primary reason for performing a Clinitest is to:
C. Protein error of indicators A. Check for high ascorbic acid levels
D. Microalbumin-Micral-Test B. Confirm a positive reagent strip glucose
18. Which of the following is not tested on the Multistix C. Check for newborn galactosuria
Pro reagent strip? D. Confirm a negative glucose reading
A. Urobilinogen
26. The three intermediate products of fat metabolism
B. Specific gravity
include all of the following except:
C. Creatinine
A. Acetoacetic acid
D. Protein-high
B. Ketoacetic acid
19. The principle of the protein-low reagent pad on the C. -hydroxybutyric acid
Multistix Pro is the:
D. Acetone
A. Binding of albumin to sulphonphthalein dye
27. The most significant reagent strip test that is
B. Immunological binding of albumin to antibody
associated with a positive ketone result is:
C. Reverse protein error of indicators reaction
A. Glucose
D. Enzymatic reaction between albumin and dye
B. Protein
20. The principle of the creatinine reagent pad on C. pH
microalbumin reagent strips is the:
D. Specific gravity
A. Double indicator reaction
28. The primary reagent in the reagent strip test for
B. Diazo reaction
ketones is:
C. Pseudoperoxidase reaction A. Glycine
D. Reduction of a chromogen B. Lactose
21. The purpose of performing an albumin:creatinine ratio C. Sodium hydroxide
is to:
D. Sodium nitroprusside
A. Estimate the glomerular filtration rate
29. Ketonuria may be caused by all of the following except:
B. Correct for hydration in random specimens
A. Bacterial infections
C. Avoid interference for alkaline urines
B. Diabetic acidosis
D. Correct for abnormally colored urines
C. Starvation
22. A patient with a normal blood glucose and a
D. Vomiting
positive urine glucose should be further checked for:
A. Diabetes mellitus 30. Urinalysis is frequently performed on a patient with
severe back and abdominal pain to check for:
B. Renal disease
A. Glucosuria
C. Gestational diabetes
B. Proteinuria
D. Pancreatitis
C. Hematuria
D. Hemoglobinuria
4 Part Two | Urinalysis

31. Place the appropriate number or numbers in front of 37. The primary cause of a false-negative bilirubin reaction is:
each of the following statements. Use both numbers
A. Highly pigmented urine
for an answer if needed.
B. Specimen contamination
1. Hemoglobinuria
C. Specimen exposure to light
2. Myoglobinuria
D. Excess conjugated bilirubin
A. Associated with transfusion reactions
B. Clear red urine and pale yellow plasma 38. The purpose of the special mat supplied with the
Ictotest tablets is that:
C. Clear red urine and red plasma
A. Bilirubin remains on the surface of the mat
D. Associated with rhabdomyolysis
B. It contains the dye needed to produce color
E. Produces hemosiderin granules in
urinary sediments C. It removes interfering substances
F. Associated with acute renal failure D. Bilirubin is absorbed into the mat

32. The principle of the reagent strip test for blood is based 39. The reagent in the Multistix reaction for urobilinogen is:
on the: A. A diazonium salt
A. Binding of heme and a chromogenic dye B. Tetramethylbenzidine
B. Peroxidase activity of heme C. p-Dimethylaminobenzaldehyde
C. Reaction of peroxide and chromogen D. Hoesch reagent
D. Diazo activity of heme 40. The primary problem with urobilinogen tests using
33. A speckled pattern on the blood pad of the reagent strip Ehrlich reagent is:
indicates: A. Positive reactions with porphobilinogen
A. Hematuria B. Lack of specificity
B. Hemoglobinuria C. Positive reactions with Ehrlich reactive substances
C. Myoglobinuria D. All of the above
D. All of the above 41. The reagent strip test for nitrite uses the:
34. List the following products of hemoglobin degradation A. Greiss reaction
in the correct order of metabolism by placing numbers 1 B. Ehrlich reaction
to 4 in the blank, where 1 indicates the beginning and
4 indicates the end product. C. Peroxidase reaction
A. Conjugated bilirubin D. Pseudoperoxidase reaction
B. Urobilinogen and stercobilinogen 42. All of the following can cause a negative nitrite reading
C. Urobilin except:
D. Unconjugated bilirubin A. Gram-positive bacteria
B. Gram-negative bacteria
35. The principle of the reagent strip test for bilirubin is the:
C. Random urine specimens
A. Diazo reaction
D. Heavy bacterial infections
B. Ehrlich reaction
C. Greiss reaction 43. A positive nitrite test and a negative leukocyte
esterase test is an indication of a:
D. Peroxidase reaction
A. Dilute random specimen
36. An elevated urine bilirubin with a normal urobilinogen B. Specimen with lysed leukocytes
is indicative of:
C. Vaginal yeast infection
A. Cirrhosis of the liver
D. Specimen older than 2 hours
B. Hemolytic disease
C. Hepatitis 44. All of the following can be detected by the
leukocyte esterase reaction except:
D. Biliary obstruction
A. Neutrophils
B. Eosinophils
C. Lymphocytes
D. Basophils
 Chapter 6 | Chemical Examination of Urine 5

45. Screening tests for urinary infection combine 48. A specific gravity of 1.005 would produce the
the leukocyte esterase test with the test for: reagent strip color:
A. pH A. Blue
B. Nitrite B. Green
C. Protein C. Yellow
D. Blood D. Red
46. The principle of the leukocyte esterase reagent strip 49. Specific gravity readings on a reagent strip are affected by:
test uses a:
A. Glucose
A. Peroxidase reaction
B. Radiographic dye
B. Double indicator reaction
C. Alkaline urine
C. Diazo reaction
D. All of the above
D. Dye-binding technique
47. The principle of the reagent strip test for specific
gravity uses the dissociation constant of a(n):
A. Diazonium salt
B. Indicator dye
C. Polyelectrolyte
D. Enzyme substrate

