LabNotes

E
FRE

A Newsletter from Volume 16, No.3, 2006

BD Diagnostics

Preanalytical Variables
Preanalytical Systems

in Urine Testing
Best Practices for Achieving Optimal
Product News Specimen Quality and Accurate Test Results
BD has received FDA by Catherine Skobe
510(k) clearance for its Second in a Two-part Series
BD Vacutainer Plus Plastic
Serum, and SST Tubes
for routine blood donor
screening and diagnostic
testing of serum for
infectious disease.* Similarly,
BD Vacutainer Plus Plastic
Serum and K2EDTA Tubes
have been cleared for
routine immunohematology
testing and blood donor
screening.**
*T
 he performance characteristics
of these tubes have not been
established for infectious disease
testing in general; therefore, users
must validate the use of these tubes
for their specific assay-instrument/
reagent system combinations and
specimen storage conditions. There are many preanalytical variables that colored urine due to medications, food dyes,
**The performance characteristics can introduce error into laboratory test or vitamins can alter the color change on
of these tubes have not been results. When unexpected results are seen dipstick test pads for tests other than color.
established for immunohematology in urine measurements, they should be This can be ruled out by doing a visual exam
testing in general; therefore, users interpreted in the context of other analytes of the urine specimen prior to performing
must validate the use of these tubes
for their specific assay-instrument/ and clinical results that measure similar the dipstick.
reagent system combinations and aspects of renal function. For this reason, the College of American
specimen storage conditions.
An example is blood and bacteria testing Pathologists (CAP) recommends that
in routine urinalysis. A false-positive laboratories have a procedure for the
result for blood can be obtained when a correlation of microscopic and macroscopic
specimen contains infection-causing bacteria. results. In general, collection time, transport,
The microbial peroxidase activity can cause a and storage conditions can be examined to
false-positive reaction for blood. In this case, determine the causes of error.
microscopic analysis will verify the presence There are some basic guidelines that should
View of bacteria and possibly the lack of red blood be followed for urinalysis and the storage and
cells. This will confirm that the response for handling of urinalysis dipsticks. By following
LabNotes blood on the reagent strip is inaccurate.
Online or Sign Up these precautions, inaccurate results can
for e-LabNotes
Another example is the effect of urine color be minimized.
at on urinalysis reagent test pads. Abnormally continued on page 2
bd.com/labnotes

This
 publication is a service to the customers and friends of BD, and is designed only to provide general
information. It is not intended to be comprehensive or provide any legal or medical advice.
 Urine Testing

