16

Automation of Urine and Body

Fluid Analysis

LEARNING OBJECTIVES
After studying this chapter, the student should be able to: 4. Compare and contrast the three technologies used to
1. Describe the principle of reflectance photometry. perform fully automated urine microscopy analysis—
2. Discuss and differentiate between semiautomated and digital flow microscopy, flow cytometry, and cuvette-based
fully automated urine chemistry analyzers. digital microscopy.
3. State advantages gained by performing automated urine 5. Discuss the advantages and disadvantages of current
sediment analysis. automated body fluid analyzers.

CHAPTER OUTLINE
Automation of Urinalysis, 339 Automation of Body Fluid Analysis, 348
Urine Chemistry Analyzers, 339 Body Fluid Cell Counts Using Hematology
Automated Microscopy Analyzers, 342 Analyzers, 349
77 Elektronika UriSed Analyzer, 345 Body Fluid Cell Counts Using iQ200, 349
Fully Automated Urinalysis Systems, 346

K E Y T E R M S*
fully automated urinalysis semiautomated
reflectance photometry semiautomated urinalysis

*Definitions are provided in the chapter and glossary.

AUTOMATION OF URINALYSIS As with all technology, new analyzers and methods are
A goal of the urinalysis laboratory is to maximize productivity constantly being developed and modified. The combinations
and testing quality while keeping costs and turnaround time of analyzers or urinalysis workstations available through the
at a minimum. The first reagent strip tests to determine the collaboration of manufacturers are dynamic and change with
chemical composition of urine were developed in the 1950s time. Note that despite our global economy, instruments that
in an effort to achieve these goals. Since that time, reagent are available in Europe or Asia may not be available in the
strips have streamlined the chemical examination, signifi- United States, and vice versa. The instruments presented in
cantly reducing the time required and increasing the number this chapter are limited to those most commonly encountered
of specimens that can be analyzed in a given time period. in US laboratories and one available outside the United States.
Efforts next focused on ensuring consistency in reagent strip Although manufacturers use similar formats for their urine
reading (e.g., color interpretation, timing), reducing the chemical analyzers, the approach used for automated micros-
amount of specimen handling, and increasing specimen copy varies among three principles—digital flow microscopy,
throughput. These efforts have resulted in the development flow cytometry, and cuvette-based digital microscopy.
of instruments that assess reagent strip results and automate
evaluation of the physical characteristics of urine. In the early Urine Chemistry Analyzers
1980s, automation of the microscopic examination was Semiautomation of the chemical examination of urine was
achieved by the development of a urine microscopy analyzer developed to standardize the interpretation of reagent strip
(i.e., Yellow Iris). Today, automated urine chemistry ana- results. Consistent, unbiased, and accurate color interpreta-
lyzers and urine microscopy analyzers are available that can tion was the goal when urine chemistry analyzers were devel-
be used as standalone instruments or linked together to oped. All reagent strip reading instruments, regardless of
enable a fully automated urinalysis system. manufacturer, use reflectance photometry to interpret the

339
340 CHAPTER 16 Automation of Urine and Body Fluid Analysis

color formed on each test pad. These semiautomated instru- Reflectance measurements are performed at specific wave-
ments require the user to properly dip the reagent strip and lengths and are expressed as percent reflectance (% R). The
place it onto a platform. After this is done, the instrument percent reflectance (% R) is the ratio of the test pad reflectance
automatically performs the remaining steps in the analysis: (Rt) compared to the calibration reflectance (Rc), multiplied
reading the reaction pads at the appropriate read time and by the percent reflectivity of the calibration reference, which
moving the strip to a waste container. is usually 100%.
Some manufacturers include a color compensation pad on
their reagent strips. The purpose of this pad is to assess urine Rt
%R¼ " 100 Equation 16.1
color and use it when interpreting the colors that develop on Rc
each reaction pad. In other words, the instrument modifies test The relationship between concentration and reflectance is
results by essentially subtracting the contribution of urine color not linear. Therefore a microprocessor is needed to apply
from the color change obtained on the test reaction pads. Note complex algorithms that convert the relationship to a linear
that this is possible only when reagent strip results are inter- one and to obtain a semiquantitative analyte value for each
preted using an automated instrument. Consequently, depend- reaction pad on the test strip.
ing on the intended use—manual or automated—reagent strips
with or without a color compensation pad are available.
Semiautomated Chemistry Analyzers
Principle of Reflectance Photometry The term semiautomated urinalysis indicates that an analyzer
Reflectance photometry quantifies the intensity of the colored is used to interpret the commercial reagent strip results of urine
product produced on the reagent strip reaction pads. When when the chemical examination is performed. The term semi-
light strikes a matte or unpolished surface (e.g., a reagent strip), automated indicates that the user performs the remaining steps
some light is absorbed, and the remaining light is scattered of the urinalysis—physical examination of color and clarity, as
or reflected in all directions. The scattered light is known as well as the microscopic examination, if performed.
diffuse reflectance. In reflectance photometers, the incident Numerous reagent strip manufacturers are located world-
light is usually of one or more wavelengths, whereas only wide, and many market a reflectance photometer for use with
reflected light of a single, specific wavelength is detected. their reagent strips. Urine chemistry analyzers commonly
These photometers are calibrated using reflectance standards used in the United States are listed in Table 16.1. Several semi-
such as magnesium carbonate or barium sulfate that automated instruments are shown in Figs. 16.1 through 16.3.
“completely” reflect all incident light. Because the potential All instruments are user friendly and include various display
colors that develop on each reaction pad dictate the wave- and audio prompts to aid in their operation. Most semiauto-
lengths of light needed for reflectance measurements, each mated systems require the user to (1) press a button to ready
reflectance photometer must have a way of selecting the appro- the analyzer for analysis, (2) properly dip the reagent strip
priate wavelength for each test pad. To obtain the desired into a suitable urine sample, (3) blot the strip to remove excess
wavelength, reflectance photometers use (1) polychromatic urine, and (4) place the strip onto an intake platform.
light and a series of filters to isolate specific wavelengths or A microprocessor controls the remaining aspects of testing:
(2) a series of monochromatic light sources (e.g., light-emitting It mechanically moves the strip through the instrument.
diodes [LEDs]). At the appropriate timed interval, reflectance readings are

