Clinitek® Atlas® Reagent Pak Clinitek® Atlas® Reagent Pak INTENDED USE: When used with the CLINITEK® ATLAS® Automated Urine Chemistry Analyzer, the CLINITEK® ATLAS® Reagent Pak determines the pH and color of urine and tests for glucose, bilirubin, protein, occult blood, ketone (acetoacetic acid), urobilinogen, nitrite, and leukocytes in urine. SUMMARY AND EXPLANATION: The CLINITEK ATLAS Reagent Pak contains a roll of firm plastic to which are affixed 490 reagent strips. Each strip contains 9 separate reagent areas that are impregnated with chemicals for the determination of a particular analyte. In addition, each strip contains a nonreactive pad that is used for the determination of the specimen color.
The CLINITEK® ATLAS® System combines the principles of reflectance spectroscopy with a convenient
and efficient reagent format to provide qualitative or semi-quantitative results for color, glucose, bilirubin, protein, pH, occult blood, ketone (acetoacetic acid), urobilinogen, nitrite, and leukocytes in urine. The CLINITEK ATLAS Analyzer electronically analyzes, at defined wavelengths, the color and intensity of light reflected from a reacted reagent area. It also determines the specific gravity of the urine specimen using a refractive index method. The instrument then reports the results in clinically meaningful units. Test results may provide information regarding the status of carbohydrate metabolism, kidney and liver function, acid/base balance, and urinary tract infection.1-2
Before loading the reagent roll, read the CLINITEK® ATLAS® Operating Manual and the CLINITEK®
ATLAS® Calibration and Control Kit package insert. All directions and procedures must be followed exactly to obtain reliable test results. CHEMICAL PRINCIPLES OF PROCEDURES: Glucose: This test is based on a double sequential enzyme reaction. One enzyme, glucose oxidase, catalyzes the formation of gluconic acid and hydrogen peroxide from the oxidation of glucose. A second enzyme, peroxidase, catalyzes the oxidative coupling of 4-aminoantipyrine and 4-methylcatechol by hydrogen peroxide. The resulting colors range from orange to dark red. Bilirubin: This test is based on the coupling of bilirubin with diazotized dichloroaniline in a strongly acid medium. The color ranges through various shades of tan. Protein: This test is based on the protein-error-of-indicators principle. At a constant pH, the development of any green color is due to the presence of protein. Colors range from yellow for "Negative" through yellow-green and green to green-blue for "Positive" reactions. pH: This test is based on a double indicator principle that gives a broad range of colors covering the entire urinary pH range. Colors range from orange through yellow and green to blue. Blood: This test is based on the peroxidase-like activity of hemoglobin, which catalyzes the reaction of diisopropylbenzene dihydroperoxide and 3,3',5,5'-tetramethylbenzidine. The resulting color ranges from orange through green; very high levels of blood may cause the color development to continue to blue. Ketone: This test is based on the development of colors ranging from buff-pink, for a negative reading, to maroon when acetoacetic acid reacts with nitroprusside. Urobilinogen: This test is based on the Ehrlich reaction in which p-diethylaminobenzaldehyde in conjunction with a color enhancer reacts with urobilinogen in a strongly acid medium to produce a pink-red color. Nitrite: This test depends upon the conversion of nitrate (derived from the diet) to nitrite by the action of Gram negative bacteria in the urine. At the acid pH of the reagent area, nitrite in the urine reacts with p-arsanilic acid to form a diazonium compound. This diazonium compound in turn couples with 1,2,3,4-tetrahydrobenzo(h)quinolin-3-ol to produce a pink color. Leukocytes: Granulocytic leukocytes contain esterases that catalyze the hydrolysis of the derivatized pyrrole amino acid ester to liberate 3-hydroxy-5-phenyl pyrrole. This pyrrole then reacts with a diazonium salt to produce a purple product. REAGENTS: (Based on dry weight at time of impregnation) Glucose: 3.8% w/w glucose oxidase (bacterial); 0.3% w/w peroxidase (horseradish); 19.2% w/w 4-aminoantipyrine; 11.7% w/w 4-methylcatechol; 26.2% w/w buffer; 38.8% w/w nonreactive ingredients. Bilirubin: 0.4% w/w 2,4-dichloroaniline diazonium salt; 37.3% w/w buffer; 62.3% w/w nonreactive