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Your Practical Guide to Urine Analysis

Siemens Healthcare Diagnostics

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Contents

Specimen Collection

History of Urine Analysis

Clinical Significance of Test Results

Specimen Collection

Factors Affecting Urine Chemistry Tests on Siemens Reagent Test Strips

Correct Technique for Visual Reading of Reagent Strip Tests

10

Test Selection Made Easy

Quality Assurance

11

Urinary Tract Infection Testing Pathway

Chemical Principles of Reagent Strip Tests

12

Services You Can Rely on for Better Patient Care

History of Urine Analysis

1500 B.C.
Egyptian writings
refer to polyuria.
700 B.C.
Hindus describe
honey urine.
400 B.C.
Hippocrates
stresses uroscopy

7th Century A.D.

Protospharius
suggests diagnosis
through urine
colour.
13th Century
A.D.
The era of the
pisse-prophet.
1674
Thomas Willis
recommends
evaporation,
distillation and
precipitation.

1673
Dekkers describes
test to detect
protein.
1827
Bright discovers
that dropsy can
be signalled by a
urine test.
1830
Routine urine
analysis consists
of:
Visual
observation
Test for protein
Test for urea.

Mid-19th Century
Heller develops
ring test for
albumin.
Bence-Jones
discovers new
protein.
Bird publishes
description of
urine crystals.
Trommer
introduces test
for glucose.

Late 19th
Century
Ehrlich devises
diazo reaction for
bilirubin.
Early 20th
Century
Folin introduces
colorimetric
method to
estimate
creatinine.
1909 Benedict
develops
qualitative/
quantitative
method to detect
sugar.

1941
CLINITEST
Reagent Tablets
introduced for the
measurement of
reducing sugars.
This test was the
forerunner of the
wide range of
convenience urine
tests made by
Siemens and used
all over the world.

Tablet Tests
1945 ALBUTEST
Reagent Tablets.
1949
HEMATEST
Reagent Tablets.
1950 ACETEST
Reagent Tablets.
1953 ICTOTEST
Reagent Tablets.

1956
CLINISTIX
Reagent Strips,
the first dip-andread test strip.
1957
ALBUSTIX and
KETOSTIX
Reagent Strip
1960s and 1970s
A range of multianalyte reagent
test strips are
developed.

1980s and 1990s

A range of
instruments for
the automated
and semiautomated
assessment of
multiple reagent
test strips are
developed, while
continually
improving the
reagent tests.

2003
The launch of
Clinitek Status. A
simple, easy to
use automated
urine testing
solution. The
Clinitek Status
provides a full
audit trail and
removes the
subjectivity of
visual testing.

Sample

Preparation

First-voided morning urine is

best for routine analysis (most
concentrated).
Void directly into clean, dry
container/bedpan.
Sterile containers are best.
Label container where
possible.

It is best to test samples

immediately. If unable to do
this, test within 4 hours. Use
uncentrifuged urine and mix
prior to testing.
OR
Refrigerate specimen
immediately at 4-8 C, and
allow to return to room
temperature before testing.

Note:
It is especially important to use
fresh urine to obtain the best
results with the tests for
bilirubin and urobilinogen, as
these compounds are relatively
unstable when exposed to
room temperature and light.
Prolonged exposure of
unpreserved urine at room
temperature may result in
microbial proliferation, with
resultant changes in pH.
A highly alkaline pH may cause
false positive results with the
protein test area. Urine
containing glucose may
decrease in pH as organisms
metabolise the glucose. Ureasplitting organisms convert urea
to ammonia, causing an
alkaline shift in pH.
Bacterial growth from
contaminating organisms may
cause positive blood reactions
from the peroxidases produced.
Red and white blood cells may
be lysed upon standing. This
will affect microscopy but NOT
the reagent strip tests.

Preservatives
Thymol a commonly-used
preservative, in amounts of
0.1 gm/dl (1 g/L) or greater, may
give false positive reactions for
albumin determinations.
Formaldehyde may give false
positive results for glucose
determinations using the
tablet test.
Hydrochloric Acid acidification
using concentrated hydrochloric
acid is recommended for 24-hour
urine collections. This is the most
frequently-used specimen for
steroid determinations, and will
also preserve cellular structures.
Boric acid is generally added for
the preservation of bacteria in
urine. However, the
concentration must not be
excessive as this will prevent
growth of bacteria during culture.
The leucocyte reagent pad may be
inhibited to varying degrees.
Please refer to the pack insert for
further information.