TABLE 16.1 Selected Urine Chemistry Analyzers

Manufacturer Analyzer Type and Features
Arkray Inc., Kyoto, Japan Diascreen 50 • Semiautomated
AUTION MAX AX-4280, AX-4030 • Fully automated
• Color (light transmittance), clarity (light scatter), specific
gravity (refractive index)
Iris Urinalysis-Beckman iChem 100 • Semiautomated
Coulter, Inc., Brea, CA iChem Velocity • Fully automated
• Color (light transmittance) and clarity (light scatter),
specific gravity (refractive index)
Roche Diagnostics, URISYS 1100, 1800, COBAS u411 • Semiautomated
Indianapolis, IN URISYS 2400 • Fully automated
• Color (reflectance photometry), clarity (turbidimetry),
specific gravity (refractive index)
Siemens Healthcare Clinitek 50, 100, 200, 200 +, 500, • Semiautomated
Diagnostics Inc., Deerfield, IL Status, Advantus
Clinitek ATLAS • Fully automated
• Color (reflectance photometry), clarity (light scatter),
specific gravity (refractive index)
 CHAPTER 16 Automation of Urine and Body Fluid Analysis 341

TABLE 16.2 Typical Features of

Semiautomated Urine Chemistry Analyzers
Tests Blood, leukocyte esterase, nitrite, protein,
performed glucose, ketone, bilirubin, urobilinogen,
pH, specific gravity
Measurement Intensity of color on reagent strip pads
principle measured by reflectance photometry;
automatic adjustments made for urine
color
Sample User manually dips and places strip onto
handling instrument platform
Sample ID User manually enters, uses a barcode
entry reader, or downloads from LIS
Results Printout and on-board data storage; can
interface to LIS
Color and clarity can be manually entered
to be included on report and printout.
FIG. 16.1 Diascreen 50 semiautomated urine chemistry Daily Clean reagent strip platform; empty used
analyzer. (Image courtesy Arkray Inc.) maintenance reagent strip container
LIS, Laboratory information system.

taken. Results are adjusted for urine color and are stored by
the microprocessor, and last, the strip is moved to a waste
container.
Patient identifiers, user identification, and the physical
parameters of the urine can be manually entered into the ana-
lyzer; a barcode reader can be used to identify specimens.
Typically, results print out, are stored within the analyzer,
or can be transmitted to a laboratory information system
(LIS). The quantity of patient and quality control results that
can be stored on-board varies with the analyzer. Table 16.2
lists some basic features of semiautomated urine chemistry
analyzers. Daily maintenance consists primarily of cleaning
the transport platform and areas in contact with the reagent
FIG. 16.2 iChem 100 semiautomated urine chemistry analyzer. strips and emptying the waste container of used reagent strips.
(Image courtesy Iris Diagnostics.)
Fully Automated Chemistry Analyzers
When using a fully automated urine chemistry analyzer, the
user simply places labeled tubes of urine into a sample rack
or carousel. Testing is initiated by pressing a button on the
instrument display or automatically with placement of a sam-
ple rack. From this point on, the instrument controls move-
ment of the specimen rack, identifies each sample, mixes it,
aspirates urine using a sample probe, and dispenses it onto
a reagent strip. At the appropriate read time, each reaction
is read using the appropriate wavelengths of light for that
specific test.
Four fully automated urine chemistry analyzers are shown
in Figs. 16.4 through 16.7. These instruments also determine
the physical characteristics of urine—color, clarity, and spe-
cific gravity (SG)—but the methods used to do so vary. To
perform urine color assessment, some manufacturers include
an additional pad on the reagent strip to determine urine
FIG. 16.3 CLINITEK Advantus semiautomated urine chemis- color by reflectance photometry; others use spectrophotome-
try analyzer. (Used with permission of Siemens Healthcare try at multiple wavelengths to assign color. Light transmit-
Diagnostics Inc.) tance or light scatter is used to determine urine clarity.
342 CHAPTER 16 Automation of Urine and Body Fluid Analysis