Case Studies and Clinical Situations

1. A patient taken to the emergency department after an pH: 6.0 UROBILINOGEN: Normal
episode of syncope has a fasting blood glucose level
of 450 mg/dL. Results of the routine urinalysis are as PROTEIN: Negative NITRITE: Negative
follows: GLUCOSE: Negative LEUKOCYTES: Negative
COLOR: Yellow KETONES: 2+ a. What would be observed if this specimen were shaken?
CLARITY: Clear BLOOD: Negative b. Explain the correlation between the patient’s
SP. GRAVITY: 1.015 BILIRUBIN: Negative sched- uled surgery and the normal urobilinogen.
pH: 5.0 PROTEIN-LOW: 15 mg/dL c. If blood were drawn from this patient, how might the
appearance of the serum be described?
PROTEIN-HIGH: 30 mg/dL NITRITE: Negative
d. What special handling is needed for specimens of
GLUCOSE: 250 mg/dL LEUKOCYTES: Negative serum and urine from this patient?
CREATININE: 200 mg/dL
3. Results of a urinalysis on a patient who is very
a. Explain the correlation between the patient’s anemic and jaundiced are as follows:
blood and urine glucose results.
COLOR: Red KETONES: Negative
b. What is the most probable metabolic disorder
CLARITY: Clear BLOOD: Large
associated with this patient?
c. Considering the patient’s condition, what is the SP. GRAVITY: 1.020 BILIRUBIN: Negative
significance of the reading of the patient’s protein- pH: 6.0 UROBILINOGEN: 8 EU
to- creatinine ratio? PROTEIN: Negative NITRITE: Negative
d. If the patient in this study had a normal blood glucose GLUCOSE: Negative LEUKOCYTES: Negative
level, as well as normal results for protein and creati- a. Would these results be indicative of hematuria
nine, to what would the urinary glucose level be or hemoglobinuria?
attributed?
b. Correlate the patient’s condition with the
2. Results of a urinalysis performed on a patient urobilinogen result.
scheduled for gallbladder surgery are as follows: c. Why is the urine bilirubin result negative in this jaun-
COLOR: Amber KETONES: Negative diced patient?
CLARITY: Hazy BLOOD: Negative d. Would this method also measure urine porphobilino-
SP. GRAVITY: 1.022 BILIRUBIN: Moderate gen? Why or why not?
6 Part Two | Urinalysis

4. A female patient arrives at the outpatient clinic with The physician requests that the athlete collect another
symptoms of lower back pain and urinary frequency with specimen in the morning before classes and practice.
a burning sensation. She is a firm believer in the curative
a. What is the purpose of the second specimen?
powers of vitamins. She has tripled her usual dosage of
vitamins in an effort to alleviate her symptoms; however, b. What changes would you expect in the second
the symptoms have persisted. She is given a sterile con- specimen?
tainer and asked to collect a clean-catch midstream urine c. Is the proteinuria present in the first specimen of
specimen. Results of this routine urinalysis are as prerenal, renal, or postrenal origin?
follows:
6. A construction worker is pinned under collapsed scaffold-
COLOR: Dark yellow KETONES: ing for several hours before being taken to the emergency
Negative CLARITY: Hazy BLOOD: Negative room. His abdomen and upper legs are severely bruised,
SP. GRAVITY: 1.012 BILIRUBIN: Negative but no fractures are detected. A specimen for urinalysis
obtained by catheterization has the following results:
pH: 7.0 UROBILINOGEN: Normal
COLOR: Red-brown KETONES: Negative
PROTEIN: Trace NITRITE: Negative
CLARITY: Clear BLOOD: 4+
GLUCOSE: Negative LEUKOCYTES: 1+
SP. GRAVITY: 1.020 BILIRUBIN: Negative
Microscopic
pH: 6.5 UROBILINOGEN: 0.4 EU
8 to 12 RBC/hpf Heavy bacteria
PROTEIN: Trace NITRITE: Negative
40 to 50 WBC/hpf Moderate squamous
epithelial cells GLUCOSE: Negative LEUKOCYTES: Negative
a. What discrepancies exist between the chemical and a. Would hematuria be suspected in this specimen? Why
microscopic test results? State and explain a or why not?
possible reason for each discrepancy. b. What is the most probable cause of the positive blood
b. What additional chemical tests could be affected by reaction?
the patient’s vitamin dosage? Explain the principle c. What is the source of the substance causing the posi-
of the interference. tive blood reaction and the name of the condition?
c. Discuss the correlation between urine color and spe- d. Would this patient be monitored for changes in renal
cific gravity results, and give a possible cause for function? Why or why not?
any discrepancy.
7. Considering the correct procedures for care, technique,
d. State three additional reasons not previously given and quality control for reagent strips, state a possible
for a negative nitrite test in the presence of cause for each of the following scenarios.
increased bacteria.
a. The urinalysis supervisor notices that an unusually
5. Results of a urinalysis collected from a 20-year-old large number of reagent strips are becoming
college athlete after practice are as follows: discol- ored before the expiration date has been
COLOR: Dark yellow KETONES: reached.
Negative CLARITY: Hazy BLOOD: 1+ b. A physician’s office is consistently reporting
positive nitrite test results with negative LE test
SP. GRAVITY: 1.030 BILIRUBIN: Negative
results.
pH: 6.5 UROBILINOGEN: 1 EU
c. A student’s results for reagent strip blood and LE
PROTEIN: 2+ NITRITE: Negative are consistently lower than those of the laboratory
GLUCOSE: Negative LEUKOCYTES: Negative staff.
d. One morning, the urinalysis laboratory was reporting
results that were questioned frequently by physicians.