A properly collected urine

sample is the first stage in
the generation of quality
clinical information

Disclaimer
This is a training guide and does not replace the package insert for each test.
Prior to preparing any test, please read and operate instruments and strips according to Siemens instructions.

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Correct Technique for Visual Reading of Reagent Strip Tests

Quality Assurance

Procedure

Use Chek-STIX for checking reactivity of Siemens test strips procedure

Chek-STIX strips offer a convenient method of generating an artificial urine sample which will give a positive or negative result to all Siemens
multiple strip tests.

Always check the appearance of the urine sample as it may give useful information.
Siemens tests are scientifically designed to react progressively and produce colour changes in the case of positive reactions at the times specified. Accurate
timing is essential for reliable quantitative results.N

Chek-STIX has been developed specifically so the user can be assured of the reactivity of the reagent areas of Siemens multiple reagent strips. The
product may also be used as a check of user technique as well as an aid to teaching.

Example
Test

The control solution generated by Chek-STIX Positive solution gives results on Siemens strips in the same manner as urine specimens. If the strips
are reacting properly a positive result will be seen on each test area, with expected values as shown in the pack insert.

1. Completely immerse all

reagent areas into fresh, wellmixed, uncentrifuged urine.
Dip briefly and remove
immediately to avoid
dissolving out reagents.

Dont forget to read the

package insert carefully

2. While removing the strip, run

the edge against the rim of the
urine container to remove
excess urine. Hold the strip in
a horizontal position to
prevent possible mixing of
chemicals from adjacent
reagent areas or soiling of
hands with urine.

3. After the appropriate time,

compare test areas closely
with the corresponding colour
chart on the bottle label or
bench reader at the time
specified. Hold strip close to
colour blocks and match
carefully. Always record the
results.

4. For enhanced convenience

and standardisation, use a
CLINITEK analyser to read the
reagent strip and print the
results.

1. Place 12 ml of distilled water in test tube

provided, by filling to graduation line.
Immerse totally one Chek-STIX strip.

3. Invert tube once more. Remove and discard

Chek-STIX strip. Solution is now ready to
test reactivity of Siemens strips or user
technique.

Glucose

5.5 mmol/L

Bilirubin

Positive

Ketones

Small-Moderate

Specific Gravity

1.000 to 1.015

Blood

Moderate-Large

pH

7.0-8.0

Protein

0.3-1.0 g/L

Urobilinogen

Positive Colours may be atypical

Nitrite

Positive

Leucocytes

Positive

Expected results may

change from the above.
Always check the pack
insert

Precautions
It is important to make sure the tests are being used and stored properly.
A few precautions will ensure meaningful results for patient management.
Do not
Do

Do read package insert

carefully before testing

2. Cap tube tightly. Invert the tube gently

back and forth for
2 minutes. Allow to stand for
30 minutes.

Expected Results

Do replace cap
immediately and
close tightly

Do check expiry date on

bottle before use

Do not remove
desiccant from bottle

Do not touch test areas

of the strip

Do not take out more

strips than are required
for immediate use

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Chemical Principles Reagent Strip Tests

Glucose
Reagents
glucose oxidase;
peroxidase; potassium
iodide; buffer;
non-reactive
ingredients.

Reagents
2, 4-dichloroaniline
diazonium salt;
buffer;
non-reactive
ingredients.

Chemical Principles
The test is based on a
double sequential
enzyme reaction
utilising glucose
oxidase and
peroxidase with a
potassium iodide
Chromagen. Colours
range from green to
brown

Chemical Principles

Sensitivity /
Specificity
The test is specific for
glucose; no substance
excreted in urine other
than glucose is known
to give a positive
result.
Approximately 5.5
mmol/L of glucose is
detectable. The test is
more sensitive than
the copper reduction
test, CLINITEST, which
will detect 13.9
mmol/L (1/4%) glucose
as a trace.

Bilirubin

This test is based on

the coupling of
bilirubin with
diazonium
dichloroaniline in a
strongly acid
medium. The colour
ranges through
various shades of tan.
Sensitivity /
Specificity
Test has sensitivity of
7 to 14 mol/L
bilirubin.