laboratory. They reduce observer-associated variation, reduce

the need for manual microscopy review, and offer results sim-
ilar to those of manual microscopy.1 Because uncentrifuged
urine is used, the time spent in handling and preparing con-
centrated urine sediment for manual microscopy is elimi-
nated; this also reduces exposure to potential biohazards.
Other benefits include increased standardization of the
microscopic examination, which enhances the accuracy and
FIG. 16.4 The iRICELL3000, a fully automated urinalysis sys- reproducibility (precision) of results. Second, because these
tem that combines the iChem Velocity urine chemistry ana- analyzers are usually interfaced to an LIS, manual data entry
lyzer (right) and the iQ200 microscopy analyzer (left). (Image is decreased, which reduces the potential for transcription
courtesy Iris Diagnostics.) errors. Last, significant data storage is available in some
instruments such that urinalysis results can be archived and
retrieved later for consultations, continuing education,
competency assessments, or training purposes (e.g., iQ200
analyzer).
Manufacturers use one of three technologies to perform
automated urine microscopic analysis: (1) digital flow micros-
copy, (2) flow cytometry, or (3) cuvette-based digital micros-
copy.1 The first two of these technologies are available on
instruments worldwide, whereas the third technology is cur-
rently unavailable in the United States (i.e., not approved by
the FDA as of this writing).
Iris Diagnostics-Beckman Coulter, Inc. (Brea, CA) was the
pioneer in urine microscopic instrumentation, introducing
FIG. 16.5 AUWi, a fully automated urinalysis system that com- the Yellow Iris in the 1980s; its most recent instrument is
bines the Siemens CLINITEK Atlas chemistry analyzer (right) the Iris iQ200 microscopy analyzer (Fig. 16.4). This analyzer
and the Sysmex UF-1000i particle analyzer (left). (Used with is based on digital flow microscopy (also called flowcell digital
permission of Siemens Healthcare Diagnostics Inc.) imaging) followed by urine particle recognition using propri-
etary neural network software. The iQ200 uses patented tech-
nologies to capture and automatically classify digital images
of urine particles as they pass through a flowcell.
Urine microscopy analyzers of the second type use flow
cytometry to identify and categorize the particles in urine. The
UF-1000i analyzer and its predecessor, the UF-100 analyzer,
were developed by Sysmex Corporation (Mundelein, IL)
(Fig. 16.5). The AUTION HYBRID was recently introduced
by Arkray, Inc. (Kyoto, Japan) (Fig. 16.6). In these flow
cytometers, urine particles are identified and categorized based-
on forward scatter, fluorescence, and adaptive cluster analysis.2,3
The third technology used to perform automated urine
FIG. 16.6 The AUTION HYBRID integrated urinalysis analyzer; microscopic analysis is automated cuvette-based digital
the chemistry and microscopy analyzers are housed together microscopy developed by 77 Elektronika (Budapest, Hungary)
in a single instrument. Sediment analysis is performed using (Fig. 16.7). The analyzer takes digital images of entire micro-
flow cytometry. (Image courtesy Arkray Inc.) scopic fields of view of urine sediment on the bottom of a
cuvette, after which proprietary software identifies and clas-
sifies the urine sediment components.
Despite the universal availability of an SG reagent strip test,
most fully automated chemistry analyzers use refractive index iQ200 Urine Microscopy Analyzer
because of its greater accuracy. A microprocessor collates all The iQ200 Microscopy Analyzer can be purchased as a stand-
results—color, clarity, SG, and chemistry tests—which are alone instrument. It is an automated system that performs the
sent to data storage but are also printed on a report form microscopic examination of urine, as well as cell counts on
or are sent to an LIS. body fluids (see “Automation of Body Fluid Analysis” later
in this chapter).
Automated Microscopy Analyzers Before the aspiration of 1 mL of urine, the analyzer mixes
Automated urine sediment analyzers assist in decreasing the sample. The aspirated urine is immediately sandwiched
labor costs and increasing productivity in the urinalysis within a special fluid called lamina (iQ Lamina, Iris
 CHAPTER 16 Automation of Urine and Body Fluid Analysis 343

FIG. 16.7 The LabUMat 2 chemistry analyzer (right) and the UriSed 2 microscopy analyzer (left), a
fully automated urinalysis system. (Image courtesy 77 Elektronika.)

