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Aims of the Guidelines on Urinary Sediment Examination Procedures Proposed by the Japanese Committee for Clinical Laboratory Standards (JCCLS)

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Aims of the Guidelines on Urinary Sediment Examination Procedures Proposed by the Japanese Committee for Clinical Laboratory Standards (JCCLS) Part 1 Aims of the Guidelines on Urinary Sediment Examination Procedures Proposed by the Japanese Committee for Clinical Laboratory Standards (JCCLS) Japanese Association of Medical Technologists; Editorial Committee of the Special Issue: Urinary Sediment 1) 1) Japanese Association of Medical Technologists (4-10-7, Omori-kita, Ota-ku, Tokyo 143-0016, Japan) Summary Among clinical laboratory tests, urine testing has a particularly long history, and it continues to serve as an important screening test for kidney, urinary tract, and systemic diseases. Urine testing can accurately detect five abnormalities of urine, i.e., (1) pyuria, (2) bacteriuria, (3) hematuria, (4) proteinuria, and (5) metabolically abnormal urine (e.g., crystalluria, glycosuria). Urinary sediment examination is a morphological examination that accurately identifies and roughly counts urine formed elements, i.e., epithelial cells, blood cells, casts, salts/crystals, and bacteria, to provide information for detecting any pathological condition accompanying urine abnormalities in combination with qualitative urinary test findings. For urinary sediment examination procedures in Japan, the Japanese Committee for Clinical Laboratory Standards (JCCLS) proposed guidelines on urinary sediment examination procedures, namely GP1-P3 (urinary sediment examination procedures 2000), in 2000, and the revised version, named GP1-P4 (urinary sediment examination procedures 2010), was released in 2010. In this part, we outline the urinary sediment examination procedures according to GP1-P4 (with some modifications). Key words urinary sediment examination, urine collection method, specimen preparation, microscopic examination 2. Precautions during urine collection I Urine Collection It is desirable to note the following points in order to report accurate results of urinary sediment examination. 1. Types of urine specimens 1) First morning and mid-stream voided specimens are Urine specimens are classified by time or type of suitable for urinary sediment examination; thus, the collection (Table 1.1). patients should be given necessary instructions. Table 1.1 Types of urine specimens Classification by time of collection Classification by type of collection 1) Morning urine: the first urine voided in the morning 1) Natural urine: urine voided naturally 2) Spot urine: any daytime urine specimen except the morning urine (1) Total urine: urine completely collected in one natural voiding 3) Post-loading urine: (2) Partial urine: part of a single natural urine voiding: (1) after exercise (i) first urine: the first part of voided urine (2) after prostatic massage etc. (ii) midstream voided urine: collected during voiding but excluding 4) 24-h urine: in principle, 24-h storaged specimens should not be used the first and last parts for urinary sediment examination. 2) Catheter urine: urine collected with a urethral catheter 3) Bladder puncture urine: urine collected by aspirating urine from a distended bladder through the anterior abdominal wall 4) Double voided urine: urine from a single voiding but dividing the specimen in accordance with the testing purposes 5) Others: urine sampled after urinary diversion surgery, e.g., ileal conduit surgery 医学検査 Vol.66 No.J-STAGE-1 尿沈渣特集 2017 9 2) Clearly document the type of specimen and collection 2. Centrifugation method (e.g., natural urine, catheter urine). 1) Centrifugation tube: Use a sharp, pointed (spitz-type) 3) It is desirable to clean the urethral meatus before centrifugation tube accurately graduated at 10 and collecting urine. In particular, in case of a female, 0.2 mL. It is desirable that the tube is composed of guidance on urine collection, including the use of a transparent polyacrylic styrene. cleaning procedure, should be given to prevent the 2) Urine volume: A volume of 10 mL is recommended specimen from being contaminated by components in principle. Even if the available urine volume is from the vulva (e.g., red blood cells, white blood lower than recommended, perform the test whenever cells, squamous epithelial cells, bacteria). possible. The use of a short sample should be recor- 4) Add formalin in a ratio of 1.0 mL per 100 mL of ded. urine as a preservative if preservation is particularly 3) Centrifuge: This should be of the swing-type and not needed. Glutaraldehyde is a preferred choice for the angle-type. sediment fixation. 