Ketones
Reagents
sodium nitroprusside;
buffer
Chemical Principles
This test is based on
the development of a
pink or maroon
colour by the reaction
of acetoacetic acid
with nitroprusside.
Sensitivity /
Specificity
The test reacts with
acetoacetic acid in
urine, but does not
react with acetone or
beta-hydroxybutyric
acid. The test detects
as little as 0.5 mmol/L
acetoacetic acid.

Specific Gravity
Reagents
bromthymol blue;
poly (methyl vinyl
ether/maleic
anhydride); sodium
hydroxide.
Chemical Principles
This test is based on
the pKa change of
certain pre-treated
polyelectrolytes in
relation to ionic
concentration. In the
presence of an
indicator, colours
range from deep
blue-green through
green and yellowgreen in urines of
increasing ionic
concentration.
Sensitivity /
Specificity
The test determines
the specific gravity of
urines in the range
1.000 to 1.030. In
general, the result
correlates within
0.005 with refractive
index values. For
increased accuracy
add 0.005 to
readings obtained
from urines with pH
values equal to or
greater than 6.5.

Blood
Reagents
disopropylbenzene
dihydroperoxide;
3,3, 5.5,
tetramethylbenizidine
; buffer;
non-reactive
ingredients.
Chemical Principles
This test is based on
the peroxidase-likeactivity of
haemoglobin, which
catalyses the reaction
of the reagent with
the chromogen. The
resulting colour
ranges from orange
through green to
dark blue.
Sensitivity /
Specificity
The test is capable of
detecting 150 to 620
g/L free
haemoglobin or 5 to
20 intact red blood
cells per microlitre in
urines with an S.G. of
1.005. The test is less
sensitive in urines
with a high S.G. and
is more sensitive to
free haemoglobin
than intact red blood
cells. The appearance
of green spots on the
reacted reagent pad
indicates the
presence of intact
erythrocytes in urine.

Clinical Significance of Test Results

pH

Protein

Urobilinogen

Reagents
methyl red:
bromthymol blue:
non-reactive
ingredients.

Reagents
tetrabromphenol
blue; buffer;
non-reactive
ingredients.

Reagents
paradiethyl-aminobenzaldehyde;
non-reactive
ingredients.

Chemical Principles

Chemical Principles

Chemical Principles

The test is based on

the double indicator
principle, which gives
a broad range of
colours covering the
pH range 5 to 8.5.
Colours change from
orange through
yellow and green to
blue.

The test is based on

the protein-error-ofindicators principle.
The pKa of some
indicators is changed
when they bind to
protein, changing
colour when protein
is added at a constant
buffered pH. Colour
ranges from yellow
for negative
through yellowgreen, green to
green-blue for
positive reactions.

The test is based on

the Ehrlich reaction,
in which paradimethyl
aminobenzaldehyde
reacts with
urobilinogen in a
strongly acid medium
to produce a brownorange colour.

Sensitivity /
Specificity
The test provides
quantitative
differentiation of
urine pH in the range
5 to 8.5. Readings are
not affected by
urinary buffer
variations, but the pH
may be changed by
certain medications.

Sensitivity /
Specificity
Quantitative test,
with trace result
indicating albumin
concentration of
between 0.15 to
0.30 g/L. Test is less
sensitive to globulin,
Bence-Jones protein
and muco-protein,
so a negative result
does not rule out the
presence of these
proteins.

Sensitivity /
Specificity
Quantitative test that
detects urobilinogen
concentrations as low
as 3 mol/L in urine.
Absence of
urobilinogen cannot
be determined by this
method.

Nitrite
Reagents
para-arsanilic acid;
1, 2, 3, 4-tetrahydrobenzo
(h)-quinolin, 3-ol;
buffer; non-reactive
ingredients.
Chemical Principles
This test is based on
the conversion of
nitrate (derived from
dietary metabolites)
to nitrite by the
action of certain
species of bacteria in
the urine. Any degree
of pink colour is
considered positive.
Sensitivity /
Specificity
The test is specific for
nitrite, with a
sensitivity of 13 to
22 mol/L nitrite in
urines of normal
specific gravity.