Diagnostics) that flows through a proprietary flowcell. The Subclassification is used to indicate the specific types of crys-
lamina and the flowcell are key to hydrodynamically orienting tals, casts, and nonsquamous epithelial cells present, as well as
the particles in the urine. The flow path is at a specific depth of to identify pseudohyphae, trichomonads, or fat (Fig. 16.10).
focus that enables precise microscopic viewing. The field of Additional free text comments can be added to reports as
view of the microscope is coupled to a digital video camera, needed, such as “Ascorbic acid positive” or “Presence of fat
and stroboscopic illumination freezes the particles in motion confirmed.”
as they stream past, which ensures blur-free imaging. With The average time required for an experienced user to
each sample, the camera captures 500 frames, digitizes them, review urinalysis results from a single urine sample is approx-
and sends them to a computer for processing (Fig. 16.8). Note imately 30 seconds. However, laboratories can select their
that the individual particles within each of the 500 frames are own auto-release criteria. When urinalysis results do
isolated as separate images, and the Auto-Particle Recogni- not exceed these criteria, the results do not require review
tion (APR; Iris Diagnostics) software classifies each image and are automatically sent to the LIS. Results that exceed
(Fig. 16.9). user-defined values are available at any time for the user to
The APR software is a highly trained neural network that review, subclassify, and forward to the LIS. Therefore the
uses size, shape, contrast, and texture to automatically classify number of reports that actually require user review will vary
each image into one of 12 categories (Table 16.3). Next, the with the auto-release criteria selected by the laboratory and
APR software calculates the concentration of each particle with its patient population.
present. The results obtained for each sample are compared
to user-defined auto-release criteria, and if the criteria are
met, results can be sent to the LIS. If the criteria are not Sysmex UF-1000i and AUTION HYBRID Flow Cytometers
met, or if the option to auto-release reports to the LIS is The UF-1000i and the AUTION HYBRID are instruments
not used by the laboratory, the results are stored and the user that use flow cytometry to categorize particles in urine on
can review them at any time on the computer monitor. the basis of their size, shape, volume, and staining character-
Using the computer monitor, the user can review results, istics.2,3 Both systems use polymethine dyes and a separate
visually assess the particles present, and subclassify them channel for bacterial analysis, which improves detection of
into the 26 additional categories, as listed in Table 16.3. bacteria.

Urine sample

Lamina

Microscope CCD
objective camera

Collector Ocular
Strobe Flow cell
light Computer
Waste
FIG. 16.8 Diagram of the iQ200 digital flow capture process. (Image courtesy Iris Diagnostics.)
344 CHAPTER 16 Automation of Urine and Body Fluid Analysis

(RBCs), WBCs, epithelial cells (squamous), hyaline casts,

or bacteria (Table 16.4). Note that the analyzer “flags” spec-
imens when it detects the presence of the following particles:
casts (other than hyaline), crystals, yeast-like cells, mucus,
small round cells (i.e., transitional or renal cells), or sperm.
Determining the specific identity of elements in “flagged”
specimens requires a manual microscopic review of the
urine by the user. In other words, to classify nonhyaline casts
(granular, cellular, RBC, WBC, crystalline), identify crystals
(e.g., calcium oxalate, uric acid, cystine), identify yeast, and
FIG. 16.9 Auto-Particle Recognition (APR) process. (Image categorize the particles identified as small round cells as
courtesy Iris Diagnostics.) transitional cells, renal cells, or another small particle, a
manual microscopic examination is required. In addition,
studies using the flow cytometry have identified an issue
with false-positive results for RBCs caused by crystals, yeast,
For automated particle analysis, the analyzers require a and sperm, or during analysis of urine samples transported
sample volume of 4 to 5 mL; however, if the instruments in preservative tubes, such as BD Vacutainer Plus UA Pre-
are used in the manual mode, only about 1 mL of urine is servative tubes (BD, Franklin Lakes, NJ), BD C&S Preserva-
required for microscopic analysis. After aspiration into the tive tubes, and Greiner Stabilur Preservative tubes (Greiner
analyzer, the urine sample is divided into two channels Bio-One N.A., Inc., Monroe, NC).1,3–6 Large quantities of
because the diluent, the staining time, and the staining tem- amorphous precipitates in refrigerated urine specimens
perature for sediment analysis differ from those used for bac- can also present a challenge.
terial analysis. Urine particles are oriented into a single file by Results from the UF-1000i can be electronically linked to
flowcell and laminar flow dynamics. As each channel passes those from a urine chemistry analyzer to obtain an integrated
through the flowcell, it is analyzed by a single red semicon- urinalysis report. The AUTION HYBRID is unique in that
ductor laser (λ635 nm), and particles in the urine are catego- it is an integrated analyzer, that is, the chemistry and micros-
rized on the basis of (1) forward scatter, (2) fluorescence copy analyzers are contained within a single unit; therefore
staining characteristics, (3) impedance signals, (4) adaptive chemistry and microscopic result reporting is also integrated.
cluster analysis, and (5) side scatter, which is specific for With both systems, user-defined criteria can be adjusted to
detection of bacteria (Fig. 16.11). reduce the review rate of specimens and increase productivity.
As with all flow cytometry systems, results are displayed When the analyzers are interfaced to an LIS, results can be
as scattergrams (Fig. 16.12). The UF-1000i and AUTION compared to user-defined auto-release criteria and reported,
HYBRID are able to report particles as red blood cells or they can be held for review and follow-up.

TABLE 16.3 iQ200 Autoclassification and Subclassification Categories for Urine Sediment
Particles
Blood Cells Crystals Casts Epithelial Cells Yeast Others
Autoclassified RBCs Unclassified Hyaline Squamous Budding yeast Bacteria
by analyzer WBCs crystals* Unclassified Nonsquamous† Mucus
WBC clumps casts* Sperm
Subclassified RBC clumps Amporphous Granular Transitional Yeast with Trichomonads
by user Calcium carbonate Cellular Renal pseudohyphae Fat
Calcium oxalate Waxy Oval fat
Calcium phosphate Broad bodies
Triple phosphate RBCs
Uric acid WBCs
Cystine Epithelial cells
Tyrosine Fatty
Leucine Unclassified
Unclassified casts
crystals
RBCs, Red blood cells; WBCs, white blood cells.
*
Unclassified crystals and casts can be reported as such, or user can specifically subclassify by type.
†
Nonsquamous epithelial cells can be reported as such, or user can specifically subclassify as transitional or renal.
 CHAPTER 16 Automation of Urine and Body Fluid Analysis 345