LabNotes
continued from page 1
Urinalysis testing should be conducted on
unspun urine.
Refrigerated specimens should come to room
temperature before analysis because many of
the enzymatic reactions on the reagent strips
Letter from the editor are temperature dependent.
This issue of LabNotes features the second in a two-part Follow the manufacturers directions for
series on urine testing. While the first part (Vol. No. 200) conditions of handling, levels of sensitivity, and
focused on proper urine collection techniques, handling, and interferences of tests.
transport, here we will focus more on the preanalytical
variables that can affect urine test results. We hope that you Reagent strips deteriorate when exposed to
find this to be a valuable resource that will aid in avoiding moisture, sunlight, heat, and volatile chemicals.
any spurious results in your urine testing practices. Do not refrigerate or freeze the reagent strips.
Also in this issue, we discuss the use of safety devices by
They should be kept at room temperature.
healthcare workers. There are some interesting statistics on Keep containers closed so the desiccant can do
the needlestick injury rates that are occurring in hospitals its job. Remove the strips as needed and do not
and on some safety devices that are designed to prevent transfer them into another type of container.
these injuries.
Use urine dipsticks prior to the expiration date.
Dr. Ana Stankovic Lastly, please continue to check the BD Web site Record the open date on the container and use the
(www.bd.com/vacutainer) for upcoming Web-based dipsticks within the opened expiration time.
seminars on issues related to blood and urine specimen Monitor deterioration of the reagent test pads by
collection and testing. We have already held Webinars on matching a dry reagent strip to the negative pattern
Latex hemolysis and elevated potassiums, and we plan to continue on the bottle to ensure the colors are stable.
providing future Webinars on topics of high interest and
Did You Know utility to our readers. Dont touch the reagent pads.
Accurate timing is important in obtaining valid
Since latex allergies have Many thanks to those of you who completed our reader
results. A timer or stopwatch should be used.
become more prevalent survey on hemolysis in the last issue of LabNotes. We are
in the patient population always interested to know what challenges our customers Good lighting is important when reading
are facing in the clinical lab, and we continue to welcome the strips because sometimes reaction colors
and among healthcare
your comments and suggestions for future issues. can be similar.
workers (HCW), healthcare
facilities have chosen Regards, Dont allow urine to run between the test pads
to enact latex-free policies
or the chemical reaction can be altered. Prevent
this by running the edge of the strip along the tube
to protect their patients
lip when the dipstick is withdrawn from the tube.
and employees from Follow up by blotting the edge of the strip on a
exposure to latex. Dr. Ana Stankovic
paper towel. This will minimize excess urine on
Ana Stankovic, Editor the reaction pads.
The following BD products
do not contain latex: MD, PhD, MSPH While waiting to read the results, keep the
Worldwide Vice President, Medical and Clinical Affairs dipstick horizontal to prevent excess urine from
BD Vacutainer BD Diagnostics - Preanalytical Systems running between reagent pads.
Stretch Latex-Free Email: [email protected]
If automated analyzers are used to read the
Tourniquet
Associate Editor, Leslie S. Magee, MBA, MT(ASCP) dipsticks, good laboratory practices should be
BD Vacutainer Production Coordinator, Marion Plumley followed. The instrument should be calibrated
Safety-Lok and maintained, and proper QC should be
Blood Collection Sets performed as described by the manufacturer and
BD Vacutainer The Vacutainer Brand and Trademark laboratory policies.
Push Button Trademarks were developed to protect the consumer from Typical urinalysis dipstick tests include: specific
Blood Collection Sets confusion as to the source of products and services available gravity, pH, protein, blood, nitrite, leukocyte
BD Vacutainer in the marketplace. Trademarks identify and distinguish the esterase, glucose, ketones, bilirubin, and
source of goods or services of one party from those of urobilinogen. Color and clarity can be measured
Multiple Sample
another. Trademarks, otherwise known as brands, are either visually or by an analyzer. The following
Luer Adapters
intellectual property and are part of the assets or good will
will be a review of some of the preanalytical
BD Vacutainer of a company.
variables that can affect these tests.
Blood Transfer Device On LabNotes, and many other pieces of information you
BD Vacutainer receive from BD and on our Web site, you see the Vacutainer
Brand represented with the registered trademark symbol .
Preanalytical Variables
Luer-Lok Access
Device Vacutainer is a registered trademark of Becton, Dickinson Color
and Company. This brand name is officially registered with The color of urine, which is normally colorless
BD Vacutainer the US Trademark office and many other local trademark or one of the various shades of yellow, can be
Urine Collection Cup authorities worldwide, and is legally owned by BD. altered by medications, vitamins, dyes, or diet. If an
with integrated unusual color is detected for the urine specimen,
transfer device
Address all correspondence to: Leslie Magee, Associate Editor, LabNotes, one of these conditions could be the cause. Once the
BD Diagnostics - Preanalytical Systems, 1 Becton Drive MC325, cause is determined, it should be noted in the
Franklin Lakes, NJ USA 07417-1885. laboratory results.