Leucocytes
Reagents
Derivatised pyrrole
amino acid ester;
diazonium salt;
buffer; non-reactive
ingredients.
Chemical Principles
This test is based on
the principle that
esterases found in
granulocytic
leucocytes catalyse
the hydrolysis of a
derivatised pyrrole
amino acid ester to
liberate 3-hydroxy-5phenyl pyrrole. This
pyrrole then reacts
with a diazonium
salt to produce a
purple complex.
Sensitivity /
Specificity
This test provides a
semi-quantitative
result for the
presence of
leucocytes, trace
indicating
approximately 5 to
15 cells/L,
+ + + indicating
approximately 500
cells/L. The test for
leucocytes is a
specific enzymatic
reaction which is
able to detect lysed
cells in addition to
undamaged cells. In
clinical studies
involving over 1000
specimens, the
sensitivity was
91.4% when
compared with the
chamber count of
numbers of 10 and
more cells/L.

Glucose
Significance of
Positive Results
Glucose is found in
urine when its
concentration in
plasma exceeds the
renal threshold.
Commonest Causes
of Positive Results
In patients with
raised blood glucose
concentration:
Diabetes mellitus
Glucose infusion
In patients without
raised blood glucose
concentration:
Pregnancy
Renal glycosuria.

Bilirubin
Significance of
Positive Results
Bilirubin in urine
indicates an excess
of conjugated
bilirubin in plasma.
Commonest Causes
of Positive Results
Liver cell injury, as in
viral or drug-induced
hepatitis;
paracetamol
overdose; late-stage
cirrhosis.
Biliary tract
obstruction, e.g. by
gall-stones;
carcinoma of the
head of pancreas;
biliary atresia in
infants; late-stage
primary biliary
cirrhosis; druginduced intrahepatic cholestasis.

Ketones

Specific Gravity

Significance of
Positive Results
Indicates
accumulation of
acetoacetate
secondary to
excessive breakdown
of body fat.

Significance of
Positive Results
A measure of total
solute concentration
health varies widely
according to the
need to excrete
water and solutes.

Acetone and
-hydroxybutyrate
are released at the
same time.

Commonest Causes
of Positive Results
Characteristic
findings High values
are found in
dehydration, except
when due to in
urine. In impaired
kidney function as in
chronic renal failure.
Low values are
found in individuals
with intact renal
function and high
fluid intake; diabetes
insipidus; chronic
renal failure;
hypercalcaemia,
hypokalaemia.

Commonest Causes
of Positive Results
Fasting, particularly
with fever and/or
vomiting; most often
seen in children.
Diabetic ketoacidosis
(grossly uncontrolled
insulin-dependent
diabetes).
Ketotic
hypoglycaemia in
young children.

Blood
Significance of
Positive Results
Intact red cells in
urine are found with
diseases of the
kidneys or urinary
tract. Free
haemoglobin has
either been excreted
from plasma or
liberated in-vivo or
in-vitro from red cells
in the urine.
Commonest Causes
of Positive Results
Haematuria (intact
red cells) Due to
kidney disorders,
including
glomerulonephritis;
polycystic kidneys;
tumours.
Due to urinary tract
disorders, including
stones; tumours;
infection; benign
prostatic
enlargement.
Haemoglobinuria
(free haemoglobin)
Severe haemolysis,
e.g. crises in sickle
cell disease or red cell
glucose-6-phosphate
dehydrogenase
deficiency;
haemolytic
breakdown of red
cells in urine
(especially when
dilute and when
testing is delayed
after voiding).
N.B. Myoglobin,
released from
muscle, gives a
diffuse reaction
indistinguishable
from that given by
free haemoglobin.

pH
Significance of
Positive Results
Urinary pH usually
reflects the pH of
body fluids, but may
also be affected by
the ability of the
kidneys to eliminate
hydrogen ions and by
infection of the
urinary tract by
organisms containing
an enzyme which
promotes production
of ammonia from
urea. In health the pH
of uncontaminated
urine varies between
4.5 and 8.0
depending on the
rate of elimination of
hydrogen ions.
(pH < 7.0 = Acid,
pH > 7.0 = Alkaline).
Commonest Causes
of Positive Results
Low values are found
in acidaemia, e.g.
diabetic ketoacidosis
and lactic acidaemia;
starvation; potassium
depletion.
High values are found
in alkalaemia (except
when due to
potassium depletion),
e.g. due to vomiting
and consumption of
large amounts of
antacids; renal
tubular acidosis;
urinary tract infection
with ammoniaforming organisms.
The commonest
cause of high values
is the use of stale
urine: such
specimens should not
be used.