Forward scatter
signal amplifier

Fluorescence
Red signal amplifier
semiconductor
laser

Side scatter
Sheath reagent signal amplifier
Conductivity
sensor
Dilution and staining Dilution and staining
A for bacteria analysis for sediment analysis

Urine sample

FIG. 16.11 Diagram of urine particle analysis in the Sysmex

UF-1000i. (Image courtesy Sysmex Corporation, Mundelein, IL.)

urine particles into a single focal plane on the bottom of the

cuvette. Next, the cuvette is pushed onto the microscopic plat-
form where a focusing procedure is performed. The analyzer
takes digital images of 15 brightfield, high-power–like fields of
view that correspond to approximately 10 manual micros-
B copy fields. Using these gray-scale, high-resolution digital
FIG. 16.10 Displays of iQ200 urinalysis results. A, On-screen images, the Auto Image Evaluation Module (AIEM; 77 Elek-
review of iQ200 results. The results for this sample did not tronika Kft.) software automatically locates, identifies, labels,
auto-release because the amount of some microscopic ele- and classifies the urine particles.
ments resided in the “Particle Verification Range” set by the The computer screen displays specimen results in a tabular
user. These results appear “yellow” and require review as form—quantitative concentration values and semiquantita-
established by this laboratory. Results that appear “green” are tive categories (Fig. 16.14). In addition, the 15 FOV images
in the normal range, and those that appear “red” are considered can be accessed and displayed individually at any time. Note
abnormal but do not need verification (as established by the
that the user establishes the number of images to be taken (5,
user-defined criteria). When no yellow results are present,
results can be automatically released without review or verifica-
10, 15, 20 images), with 15 being the standard protocol. User-
tion. B, On-screen display of automatically classified images of defined criteria can be applied to allow automatic release of
budding yeast (BYST). (Image courtesy Iris Diagnostics.) results to an LIS or to hold samples for user review and
follow-up. Last, the used cuvette is dropped into a waste bin.
The AIEM automatically classifies identified particles
77 Elektronika UriSed Analyzer into 15 categories, and 28 additional categories are available
The UriSed analyzer is a cuvette-based technology (CBM) for manual subclassification or addition by the user (see
that is essentially automating a traditional manual micros- Table 16.5). Because the digital images contain the whole field
copy process. Urine samples (2 mL, minimum volume) are of view, the context or environment of the entire urine sedi-
poured into tubes that can be barcoded for identification ment is observable (i.e., no content is cropped). Hence review-
and placed into a sample rack. The analyzer moves the sample ing the images resembles performing a manual microscopic
racks and each specimen tube into position for sampling. A evaluation. When each square-shaped FOV is viewed, the urine
sample probe mixes the urine sample and then aspirates particles that were recognized are labeled on the image. The
and dispenses 200 μL of urine into a proprietary cuvette computer has digital zooming capability, which enables a closer
(Fig. 16.13). Note that the probe is washed after each sam- look at any specific particle or area of an image (Fig. 16.15).
pling, which eliminates the potential for carry-over between Users can easily edit (correct, subclassify) or add additional
specimens.7 The loaded cuvette is automatically inserted into findings, if desired. The computer database stores all images
a unique onboard mini-centrifuge that centrifuges the sample and statistical data, which can be later referenced, used for
at 260 g for 10 seconds. This centrifugation step moves all the training, or used for continuing education purposes.
346 CHAPTER 16 Automation of Urine and Body Fluid Analysis

S FSC

RBC
WBC

YLC
Bacteria

FIG. 16.13 Cuvette used by the UriSed 2 automated urine sed-

iment analyzer. (Image courtesy 77 Elektronika Kft.)
A S FLH

EC

WBC
C
YL
S FSC

Bacteria
B S FLL
FIG. 16.12 Sysmex UF-1000i urine particle results. A, Scatter-
gram of forward scatter (S_FSC) versus fluorescent light
intensity-high sensitivity (S_FLH). B, Scattergram of forward
scatter (S_FSC) versus fluorescent light intensity–low sensitiv-
ity (S_FLL). EC, Epithelial cells; RBC, red blood cells; WBC, FIG. 16.14 Computer display of tabular sediment results using
white blood cells; YLC, yeastlike cells. (Images courtesy the UriSed 2. The quantitative concentration values and semi-
Sysmex Corporation, Mundelein, IL.) quantitative results determined from the digital images are
available for user review. (Image courtesy 77 Elektronika Kft.)