4) Conditions of centrifugation: Centrifugation tubes 5) In principle, the time of urine collection should be must be placed in the centrifuge in a manner such noted. that horizontal balance is maintained during opera- 6) Quickly examine the submitted urine specimens tion. The centrifuge must be allowed to stop naturally within no more than 4 h after collection. The duration before attempting to remove any centrifugation tubes. of storage affects urine properties differently between (1) A relative centrifugal force (RCF) of 500 × g is specimens. After prolonged storage, red blood cells, recommended. Because the RCF at a given num- white blood cells, epithelial cells, and casts tend to ber of rotations varies with the size (radius) of decrease in number, whereas the number of bacteria the centrifuge, the number of rotations for each and yeast tend to increase. centrifuge should be calculated using the follow- 7) Specimens collected from females during menstru- ing formula: ation are not appropriate for testing. In cases of RCF (g) = 11.18 × (rpm/1,000)2 × R absolute necessity, the specimens should be labeled rpm: rotations per minute as such. R: radius, i.e., the distance (cm) 3. Urine collection containers from the center of the centrifuge 1) Collection containers should be made of resin- spindle to the bottom of the centri- precoated clean paper, polystyrene resin, plastic, or fugation tube glass. The inside of the containers should not be (2) Five minutes is the recommended duration for coated. centrifugation. 2) If only an aliquot of the specimen is to be submitted 5) Sediment volume: The supernatant urine should be for testing, the entire specimen must be mixed well removed with an aspirator or pipette or by decanta- before aliquoting. The lid must be placed on the tion to leave a sediment volume of 0.2 mL. This container. should be followed in principle because essential 3) When using urine-collecting bags (particularly for urine formed elements would be diluted if the sedi- newborns and infants), care should be taken to attach ment volume exceeds 0.2 mL. the bags properly such that urine does not leak. 3. Slide preparation for microscopy 1) Loading urine on slide: Use 75 × 26-mm glass slides. II Specimen Preparation The sediment should be mixed well using a pipette or another device to achieve uniformity while avoiding It is important to first observe and record the appear- damage to urine formed elements. Place 15 μL of the ance of urine when preparing specimens for urinary sediment on a glass slide. sediment examination. Specific points including color, 2) Applying the coverslip: Place an 18 × 18-mm cover- turbidity, hematuria, and foreign matters (e.g., feces, slip over the sediment, ensuring that the sediment is paper) is desirable to be reported as much as possible. uniformly distributed but not escaping from the edges 1. Mixing of the coverslip. Mix the urine well to achieve uniformity. 10 Part 1 Aims of the Guidelines on Urinary Sediment Examination Procedures centrifuge the resulting sample to prepare a uri- III Microscopic Examination nary sediment specimen. (2) Care should be exercised during observation of A microscope with an eyepiece with a field number = large matters, such as cells and casts, because 20 [×400 (objective lens 40×) field area is 0.196 mm2] is they tend to gather along the sides of the cover- recommended. When using lenses with different condi- slip. tions, a correction should be made according to the appli- (3) The occurrence of urinary sediments is not neces- cable information obtained from the manufacturers. sarily in parallel with findings from qualitative or 1. The order of microscopic examination semiquantitative method such as urine protein The whole field (WF) of the preparation is examined test, urine occult blood reaction, and leukocyte under a low power field (LPF), and selected fields are esterase test. Even when the sample tested nega- then examined under a high power field (HPF). tive using multi-item test strips, urinary sediment 1) LPF [×100 (objective lens 10×)] microscopic exami- examination can be useful for the differential nation diagnosis of kidney and urinary tract diseases as (1) Confirm that the urine formed elements are uni- well as systemic diseases. formly distributed. (2) If the distribution is uneven, then it is advisable to IV Identification of Urine Formed make a new preparation. However, if this is not Elements possible, then perform a microscopic examina- tion such that the mean value for the WF can be Urine formed elements are divided into components obtained. as shown in Table 1.2 according to JCCLS’s proposed (3) Note that urine formed elements tend to gather guidelines on urinary sediment examination procedures along the sides of the coverslip. GP1-P4 (2010). (4) It is advisable to diaphragm an aperture stop un- der low-power magnification to not miss hyaline V Reporting Format casts, cell aggregates, or other variables. 2) HPF [×400 (objective lens 40×)] microscopic ex- The reporting format described below is for reference. amination Different patient groups have differing requirements for It is desirable to examine 20–30 fields. The number of urine sediment reports. Where possible, the report should fields examined must be at least 10. be tailored to the individual needs in consultation with 2. Specimen observation attending physicians. 1) Microscopic examination without staining 1. Reporting non-epithelial cells/epithelial cells In principle, urine sediments should be examined Results from HPF (40×) microscopic examination without staining. should be described. 2) Microscopic examination after staining Less than 1 cell/HPF 20–29 cells/HPF Staining methods are used for the confirmation and 1–4 cells/HPF 30–49 cells/HPF identification of urine sediment components if necessary.
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