2 www.bd.com/vacutainer LabNotes a newsletter from BD Diagnostics - Preanalytical Systems, Volume 16, No.3, 2006
Some abnormal urine colors and their (which dissolve when the specimen is Dehydration, sweating, diarrhea,
possible causes are: brought to room temperature). Amorphous radiopaque dyes, and antibiotics can
R
 ed blood (or hemoglobin), laxatives urates are observed in acidic urines and cause high results because the ratio
such as senna, beets, and rhubarb amorphous phosphates are found in of dissolved particles in low volumes of
alkaline urine. The collection time and solute will be elevated. A high fluid intake
Black melanin in patients with storage conditions of the specimen should or consumption of diuretics can cause
melanoma be reviewed to determine if cloudiness may low measurements because of the low
Brown bilirubin in patients with be caused by storage conditions. Other quantity of dissolved particles in a large
obstructive jaundice causes of cloudy samples include talcum volume of solute.
Black/brown fava beans powder, mucus, crystals, leukocytes, The pH test indicates whether a specimen
epithelial cells, and fat. is acidic (pH <7) or alkaline (pH >7).
Green medications, chlorophyll
in mouthwash Clear tubes are best for examining urine A normal urine pH ranges from 5-7 and
clarity. Result reporting should be is a useful tool for the laboratorian, often
Blue multivitamins, Vitamin E standardized, with clear, hazy, cloudy, predicting what may be seen in subsequent
Green/blue - Pseudomonas infection and turbid being the most commonly microscopic examination. Certain crystals
These abnormal urine colors can affect used descriptors. exist in either an acidic or alkaline environ-
other dipstick results by causing a colori- ment. Some examples of these are uric acid
metric reaction that may be misinterpreted or calcium oxalate crystals in acidic urine
by the instrument and give incorrect results. and calcium carbonate or magnesium
It is important that the tube be of a clear
Part 1 of this article phosphate in alkaline urine. Dilute and
alkaline urines can dissolve casts and cells.
material when determining the color of can be found online
the urine. Using good lighting and a white Bacterial overgrowth in a specimen
background helps to ensure the color is Volume 14, No.2 standing at room temperature will produce
being read accurately and consistently. www.bd.com/labnotes a higher pH due to the conversion of urea
Color descriptions should be standardized. into ammonia.1 Diets high in vegetables,
citrus fruits, and dairy produce an alkaline
Clarity pH. Lower pH levels may be seen in
Another visual measurement is clarity. Specific gravity, or the amount of dissolved uncontrolled diabetes or may reflect a diet
(A normal urine specimen is typically clear.) particles in a solution, is another measure- high in meat or cranberries. Starvation and
Urine clarity can be related to the handling ment performed on urine. Specific gravity diarrhea can produce a more acidic urine.
conditions of the specimen. If a urine is affected by the number, amount, and Lastly, mishandling the reagent strips by
specimen is old and unpreserved, it can weight of solutes in the specimen. It serves allowing runover from the protein reagent
become cloudy from bacterial overgrowth. as a measure of the kidneys ability to pad can cause false negative pH results.
In turn, if a specimen has been stored in a dilute and concentrate urine. A normal
refrigerator, amorphous urates or phos- random urine has a specific gravity range
of 1.0011.035. continued on page 4
phates can cause temporary cloudiness

LabNotes a newsletter from BD Diagnostics - Preanalytical Systems, Volume 16, No.3, 2006
Related Industry Web site: www.cap.org

Q-Probes 2005 Urine Culture Contamination (QP052)

Participants from 127 institutions reviewed a total of 14,739 urine-culture

specimens and submitted data related to microbiological results, patient gender,
age, and site of specimen collection. If more than 2 isolates were found in
quantities of >10,000 colony-forming units (CFU)/mL, the urine culture was
classified as contaminated. The overall rate of urine-culture contamination and
rates by gender, age, and collection site based on these criteria are listed below.
The urine-culture contamination rate for patients less than two years old may
not be comparable due to the low frequency of events.
Excerpted with permission from the College of American Pathology. To obtain this full
Q-Probe document, contact College of American Pathologists directly by visiting their
Web Site www.cap.org.

Aggregate Urine Culture Contamination Rates Overall 17.8%

By Gender By Age By Collection Site
Male 9.2% <2 years 5.3% Emergency Department 18.0%
Female 20.8% 2-50 years 20.0% Site adjacent to lab 18.7%
>50 years 16.1% Site not adjacent to lab 17.3%