TABLE 16.4 UF-1000i Particle Detection

Categories approved as of this writing). Fully automated urinalysis sys-
Particles Enumerated Flagged Particles tems automatically identify and process each barcoded sam-
RBCs Nonhyaline (pathologic) casts* ple tube according to the tests requested in the LIS. These
WBCs Crystals* systems are flexible and user-friendly. Urine specimens
Epithelial cells Small round cells* can undergo physical and chemistry testing only, microscopy
Hyaline casts Yeast
testing only, or both (i.e., complete urinalysis). After analysis,
a computer system integrates the physical, chemical, and
Bacteria Mucus
microscopic results to create a urinalysis report that can be
Sperm
sent to the LIS and printed.
RBCs, Red blood cells; WBCs, white blood cells.
*
Manual microscopic examination by user is required to specifically iRICELL Urinalysis Systems
identify and categorize the type present.
The iRICELL Automated Urinalysis Systems (iRICELL3000,
iRICELL2000) (Iris Diagnostics) consists of the iChem Veloc-
Fully Automated Urinalysis Systems ity urine chemistry analyzer used with the iQ200 (Fig. 16.4).
A variety of fully automated urinalysis systems are now Before the iChem Velocity, the iQ200 was available in combi-
available worldwide, and some of them are listed in nation with the AUTION MAX AX-4280 chemistry analyzer.
Table 16.6. Note that the LabUMat 2/UriSed 2 combination To perform a complete urinalysis, a minimum of 3 mL urine is
is currently not available in the United States (i.e., not FDA poured into a barcode-labeled tube. Specific tubes are not
 CHAPTER 16 Automation of Urine and Body Fluid Analysis 347

TABLE 16.5 UriSed Autoclassification and Subclassification Categories for Urine Sediment
Particles
Blood Cells Crystals Casts Epithelial Cells Yeast Others
Autoclassified Red blood Crystals* (CRY) Hyaline (HYA) Squamous (EPI) Yeast (YEA) Bacteria (BAC)
by analyzer cells (RBC) Calcium oxalate Pathologic* (PAT) Nonsquamous† Mucus (MUC)
White blood monohydrate (NEC) Sperm (SPRM)
cells (WBC) (CaOxm)
White blood Calcium oxalate
cell clumps dihydrate
(WBCc) (CaOxd)
Triple phosphate
(TRI)
Uric acid (URI)
Subclassified or Isomorphic Amorphous Hyaline granular Superficial Fat globules
added by user RBC (RBCi) phosphates (C-HGR) transitional • Lipid droplets—
Dysmorphic (P-AMO) Granular (C-GRA) (s-TRA) neutral fat
RBC (RBCd) Amorphous urates RBC (C-RBC) Deep (LDR)
Acanthocyte (U-AMO) WBC (C-WBC) transitional • Cholesterol
RBC (RBC- Atypical crystals Mixed (C-MIX) (d-TRA) (CHOL)
G1) (ATY) Nonsquamous Renal (REC) Oval fat bodies
Other RBC Calcium oxalate epithelial cell (REN-L)
(RBC-Oth) (CaOx) (C-NEC) Trichomonas
Calcium Fatty (C-FAT) vaginalis (TRV)
phosphate Waxy (C-WAX) Schistosoma
(CaPh) Cast with crystals haematobium
Cystine (CYS) (C-CRY) (SCH)
Leucine (Leu) Cast with Artifacts (ART)
Tyrosine (TYR) microorganisms
(C-MIC)
RBCs, Red blood cells; WBCs, white blood cells.
*
Crystals (CRY) and pathologic casts (PAT) can be reported as such, or user can specifically subclassify by type.
†
Nonsquamous epithelial cells (NEC) can be reported as such, or user can specifically subclassify as transitional or renal.

TABLE 16.6 Fully Automated Urinalysis

(UA) Systems
Fully Automated Chemistry Microscopy Analyzer
UA System Analyzer and Technology
iRICELL3000, iChem iQ200,* digital flow
2000, 1500* Velocity* microscopy
CLINITEK AUWi CLINITEK UF-1000i,§ flow
Work Cell Atlas{ cytometry
System{
AUTION HYBRID† AU-4050† (chemistry and microscopy
components are integrated into a
single analyzer); flow cytometry
LabUMat 2 with LabUMat 2¥ UriSed 2,¥ cuvette-
FIG. 16.15 Computer display of a single image taken during UriSed 2¥ based digital
sediment analysis using the UriSed 2 analyzer; typically 15 microscopy
high-power–like images are taken. All particles recognized *
Manufactured by Iris Urinalysis-Beckman Coulter, Inc., Brea, CA.
and enumerated by the Auto Image Evaluation Module (AIEM) †
Manufactured by Arkray Inc., Kyoto, Japan.
are labeled on the image. Note that digital zooming enables a {
Manufactured by Siemens Healthcare Diagnostics Inc., Deerfield, IL.
§
closer look at specific components or an area of the FOV. Manufactured by Sysmex Corporation, Mundelein, IL.
¥
(Image courtesy 77 Elektronika Kft.) Manufactured by 77 Elektronika, Budapest, Hungary.
348 CHAPTER 16 Automation of Urine and Body Fluid Analysis