Protein
Significance of
Positive Results
Strip tests will detect
a range of proteins
but are most
sensitive to albumin.
Excess albumin in
urine is usually due
to increased
permeability of the
basement
membrane of
glomeruli.
Commonest Causes
of Positive Results
Clinically important
albuminuria, as in
acute and chronic
glomerulonephritis;
glomerular
involvement in
systemic lupus
erythematosus;
nephrotic syndrome;
pre-eclampsia
(toxaemia of
pregnancy).
Clinically
unimportant
albuminuria, as in
postural
(orthostatic)
proteinuria; fever;
heart failure.

Urobilinogen
Significance of
Positive Results
Urinary excretion of
urobilinogen reflects
the combined effects
of production of
bilirubin, conversion
of bilirubin to
urobilinogen in the
gut, reabsorption into
the blood stream.
Commonest Causes
of Positive Results
Increased excretion,
increased production,
e.g. inborn red cell
disorders including
sickle cell disease,
glucose-6-phosphate
dehydrogenase
deficiency and final
elimination by the
kidney; hereditary
spherocytosis;
acquired immune-and
drug-induced
haemolysis;
ineffective
erythropoiesis, e.g. in
thalassaemias

Nitrite
Significance of
Positive Results
Most of the
organisms which
infect the urinary
tract contain an
enzyme system
which catalyses the
conversion of
nitrate, which is
normally present in
urine, to nitrite,
which is not found in
urine in the absence
of a urinary tract
infection.
Commonest Causes
of Posoiive Results
Urinary tract
infection due to
nitrite-producing
organisms.

Leucocytes
Significance of
Positive Results
Some of the
leucocytes which
have entered
inflamed tissue from
the blood are shed
into the urine.
Commonest Causes
of Positive Results
Urinary tract
infection; especially
when acute
inflammation of
urinary
tract.
N.B. Infection is by far
the commonest cause
of urinary tract
inflammation.

N.B. A negative
result does not
exclude infection,
because some
organisms are
unable to convert
nitrate to nitrite.

Decreased uptake by
liver, e.g. in viral
hepatitis and
cirrhosis.
Decreased excretion
Biliary tract
obstruction, as with
gallstones, carcinoma
of pancreas.
(Prevention/restrictio
n of bilirubin entering
the gut).
Sterilisation of colon
by administration of
unabsorbable
antibiotics, e.g.
neomycin.
(Prevents/reduces
bacterial conversion
of bilirubin to
urobilinogen).

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Factors Affecting Urine Chemistry Tests on Siemens Reagent Test Strips

Glucose

Bilirubin
DIASTIX

Reducing sugars other than glucose

CLINITEST

CLINISTIX

(Multiple Strips)

Galactose

no effect

no effect

Lactose
Fructose
Maltose

+
+
+

no effect
no effect
no effect

no effect
no effect
no effect

Pentose

no effect

no effect

High concentrations of L-Dopa

may cause false +

false

false

Ketones

no effect

no effect

high concentrations

May mask a small

reaction
(May give red and
other colours)
Phenothiazines
High doses can cause
hepato-cellular
damage giving true +
Chlorpromazine
metabolites

development.

Can also cause false +

by reacting with
reagent area.
Urine not freshly
voided

may depress colour

Ascorbic acid

Azo dye metabolites

and other highly
coloured
compounds, e.g.
rifampicin and
phenazopyridine

high concentrations

moderate concentrations

high concentrations

may cause false +

may cause false

may slightly depress

colour development.

May give false

Lodine (Etodolac)

Hypochlorite or chlorine

no effect

false +

false +

Peroxide

no effect

false +

false +

Nalidixic

false +

no effect

no effect

Cephalosporins

give black colours

no effect

no effect

Probenecid

false +

no effect

no effect

High specific gravity

no effect

decreases sensitivity

no effect

Low specific gravity

no effect

intensifies colour

no effect

May give false +

Positive or atypical
colour.

