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CONTENTS
1 Quality Assessment and Safety, 1
2 Urine Specimen Types, Collection, and Preservation, 18
3 The Kidney, 28
4 Renal Function and Assessment, 50
5 Routine Urinalysis—the Physical Examination, 71
6 Routine Urinalysis—the Chemical Examination, 84
7 Routine Urinalysis—the Microscopic Exam of Urine Sediment, 124
Urine
Sediment Image Gallery, 195
8 Renal and Metabolic Disease, 215
9 Cerebrospinal Fluid Analysis, 247
10 Pleural, Pericardial, and Peritoneal Fluid Analysis, 267
11 Synovial Fluid Analysis, 283
12 Seminal Fluid Analysis, 298
13 Analysis of Vaginal Secretions, 310
14 Amniotic Fluid Analysis, 323
15 Fecal Analysis, 333
16 Automation of Urine and Body Fluid Analysis, 350
17 Body Fluid Analysis: Manual Hemacytometer Counts and Differential Slide Preparation, 361
18 Microscopy, 369
REVIEWERS
Christine M. Nebocat, DHEd, NYS CLS, MLS(ASCP)CM,
CHES®
Assistant Professor
Medical Laboratory Science
Farmingdale State College SUNY
Farmingdale, New York
Janis Livingston
Bachelor of Health Science, (ASCP) MT
MLT Clinical Education Coordinator
Medical Laboratory Technology
Midlands Technical College
West Columbia, South Carolina
Margaret S. Mayo
Faculty
Medical Laboratory Technology/Allied Health Professions
Columbus State Community College
Columbus, Ohio
Jeanne M. Isabel, EdD, MLS(ASCP)CM SH(ASCP)CM
Chair and Associate Professor
School of Health Studies
Northern Illinois University
DeKalb, Illinois
Pamela B Primrose, Ph.D. MT ASCP
Professor
Health Sciences
Ivy Tech Community College
South Bend, Indiana
Phyllis Ingham, Ed.D. MEd. M.T.(ASCP) AHI(AMT)
Program Director/Chair Clinical Laboratory Technology
Health Sciences
West Georgia Technical College
Waco, Georgia
Ronald Walker, PhD, MBA, CNMT, PET
Professor
College of Health Professions
University of Findlay
Findlay, Ohio
Amy R. Kapanka, MS, MT(ASCP)SC
MLT Program Director
School of Health Sciences
Hawkeye Community College
Waterloo, Iowa
Linda L. Williford Pifer, Ph.D., SM (ASCP), GS (ABB)
Professor
Diagnostic and Health Sciences
University of Tennessee Health Science Center
Memphis, Tennessee
Michele B. Zitzmann, MHS, MLS(ASCP)
Associate Professor
Dept. of Clinical Laboratory Science
Louisiana State University Health Sciences Center
New Orleans, Louisiana
Amber G Tuten, MLS(ASCP), DLM(ASCP), M.Ed.
Former MLS and MLT Program Director
Allied Health
PREFACE
As stated in the preface of the first edition (1994), “the purpose of this textbook is to present the fundamental principles
of urine and body fluid analysis” and “to serve as a straightforward, in-depth teaching and reference text”. As with previous
editions, the task of achieving a balance in depth and breadth
of content to meet all needs is challenging. I still believe that
to gain a true understanding of a subject requires more than
the mere memorization of facts. Therefore a guiding principle
in the format and writing of this book is to present basic and
comprehensive information in a manner that arouses interest,
enhances learning, and facilitates understanding and mastery
of the content. A foundation knowledge of each body fluid
in health is established before pathologic conditions are discussed. This enables readers to build their skills in interpreting and correlating test results with disease states.
The intended audience is practicing laboratory professionals—medical laboratory scientists, medical laboratory
technicians—as well as faculty of undergraduate and graduate educational programs in medical laboratory science. In
the medical laboratory, this text is useful as a training guide
and reference. Note that other healthcare professionals, such
as physicians, physician assistants, nurse practitioners, and
nurses can also benefit. Although the content can be comprehensive and detailed, educators can easily adapt it to the level
desired for their students.
ORGANIZATION
This, the revised fifth edition, is organized into 4 sections
that contain 18 chapters. Throughout the text, content has
been updated, figures added, and numerous tables have been
revised or added (see sections below for more details). In
addition, the five appendices continue to provide reference
intervals, tabular summaries, as well as resource methods and
materials for all body fluids discussed in an easily accessible
location. To facilitate learning and quick access to desired
photomicrographs, Quick Reference Guides are available on
the inside front and back covers.
Part I: Quality Assessment and Safety
Chapter 1 provides an overview of quality assessment and
safety protocols that are specifically required in medical laboratories in the United States. However, these are key components found in laboratories throughout the world.
Part II: Urinalysis
Chapter 2 provides a thorough discussion of urine specimen
collection, handling, and preservation, whereas Chapters
3 and 4 review the anatomy and physiology of the urinary
system. Together, these three chapters set the stage for an
in-depth discussion of the three components of a complete urinalysis—namely, the physical exam (Chapter 5),
chemical exam (Chapter 6), and microscopic exam of urine
sediment (Chapter 7). In contrast with previous editions,
the in-depth discussion of specific gravity has been localized
to a single chapter (Chapter 5), with pertinent callouts provided in other chapters when necessary. In Chapter 6, the
commercial reagent strips as well as the principles, sensitivity, and specificity for each chemical test has been updated.
In Chapter 7, several new tables with embedded thumbnail
images have been added. These include a table for the identification of urine crystals based on shape and pH, a table of
urine contaminants, and one specific for urine drug crystals.
Each is unique, useful, and serves as a resource for training
or reference.