required; a variety of tubes can be used, including commercial It is important to note that in different parts of the world
urinalysis tubes (e.g., KOVA, Vacuette, BD) or disposable glass UriSed technology is also available that is configured to urine
test tubes (e.g., 16 " 100 mm). The tubes of urine are placed chemistry analyzers from other manufacturers. These combi-
into racks (10-position) that are loaded directly onto the sys- nations provide a variety of fully automated urinalysis systems.
tem and sequentially moved to the first sampling station at For example, the UriSed technology analyzer is called the Sedi-
the iChem Velocity. The identity of each sample is determined Max2 when connected to the AUTION MAX (Arkray, Inc.,
by reading the tube’s barcode label, the sample is mixed, and Kyoto, Japan) and the COBIO XS when connected to the
the urine is aspirated. After physical and chemical analyses, CombiScan XL (Truth Enterprise Inc., Shanghai, China).
the rack moves across a connecting bridge to the iQ200 for
microscopic analysis.
AUTOMATION OF BODY FLUID ANALYSIS
CLINITEK AUWi System Analysis of body fluids by manual hemacytometer methods is
The CLINITEK AUWi System uses an ATLAS urine chemistry an ongoing challenge in clinical laboratories because these
analyzer connected to a UF-1000i flow cytometer to perform analyses are time-consuming to perform, require skilled per-
fully automated urinalyses (see Fig. 16.5). For a complete sonnel, show high interoperator variability, and are plagued
urinalysis, 5 mL of uncentrifuged urine is poured into a by low precision (reproducibility). In contrast, automation
barcode-labeled tube, which is placed into a 10-place sample offers better precision and turnaround times. However, body
rack. Tubes up to 16 mm wide can be used, but they must be fluids with low cell counts (<30 cells/μL) present a challenge
“lipless” for 10 samples to fit in a rack. The sample racks are for automated systems. Despite this issue, automated ana-
placed onto the system, and as each rack is moved to the sam- lyzers could be used as a first step in triaging specimens
pling position of the ATLAS analyzer, the barcoded sample (i.e., identifying those with low cell counts that require a man-
tube is automatically identified. After physical and chemical ual hemacytometer count).
testing, the sample racks move by way of an interconnecting Note that despite the advantages of better precision,
bridge between the instruments, from the ATLAS analyzer reduced interoperator variation, and shorter turnaround
to the UF-1000i for particle analysis. time, some issues with automated analyzers remain. For
example, these analyzers cannot identify malignant cells.
AUTION HYBRID System Therefore any fluid that could potentially have malignant cells
The AUTION HYBRID System is the only integrated urinal- present should have a manual WBC differential performed
ysis system currently available, and because of this combina- using a stained cytospin preparation. Three analyzers that
tion, the analyzer has the smallest footprint, or space needed have been designed to perform body fluid cell counts are listed
(see Fig. 16.6). This system combines the AUTION MAX in Table 16.7. Note that it is the manufacturer’s responsibility
(AU-4030, AU-4280) urine chemistry technology with a flow
cytometer for urine sediment analysis. To complete a full
urinalysis, 5 mL of uncentrifuged urine is poured into a bar- TABLE 16.7 Selected Automated Body
coded sample tube and placed into a 10-position sample rack. Fluid Analyzers
The rack is loaded onto the analyzer and is automatically
Body Fluids
moved into position for sampling. The analyzer has dual sam-
Analyzer (FDA approved, USA)
ple probes; one probe takes a sample to the chemistry module
for physical (color, turbidity, specific gravity) and chemical ADVIA 2120i with Body Fluid Cerebrospinal fluid (CSF)
Software Pleural
(reagent strip) testing. The second probe aspirates the sample
Peritoneal
into the flow cytometry module for sediment analysis. After Peritoneal dialysate
testing, the sample rack proceeds to the other side of the ana- Serous fluids
lyzer for off-loading. iQ200 using Body Fluid CSF
Module Pericardial
LabUMat 2 with UriSed 2 System Peritoneal
Combining the LabUMat 2 automated urine chemistry ana- Peritoneal dialysate
lyzer (77 Elektronika, Budapest, Hungary) with the UriSed 2 Peritoneal lavage
automated urine sediment analyzer provides a fully automated Pleural
urinalysis system (see Fig. 16.7). As with other systems, bar- Serous fluids
coded tubes with urine are loaded into 10-position sample Synovial
racks. The physical (color, turbidity, specific gravity) and Sysmex XE-5000 using Body CSF
reagent strip tests (10 parameters) are completed by the chem- Fluid mode Pleural
istry analyzer (LabUMat 2); then the sample racks are trans- Pericardial
ferred across a connecting bridge to the urine sediment Peritoneal
Peritoneal dialysate
analyzer (UriSed 2). A complete urinalysis requires 3 mL of
Serous fluids
uncentrifuged urine, and a liquid level sensor ensures adequate Synovial
urine volume before analysis begins.
 CHAPTER 16 Automation of Urine and Body Fluid Analysis 349