www.bd.com/vacutainer 
 Urine Testing
continued from page 3

Protein is a very important analyte

measured in urine because it monitors the
function of the kidneys. A normal urine For more than 100 years, BD has led the
specimen should not contain more than medical technology industry by partnering
trace amounts of protein. Most reagent with leading organizations to address
pads primarily measure albumin and, to global health issues that are devastating
a lesser extent, other proteins. to human life.
Residue of disinfectants in contaminated
urine containers can cause false-positive
protein results. Similar false positives may
be seen after strenuous exercise and in
highly alkaline urines. Urine specimens
with a high specific gravity can produce
trace results. Dilute specimens, fever,
mental stress, mucus, and exposure to
extreme heat or cold can produce false-
negative protein results.
Blood is another measurement on the urine
dipstick, detecting intact red blood cells,
free hemoglobin, and myoglobin. A normal
urine specimen is usually negative for
blood. False positives can be caused by the
presence of chlorine bleach, consumption
of colored medications by the patient, or
a microbial peroxidase reaction from
bacterial presence.
False-positive-causing contaminants
can also be introduced during time of
collection, such as in specimens submitted
by women during menstruation. High levels
of a reducing substance such as ascorbic
acid at >25 mg/dL can produce false-
negative results. False-negative blood
results can also occur when formalin
is used as a preservative, when there is
LabNotes a newsletter from BD Diagnostics - Preanalytical Systems, Volume 16, No.3, 2006

>10 mg/dL of nitrite, or when mixing

is inadequate and red blood cells have
settled in the tube.
Nitrite is also a test on urine dipsticks.
A normal urine specimen is negative for
nitrite. Some of the ways in which false-
positive results can occur include bacterial
overgrowth in specimens that have not
been stored properly, colored medications,
and dyes.
False-negative results can be seen with
high levels of ascorbic acid, >25 mg/dL, Partnering for health
or when dietary nitrate is missing due to
starvation, IV feeding, or fasting. Helping to provide relief in the wake Selected as one of Americas Most
The conversion of nitrate to nitrite takes of natural and man-made disasters. Admired Companies by FORTUNE
about 4 hours in the bladder. If this Helping to eliminate deadly diseases like magazine1BD is privileged to work
hasnt occurred, results could be negative measles, maternal and neonatal tetanus, with governments, nonprofit groups,
for the presence of nitrite. This can be and TB. Fighting the spread of diabetes. and other organizations to address
seen in randomly collected specimens. broad health issues, develop an array of
BD serves healthcare institutions, life
responses, and pioneer technologies.
Leukocyte esterase is an indicator of science researchers, clinical laboratories,
white blood cells. It is typically negative industry, and the general public every day. BDHelping all people live healthy lives.
in normal specimens. False positives can Around the globe BD manufactures and
occur when collection containers have sells a broad range of medical supplies,
been contaminated with chlorine bleach devices, laboratory equipment, and
or other oxidizing detergents. Other diagnostic products.
influences that can produce false-positive
results include formalin as a preservative Please visit www.bd.com.
and vaginal discharge. 1
Americas Most Admired Companies annual survey, 2005; FORTUNE magazine, March 7, 2005.
BD and BD Logo are trademarks of Becton, Dickinson and Company. 2006 BD