New photomicrographs have been added to the Urine
Sediment Image Gallery, which is located between Chapters
7 and 8. This unique gallery provides alternate views of urine
sediment elements to assist in their proper microscopic identification, especially in those specimens that are not ‘picture
perfect’. Minor formatting and organization changes were
also made to enhance navigation within the image gallery. Chapter 8 completes this section on the formation and
analysis of urine with a discussion of the clinical features of
renal and metabolic disorders and their associated urinalysis
results.
Part III: Other Body Fluids
Chapters 9 through 15 are dedicated to the study of other
‘non-blood’ body fluids that are frequently encountered in
the medical laboratory. Each chapter has been updated and
describes the physiology, normal composition, and clinical
value associated with laboratory analysis of the body fluid.
Preanalytic factors in specimen collection and handling are
discussed along with the significance of specific tests that provide clinically useful information. Note that laboratory tests
routinely performed on one body fluid may not have clinical
value when analyzing another body fluid.
In this edition, take note of the following enhancements.
Chapter 9, Cerebrospinal Fluid, is updated with several new
figures, expanded discussion of hemorrhagic events and the
morphologic transitioning of monocytes to macrophages,
and thumbnail images added to several tables. In Chapter 10,
Pleural, Peritoneal, and Pericardial Fluids, discussion of the
nucleated cell differential has been enhanced, new figures
added, and a table with embedded images created to assist in
the microscopic differentiation of monocytes, macrophages
and mesothelial cells.
Part IV: Laboratory Techniques and Tools
The three chapters in this section cover the laboratory techniques, manual and automated, that can be used to analyze
urine and other ‘non-blood’ body fluids. Chapter 16 provides a snapshot of automation currently available for their
analysis. Because of the robust and dynamic nature of laboratory instrumentation, the content of this chapter can change
dramatically and quickly outdate. However, the intent is to
provide an understanding of the analytic principles used
in automated instruments. In this regard, the basic analytic
principles for urine chemical (reflectance photometry) analysis have stood the test of time and continue to endure. The
arena of automated microscopic analysis of urine is broadening with three alternatives: digital flow microscopy, flow
cytometry, and cuvette-based digital microscopy. Future
developments in the analysis of urine and body fluids will
undoubtedly bring to the marketplace new analyzers and
manufacturers.
For a variety of reasons, manual cell counts of body fluids
using a hemacytometer persist today. Therefore Chapter 17
and Appendix D are provided as resources for the preparation of dilutions and the performance of manual body fluid
cell counts. Pretreatment solutions and a variety of diluents
for body fluids are discussed; step-by-step instructions and
calculations for performing manual cell counts are included.
This chapter closes with a discussion of cytocentrifugation
and the preparation of slides for a nucleated cell (or white
blood cell) differential.
Last, but definitely not least is Chapter 18, Microscopy. The
importance of familiarity with and the ability to optimize
a microscope cannot be overemphasized. These skills are
required because the detection and proper identification of
microscopic elements are adversely affected when a microscope is not properly adjusted. In many laboratory settings
globally, automation isn’t available or financially feasible,
but microscopes are. Chapter 18 describes various types of
microscopy, including their uses and their advantages. Proper
microscope handling, care, and important do’s and don’ts
are included. Step-by-step instructions are provided (1) to
properly adjust a brightfield microscope for optimal viewing using Köhler illumination (Box 18.1) and (2) to convert
a brightfield microscope for polarizing microscopy including directions for synovial fluid crystal analysis (Box 18.3,
Fig. 18.18). Tables and photomicrographs are provided of
polarizing microscopy, with and without a red wave compensator, as well as variations in birefringence intensity.
APPENDICES
The five appendices provided complement the chapters.
Appendix A, Reagent Strip Color Charts, supplements the
chemical examination of urine (see Chapter 6) by providing figures of manufacturer color charts used to manually
determine reagent strip results. These figures are a useful
reference and assist in highlighting differences in reagent
strip brands, such as physical orientation of strip to chart
and variations in result reporting. Appendix B, Comparison
of Reagent Strip Principles, Sensitivity, and Specificity, gathers the information for each chemical reaction discussed in
Chapter 6 into one location. Here, a table summarizes the
test principles employed on reagent strips from three popular brands. Similarly, a tabular comparison is provided of the
sensitivity and specificity of each test. Appendix C serves as a
handy resource and single location for the Reference Intervals
of the body fluids that are provided in the various chapters.
As previously stated, Appendix D, Body Fluid Diluent and
Pretreatment Solutions, supplements Chapter 17 (manual
hemacytometer counts) by providing detailed instructions
for the preparation and use of diluents and pretreatment
solutions. Last, Appendix E provides information for the
performance of manual and historic methods of interest.
These methods are valuable tests that are no longer routinely
performed in some regions, are used only under rare circumstances, or are of historical interest. Note that this section
provides detailed information that enables test performance,
including specifics for reagent preparation.
This text concludes with two additional sections, the
Answer Key and a Glossary. The Answer Key provides the
answers and explanations (when necessary) to the end-ofchapter study questions and cases in a convenient, readily
accessible location. The glossary includes the key terms that
are bolded in each chapter as well as additional clinical and
scientific terms that may be new to readers.
TEXTBOOK FEATURES
Each chapter has the following pedagogical features to
enhance mastery of the content:
• Learning Objectives at three cognitive levels (Recall, Application, Analysis).
• A Chapter Outline that provides an overview and quick
content location guide.
• Key Terms that are bold in the chapters and defined in the
Glossary
• Many Tables that capture, summarize, and enhance the
content
• Numerous high-quality Figures and photomicrographs in
full color
• Study Questions at the end of each chapter that correlate to
the learning objectives. Note that most are in the multiplechoice format used on certification examinations.
• Case Studies at the end of pertinent chapters, which assist
the reader in applying the content to real-life situations.