to have an intended use statement that clearly defines which and (2) identify possible interference from large cells. In addi-
body fluids have been approved by a regulatory agency for tion, when the WBC count is below 10 " 106 cells/L, differen-
testing.8 Similarly, it is the laboratory’s responsibility to define tiation between PMNs and mononuclear cells (MNCs) should
the lower limits for cell counting and to clearly state when not be done.11
fluids must be analyzed by an alternate method (e.g., hema-
cytometer count).8 Body Fluid Cell Counts Using iQ200
The method of cell measurement used by the iQ200 differs
Body Fluid Cell Counts Using from that used on hematology analyzers. The iQ200, an auto-
Hematology Analyzers mated microscopy analyzer primarily used to analyze cells
Many hematology analyzers have been used to perform body and other particles in urine, can also be used to perform body
fluid cell counts; although they improve precision and turn- fluid cell counts (see Table 16.7). However, its use requires the
around time, problems have been encountered. Some of these purchase of the Body Fluid software module. In contrast to
problems occur because the matrix of body fluids differs from hematology analyzers, body fluid analysis on the iQ200 can
that of whole blood. Other problems are due to interference be performed at any time without prior cleaning or prepara-
by large cells (mesothelial cells, macrophages, tumor cells) tion of the instrument.
or noncellular particulate matter that can be present in body When the iQ200 is used, body fluids are diluted on the
fluids. Last, most hematology analyzers based on impedance basis of the fluid type (e.g., CSF, serous) and its appearance
technology have high background counts that prevent or hin- (e.g., clear, bloody). Two dilutions are made in tubes: one
der accuracy in detecting low cell counts in body fluids (e.g., using Iris diluent, the other using Iris RBC lysing reagent.
cerebrospinal fluid [CSF]). Precleaning the instrument may Note that these tubes are labeled with dilution-specific bar-
be required before body fluid analysis can be performed. codes, which enable automatic calculation of cell counts by
One modification made for analyzing body fluids is that the instrument based on the dilution prepared. The labeled
the duration of the cell count has been increased. This results tubes are placed in a sample rack and onto the instrument
in a higher number of cells counted and a concomitant for analysis. The total cell count is determined using the dilu-
increase in precision. Two hematology analyzers have been tion prepared with iQ diluent (unlysed), whereas the nucle-
specifically modified to enhance body fluid cell counts: the ated cell count is determined using the dilution prepared
ADVIA 2120i (Siemens Healthcare Diagnostics Inc., Deer- with the lysing agent. The difference between these two values
field, IL) and the Sysmex XE-5000 (Sysmex Corporation, (Total cell count # Nucleated cell count) is the RBC count.
Mundelein, IL). When the iQ200 is used, the same digital flowcell imaging
Before CSF is analyzed using the ADVIA 2120i, the CSF technology used for urine applies to body fluid analysis (see
sample must be pretreated for a minimum of 4 minutes using “iQ Microscopy Analyzer”). Numeric results and digital cell
a special CSF reagent. This reagent fixes and converts RBCs to images are displayed for verification and manual editing, if
spheres.9 For body fluid applications, the analyzer uses the desired.
basophil/lobularity channel, the peroxidase channel, and
the RBC/platelet channel to determine the total nucleated cell REFERENCES
count (TNC), the WBC count, and the RBC count, respec-
tively.10 Numeric data and scattergram results are provided. 1. Budak YU, Huysal K: Comparison of three automated systems
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2. US Food and Drug Administration 510(k) Premarket
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but are excluded from the cell counts. between the Iris iQ200 urine microscopy system, the Sysmex
Body fluid analysis using the Sysmex XE-5000 has some UF-100 flow cytometer and manual microscopic particle
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STUDY QUESTIONS
1. When semiautomated urine chemistry analyzers are used, 5. The benefits of performing automated urine microscopy
the color that develops on the reaction pads is measured by include all of the following except it
A. spectrophotometry. A. increases precision of microscopy results.
B. reflectance photometry. B. decreases exposure to urine, a potential biohazard.
C. fluorescence photometry. C. increases the time required for the microscopic
D. comparing reaction pads with a color chart. examination.
2. What is the purpose of the color compensation pad on D. decreases manual entry and potential transcription
reagent strips? errors.
A. To compensate for the effect of specific gravity on 6. Which of the following statements about the iQ200
urine color microscopy analyzer is true?
B. To calibrate the instrument for color assessment of A. Particle analysis is performed using flow cytometry.
reaction pads B. Urine particles are automatically classified into 12
C. To account for the contribution of urine color to the categories.
colors on the reaction pads C. Concentrated urine sediments must be prepared
D. To detect substances (e.g., phenazopyridine) that before analysis by the analyzer.
mask color development on the reaction pads D. It cannot be used as a stand-alone instrument (i.e., it
3. Select the true statement regarding reflectance photometry. must be attached to a urine chemistry analyzer
A. The amount of light that is absorbed is detected and for use).
measured. 7. Which of the following statements about the UF-100 and
B. The same wavelength of light is used to evaluate all UF-1000i urine particle analyzers is true?
reaction pads. A. A separate channel is used to detect bacteria.
C. The intensity of light reflected from a polished surface B. Digital images of each urine particle are available for
is quantified. review and archival storage.
D. The relationship between reflectance and concentra- C. The analyzers can specifically identify pathologic casts
tion is not linear. and renal epithelial cells.
4. Select the true statement regarding semiautomated urine D. Impedance technology is the primary method by
chemistry analyzers. which these analyzers detect and categorize particles.
A. Results cannot be automatically transmitted to 8. Which of the following statements is not an issue for the
an LIS. instruments used to perform body fluid analysis?
B. Specific gravity is usually determined by refractive A. Unable to perform five-part WBC differentials
index. B. Have difficulty detecting and enumerating RBCs
C. Urine color and clarity are manually determined and C. Unable to detect and specifically identify malignant
entered into the analyzer. cells
D. Well-mixed uncentrifuged urine is placed onto the D. Unable to perform accurate and precise counting of
intake platform for analysis. low WBC numbers (<20 cells/μL).