continued on page 6
 www.bd.com/vacutainer
 USE OF SAFETY DEVICES
Reduces Exposure of Healthcare Workers to Bloodborne Pathogens
Healthcare worker (HCW) safety is an A great impact on HCW safety can be achieved activation devices will further reduce the number
important aspect of infection control. HCWs through the replacement of conventional of PIs. BD (Becton, Dickinson and Company)
are at risk of occupational exposure to devices with safety-engineered products (e.g., released the first passive needle for blood
pathogens present in blood and body fluids. shielded, retracted, or self-blunting conventional collection in the spring of 2005, and the
Although the use of universal precautions and winged set needles, plastic blood collection BD Vacutainer Push Button Blood Collection
has significantly reduced this risk, accidental vacuum tubes, round-tipped scalpel blades, Set was also released in 2005 .
puncture of skin by needles, other instruments, retracting-blade or shielded-blade scalpels, etc.).
TM In recent years, major improvements have been
or broken glass (sharps) still remains an Data from the EPINet Multihospital Sharps
made in the area of HCW safety. New and
important source of HCW acquired infections Injury database showed that although conversion
innovative safety devices, combined with
and necessitates further action in order to to safety devices was not proportional across
effective HCW training, have ensured continued
achieve the desired level of HCW safety. different device categories, it resulted in a
reduction of PI injuries and occupational
51% decline of PIs (from 19.5 to 9.6 PIs per
Although more than 20 different infectious exposure to pathogens, thus successfully
100 occupied beds).6
agents have been shown to be transmissible by lowering rates of HCW acquired infections.
exposure to blood and body fluids,1 most of Legislation has significantly increased the rate Conversion to passive safety devices, safety
the attention is currently focused on prevention of conversion to safety devices. In the United legislation, and discontinuation of unnecessary
of viral infections caused by human States, the Needlestick Safety and Prevention use of sharps will move this process even further.
immunodeficiency virus (HIV), hepatitis B virus Act of 2000 made the use of safety devices
(HBV), and hepatitis C virus (HCV). Traditionally, mandatory as of July 2001. As a result of that, References
the average transmission rates of infection healthcare employers in the United States must 1. Collins C.H. and Kennedy D.A. Microbiological
following a needlestick injury from an infected document annually in their exposure control hazards of occupational needlestick and sharps
injuries. Journal of Applied Bacteriology
patient are: 0.3% for HIV, 30 (23-62)% for HBV, plan that they have evaluated and implemented 62:385-402, 1987.
and 1.8% for HCV.2,3 The major population at safer medical devices designed to eliminate or
2. Centers for Disease Control and Prevention. Updated
risk for percutaneous injuries (PI) are nurses. minimize occupational exposure to bloodborne U.S. Public Health Guidelines for management of
diseases and have taken into consideration occupational exposures to HBV, HCV and HIV and
It was estimated that the total US annual rate
changes in sharps safety technology. During recommendations for postexposure
of HCW injuries involving contaminated sharps prophylaxis. MMWR 50(RR11): 1-42, 2001.
this process, input from nonmanagerial HCW is
is close to 650,000.4 This estimate took into
mandatory, as well as maintenance of a sharps 3. United States General Accounting Office. Needlestick
consideration the rate of PI underreporting, prevention, GAO 01 60R, 1-18, 2000.
injury log.
which can in certain settings be as high as 73%.5
4. Perry J, Jagger J. Healthcare worker blood
Seventy-five percent of needlesticks that However, in order to achieve maximum effect, exposure risks: correcting some outdated statistics.
occur annually in hospital settings are the safety features of the devices have to be Advances in Exposure Prevention 6:28-31, 2003.
preventable either by: eliminating unnecessary engaged appropriately. When analyzing the 5. Alvarado F, Panlilio A, Cardo D. NaSH Surveillance
use (25%), using needles with safety features injuries that occurred during the use of safety Group. Percutaneous injury reporting in U.S.
(29%), or using safer work practices (21%).3 devices, it was shown that injuries occurred hospitals, 1998 (abstract). Infection Control and
Using these three approaches, 65 infections frequently either before the activation of the Hospital Epidemiology 21:106, 2000.

LabNotes a newsletter from BD Diagnostics - Preanalytical Systems, Volume 16, No.3, 2006
with HBV and 42 infections with HCV can device (in 56.9% of cases) or during the 6. Jagger J, Perry J. Marked decline in needlestick
be prevented; however, the number of HIV activation (in 26.3% of cases).7 Because of that, injury rates. Advances in Exposure Prevention
6:25-27, 2003.
infections that would be avoided could not use of passive needles that automatically allow
7. Perry J, Parker G, Jagger J. EPINet report: 2001
be validly estimated.3 engagement of safety features as soon as the
percutaneous injury rates. Advances in Exposure
Epinet is a trademark of the University of Virginia needle is out of the blood vessel and in-vein Prevention 6:32-36, 2003.
Patent Foundation