Ketones
Mesna
Red/Violet colour
L-Dopa
Atypical colours
PKU (large quantities
of phenylketones)
+
BSP Test
(Bromosulphthalein)
False +
Phenazopyridine
Atypical colour
Captopril
May give false +

Specific Gravity

Blood

pH

Protein
Elevated readings may
be obtained in the
presence of 1-7.5 g/L
protein

Ferrous sulphate
peroxidase

Acid
High protein diet

like activity gives +

reaction

Glucose Urea
Urines containing
glucose or urea
greater than 1% may
cause a low specific
gravity reading
relative to other
methods

Myoglobin
Gives a + reaction

Prolonged exposure
of unpreserved
urine at room
temperature

pH
For increased
accuracy, 0.005 may
be added to the
readings from urines
with pH equal to or
greater than 6.5.

Ascorbic acid
High concentrations
reduce the sensitivity
N.B. The commonest
cause of a so-called
false-positive reaction
for blood is that the
laboratory method,
microscopy, only
measures red cells
and, since these
readily lyse, a positive
result for
haemoglobin with the
blood test can be
obtained without any
cells being present
when the urine is
ultimately examined
under the microscope

Ammonium chloride
medication
Alkaline
Diet high in
vegetables, citrus
fruits, milk and
other dairy products
Prolonged exposure
of unpreserved
urine at room
temperature
Antacid buffers.

Protein
Highly buffered
alkaline urines
May cause false +
Quaternary
ammonium salts,
e.g. Benzalkonium
chloride,
Chlorhexidine
May cause false +
Phenazopyridine
May give atypical
colour.

Urobilinogen

Nitrite

Leucocytes

PAS
(p-aminosalicylic
acid) metabolites
Atypical colours

Ascorbic acid
Large quantities may
cause false
reaction

Decreased Test
Results
Elevated glucose
concentration

Azo dye
metabolites
Mask reaction
(phenazo-pyridine
gives an orange/red
colour)

High Specific
Gravity
Sensitivity is reduced

High specific gravity

Urine not freshly

voided
False
Lodine (Etodolac)
May give false+

Azo dye
metabolites
(phenazopyridine)
Could mask or mimic
+ reaction.

Presence of
Cephalexin,
Cephalothin, oxalic
acid or Tetracycline
Masked colour
reaction
Nitrofurantoin
(brown urine)
Any substance that
causes abnormal
urine colour
Boric Acid
Inhibits reaction to
varying degrees.

Captopril
May cause decreased
reactivity.

development
High doses of salicylates

false +

false

false

For technical and product support

information or queries, please contact our
Technical Solutions Centre on:
0845 600 1955
9

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Test Selection Made Easy

Urinary Tract Infection

Testing Pathway

If ALL of the following are

Creatinine
Albumin

NEGATIVE

DISCARD

Nitrite
Leucocytes
Blood or
Protein

Report as
no evidence of
infection

Leucocytes
Nitrite
Urobilinogen

Urine
Specimen

Protein

Visual
Appearance

Clear

Test with
Multistix*
8SG/10SG
If ANY of the following are

pH

POSITIVE
Blood

Nitrite
Leucocytes
Blood or
Protein

Specific Gravity
Ketones

Culture

Microscopy

Culture

Microscopy

Bilirubin

10

100

100

25

100

100

100

100

100

100

50

50

50

50

25

25

25

2304 Multistix* 8SG

2283 Multistix* GP

2740 N-Multistix* SG

2741 Multistix* SG

2743 Labstix* SG

2815 N-Labstix*

2814 Bili-Labstix*

2810 Labstix*

2877 Hema-Combistix*

2857 Uristix*

2872 Albustix*

2816 Hemastix*

Microalbustix

Clinitek Microalbumin

Microalbumin 9

Obviously infected
or blood stained

2300 Multistix* 10SG

Code No

Product

Pack size

Glucose

This approach gives the power to confidently avoid sending noninfected urine samples for microscopy and culture, and enables
appropriate, timely and cost-effective patient management in the
clinic, ward or surgery.

11

40619_PRACGUIDE_Rebrand.04.09:Layout 1

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09:42

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leading clinical diagnostics company, is
committed to providing clinicians with
the vital information they need for the
accurate diagnosis, treatment and
monitoring of patients. Our
comprehensive portfolio of
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www.siemens.com/diagnostics
Practical guide to urine analysis leaflet I Printed in UK I 04/2009 Siemens Healthcare Diagnostics.

Global Division
Siemens Healthcare Diagnostics Inc
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www.siemens.com/diagnostics