Industry News For Research Use Only Not For Use in Diagnostic Procedures

NEW BD P700 Blood Collection and Preservation System for GLP-1 Analysis
BD P700 is a new blood collection BD P700 Enhances Preservation
tube that provides immediate of GLP-1 (7-36)-Amide*
stabilization of plasma GLP-1, an
important gastrointestinal hormone BD P700 v1.0 versus EDTA Plasma
that is known to stimulate insulin BD P700 v1.0 K2EDTA
secretion in the presence of glucose. Mean 2.5 1.1
BD P700 contains a proprietary Standard Deviation 3.4 1.8
protease inhibitor that protects GLP-1
Minimum 0 0
GLP-1, at the point of collection, from degradation by (pM/mL)
Maximum 10.2 4.3
the aminopeptidase DPP-IV (CD26). Plasma obtained
Total Subjects 12 12
from BD P700 can be used in assays that require the
Table 1. Comparison of plasma GLP-1 levels obtained from
reliable detection and quantitation of GLP-1. Studies whole blood samples collected into BDP700 and K 2EDTA Tubes.
show that BD P700 enables significant increase in Blood was drawn directly from 12 subjects into BDP700 and K 2EDTA
GLP-1 recovery (Table 1). evacuated tubes at room temperature. GLP-1 was measured using a
GLP-1 (7-36)-Amide competitive enzyme immunoassay.
* Based on using 12 samples; cannot be guaranteed to be statistically valid.

www.bd.com/vacutainer 
 Urine Testing
continued from page 4
High specific gravity, some antibiotics, such will cause false-negative urobilinogen The urine becomes alkaline, causing red
as tetracycline, and large amounts of results, as can ascorbic acid or nitrite. blood cells and white blood cells to lyse
glucose or ascorbic acid can cause false- Standardization when processing urine and casts to dissolve.
negative leukocyte esterase results. specimens for microscopic sediment If a specimen has been refrigerated for
Glucose, another urine dipstick test, is analysis has become a very important storage, it should be allowed to come to
mainly used to monitor diabetes. Normal guideline as recommended by the Clinical room temperature and mixed well prior to
urines are negative for glucose. Some and Laboratory Standards Institute (CLSI, analysis. Amorphous urates or phosphates
normal specimens have small amounts formerly known as NCCLS). This includes develop in cold conditions and will affect
of glucose, that are below levels of the use of engineered tubes, pipettes, and the analysis. Contaminants that can be seen
sensitivity for the reagent strip. standardized calibrated slides. The best during sediment analysis include mucus,
Just like leukocyte esterase, false-positive types of tubes for microscopic sediment spermatozoa, fibers, talcum powder, and
glucose results are achieved when collection analysis are clear, plastic tubes with oil. It is important not to confuse these
devices have been exposed to chlorine bleach conical bottoms. A cap or lid and volume contaminants with cellular components.
or detergents. Improper storage of reagent gradations are valuable features. CLSI does Stains can help in the identification of cells.
strips, when exposed to air, have been not support the use of glass slides and Flow cytometry is another method of
noted to produce false-positive results. cover slips due to the lack of sample examining the urine for microscopic
volume standardization. The chambers on elements. This method of microscopic
Ascorbic acid, >50 mg/dL, is again a culprit the specially designed slides are calibrated
in causing false-negative glucose results. analysis, however, is almost unaffected by
for a specific urine sediment volume that preanalytical variables. The greatest factor
Over time at room temperature, glucose ensures standardization.
will decrease due to glycolysis from that could affect flow cytometry test results
bacteria. Tetracycline has been determined is insufficient mixing of the specimen.
to cause false-negative glucose results, Urine Culture and Sensitivity
and refrigerated specimens that were not Some of the more common The microbiology lab also conducts
allowed to reach room temperature can
produce false-negative results because the
analytes in the long list of clinical testing on urine. Preanalytical
variables that could affect culture and
enzymatic reaction is affected. urine chemistry assays sensitivity testing include:
Ketone bodies are a by-product of fat includes the following: A contaminated collection container
breakdown. Normal urines are negative for
ketones. Increased ketones can be due to Sodium Potassium Other specialty tests:
A leaky container
starvation or alcoholism. Also strenuous A midstream clean catch specimen is
Chloride Creatinine 5-HIAA
exercise, fever, fasting, vomiting, and high- less likely to produce contaminants as
Urine urea nitrogen Calcium Porphyrins compared to a random urine. It has been
protein diets can cause high ketone values.
Urine specimens with a high specific Magnesium Phosphorus Catecholamines documented that the contamination rate
gravity and low pH have been known to Glucose Amylase Porphobilinogen
for females is double the rate for males.
cause trace ketone results. Generally, contamination has been
Uric acid Urine total protein VMA defined as >10,000 CFU/mL of 2 or more
LabNotes a newsletter from BD Diagnostics - Preanalytical Systems, Volume 16, No.3, 2006

Acetone, one by-product of fat breakdown,

Microalbumin Osmolality organisms. Each facility should define
evaporates rapidly if the uncovered
their own level of contamination based
specimen is left standing at room
on the patient population and the collec-
temperature. Specimens should, therefore,
tion and transport methods authorized
be tested immediately for ketones or As part of specimen processing standard-
refrigerated in a closed container.2 Some ization, the ratio of the volume of urine When there is a delay in specimen
urinalysis preservatives can maintain required to fill the tube is compared with transportation, specimens that are not
ketone levels. It is important to check the the volume of urine and sediment, which handled immediately, are left unrefriger-
manufacturers claims. remain in the tube after centrifugation and ated, or do not have a bacteriostatic
decanting. Ensuring that these two are preservative may contain bacterial
Bilirubin measures liver function and is
maintained is one of the keys to standardiz- overgrowth causing colony counts that
usually negative in normal urine specimens.
ing microscopic sediment analysis. may be almost impossible to read
Colored medications, those in the yellow,
orange, and red spectrum, can cause CLSI recommends centrifugation of urine Extraneous sources of bacterial contami-
false-positive results. specimens at 400 RCF (g). Most hospitals nation include hands, skin, and clothing
Ascorbic acid, >25 mg/dL, causes false- typically centrifuge for 5 minutes. Any False-negative growth may be seen
negative results, as can specimens with variations in speed and time can change the in specimens submitted from patients
high nitrite concentrations. Exposure to cellular elements obtained in the sediment. who are taking antibiotics
light causes bilirubin to degrade over time, All equipment used for sediment processing
and analysis should be properly maintained.
Urine Chemistry
leading to false-negative results. It is Random testing of urine chemistry analytes
recommended that specimens submitted for Centrifuges should be calibrated and
microscopes should be quality-control and is not usually considered valuable because
bilirubin measurements be kept in a dark of the lack of collection of these analytes
place or collected in an amber container. proficiency tested regularly to guarantee
accurate testing. at any given time in the bladder. Timed
Urobilinogen is another measurement of specimens provide the most valuable
liver function. A normal urobilinogen result Unpreserved specimens that have been information for the concentration of a
is <1 Ehrlich unit/dL. The same factors unrefrigerated for more than 2 hours from specific analyte.
that affect bilirubin (exposure to light time of collection should not be accepted for
microscopic analysis due to the increase in Some of the preanalytical variables that
and colored medications) also affect affect these tests are redundant to those
urobilinogen. In addition, formalin, bacterial overgrowth and the disintegration
of cells and casts. for urine dipstick chemistries. There are
which is sometimes used as a preservative, various factors, that can affect any one of
 www.bd.com/vacutainer
these analytes. The most common influences walnuts, avocados, tomatoes, bananas, and are requested. This can be accomplished
are preservatives, diet, and medication. eggplants. It is recommended they not be by pooling the collections over time, then
More specifically some of the drugs and eaten 3 days prior to testing. evenly distributing the specimen into
foods that affect urine chemistry results 5-HIAA can be increased by cough syrup. multiple containers. Another option would
are as follows: It can be decreased by heparin, methyldopa, be to collect multiple 24-hour specimens.
and tricyclic antidepressants. Drugs of abuse are tested on urine.
Sodium is influenced by diet. Increased
sodium results can be caused by Porphyrins are affected by morphine, oral The preanalytical variables that affect testing
antibiotics, cough medicines, or laxatives. contraceptives, and sulfonamides. Some drugs of abuse in urine are listed below:
Decreased sodium results will be seen of these also apply to porphobilinogen. In the US, 4% of urine samples are
with diuretics. Catecholamines are influenced by adulterated. Some of the common
Potassium can also be influenced by diet. chocolate, cocoa, coffee, tea, bananas, adulterants used are: water, bleach,
Increased measurements can be seen with and vanilla. They are also affected by eye drops, and vinegar.4 Commercial
diuretics, salicylates, or glucocorticoids. stress and exercise. They can be increased adulterants can be purchased.
by lithium, insulin, tetracycline, and A common interference in urine
Chloride is falsely decreased by androgens,
nitroglycerin. Catecholamines can be drug testing is poppy seeds. They can
estrogens, methyldopa, or cortisone.
decreased with salicylates and imipramine. cause false-positive opiate screens.
It is falsely increased by bicarbonates or
These same factors also affect VMA, a
corticosteroids. Specimens must be refrigerated
metabolite of catecholamines.
Creatinine is increased by gentamycin until tested.
or heavy metal chemotherapeutic agents. It is recommended that any drug known
to interfere with a test be discontinued until Urine is a valuable specimen for the screen-
Calcium shows increases by antacids, a drug-free specimen can be produced. ing, diagnosis, and monitoring of diseases.
anticonvulsants, and some diuretics, It can also be used to monitor therapy.
while adrenocorticosteroids and oral It is important that the total urine volume There are various collection methods for
contraceptives cause decreases. be collected and recorded during the time acquiring this specimen, each of which has
period in order to correctly calculate the its merits. By minimizing the preanalytical
Urine total protein is affected by heavy
analyte concentrations. Other guidelines influences during specimen collection
exercise, dehydration, food, and
that should be followed when performing and handling, a suitable specimen can be
emotional stress. It can be increased with
urine chemistry testing are: obtained. Specimen handling is probably
acetaminophen, antibiotics, and x-ray
contrast media. Consideration should be given as to whether the most important step in obtaining a
preserved or unpreserved specimens are good urine specimen that can provide the
Microalbumin is affected by dehydration
used. Proliferation of bacteria could be a most useful clinical information. It is also
or strenuous exercise.
concern with unpreserved specimens. important to carefully record any details
Glucose can be increased by lithium, that may be beneficial in the interpretation
estrogen, diuretics, chloramphenicol, and Potential interference with assay methods
of the urine results. After all, the results are
ascorbic acid. should be considered when chemical
only as good as the specimen collected.
preservatives are used. Each institution
Uric acid is influenced by high levels of
should perform evaluations to make these References

LabNotes a newsletter from BD Diagnostics - Preanalytical Systems, Volume 16, No.3, 2006
ascorbic acid, x-ray contrast media,
determinations for their facility based on
alcohol, anti-inflammatory drugs, 1. Ringsrud KM and Linne JJ. Urinalysis and Body Fluids:
their populations and levels of clinical A Color Text and Atlas. Mosby; 1995:chap 4, pg 48.
salicylate, and warfarin.
acceptance.  raff SL. A Handbook of Routine Urinalysis. Lippincott
2. G
Bilirubin is decreased by light and
NCCLS GP16-A2 provides a table of Williams & Wilkins; 1983:chap 2, pg 45.
ascorbic acid and can be increased with
common 24-hour urine preservatives 3. Clinical and Laboratory Standards Institute (CLSI;
antibiotics, diuretics, oral contraceptives,
corresponding to the chemistry tests. formerly NCCLS). Urinalysis and Collection,
sulfonamides, and steroids. Transportation, and Preservation of Urine Specimens;
The most commonly cited methods for
Amylase can be increased with aspirin, Approved Guideline-Second Edition. Vol 21. No. 19.
preservation were refrigeration, freezing, Document GP16-A2. Wayne, PA: NCCLS; 2001:26-27.
corticosteroids, codeine, and oral HCl acid, boric acid, and acetic acid.3
contraceptives. 4. Substance Abuse Specialties, Inc., retrieved from
Specimens may need to be split if various the World Wide Web on December 15, 2001
5-HIAA is influenced by many types tests that require different preservatives at www.sas-i.com.
of foods, such as plums, pineapples,

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LabNotes
BD

A Newsletter from Volume 16, No.3, 2006

BD Diagnostics
Preanalytical Systems IN THISISSUE
PreanalyticalVariables
in Urine Testing
Letter from the Editor

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