ingredients. Protein: 0.3% w/w tetrabromphenol blue; 97.3% w/w buffer; 2.4% w/w nonreactive ingredients. pH: 0.2% w/w methyl red; 2.8% w/w bromthymol blue; 97.0% w/w nonreactive ingredients. Blood: 6.8% w/w diisopropylbenzene dihydroperoxide; 4.0% w/w 3,3',5,5'-tetramethylbenzidine; 48.0% w/w buffer; 41.2% w/w nonreactive ingredients. Ketone: 7.1% w/w sodium nitroprusside; 92.9% w/w buffer. Urobilinogen: 0.2% w/w ρ-diethylaminobenzaldehyde; 99.8% w/w nonreactive ingredients. Nitrite: 1.4% w/w p-arsanilic acid; 1.3% w/w 1,2,3,4-tetrahydrobenzo(h)quinolin-3-ol; 10.8% w/w buffer; 86.5% w/w nonreactive ingredients. Leukocytes: 0.4% w/w derivatized pyrrole amino acid ester; 0.2% w/w diazonium salt; 40.9% w/w buffer; 58.5% w/w nonreactive ingredients. WARNINGS AND PRECAUTIONS: CLINITEK ATLAS Reagent Pak is for in vitro diagnostic use. It has been determined to be nonhazardous under the guidelines issued by OSHA in 29 CFR 1910.1200(d). STORAGE AND HANDLING: Store the unopened reagent canister at room temperatures between 15?30癈 (59?86癋). Do not store in a refrigerator. Immediately after removing the reagent roll from the canister, load the roll into the instrument. Do not remove the packet of desiccant from the center of the reagent roll.
The reagent roll must be used within 14 days after loading into the instrument. If the reagent roll is
exposed outside the sealed canister or the closed reagent compartment of the instrument for longer than 15 minutes, the reagents may not yield satisfactory results. When the reagent roll is properly stored in its sealed canister, it is stable until the expiration date. IMPORTANT NOTE: PROTECTION AGAINST EXPOSURE TO LIGHT, HEAT AND AMBIENT MOISTURE IS MANDATORY TO GUARD AGAINST ALTERED REAGENT REACTIVITY. Discoloration or darkening of reagent areas may indicate deterioration. If this is evident, or if test results are questionable or inconsistent with expected findings, the following steps are recommended: (1) confirm that the product is within the expiration date shown on the label and that the reagent roll has been installed in the instrument for no longer than 14 days; (2) check performance using CLINITEK® ATLAS® Control Strips; (3) retest with fresh product. If proper results are not obtained, contact your nearest Bayer Customer Service Representative.
In the United States, contact National Phone Support of Bayer Corporation by calling 1-800-442-8400.
SPECIMEN COLLECTION AND PREPARATION: Collect urine in a clean container and test it as soon as possible. If testing cannot be performed within an hour after voiding, refrigerate the specimen immediately and let it return to room temperature before testing. The use of urine preservatives is not recommended.
Mix well immediately before testing; do not centrifuge. Transfer at least 2 mL of urine into a properly
labeled URIN-TEK® or similar plastic tube and place the tube into the sample tray. Test according to the instructions given in the instrument Operating Manual.
It is especially important to use fresh urine to obtain the best results for bilirubin and urobilinogen, since
these compounds are very unstable when exposed to room temperature and light. Nitrite test results are optimized by using a first morning specimen or one that has incubated in the bladder for four hours or more. The presence of colored precipitates may cause a false positive result with the nitrite test.
Prolonged exposure of unpreserved urine to room temperature may result in microbial proliferation with
resultant changes in pH. A shift to alkaline pH may cause false positive results with the protein test. Urine containing glucose may decrease in pH as organisms metabolize the glucose. Bacterial growth from contaminating organisms may cause false positive blood reactions from the peroxidases produced. In random urine specimens from females, a positive result for leukocytes may be due to a source external to the urinary tract.
Contamination of the urine specimen with skin cleansers containing chlorhexidine may affect protein (and
to a lesser extent bilirubin) results. The user should determine whether the use of such skin cleansers is warranted. DIRECTIONS FOR LOADING REAGENT ROLL: (Follow the prompts on the instrument display and the loading diagram located on the inside of the instrument door. Refer to the Operating Manual for complete information.)
Press "4" from the Main Menu to enter the "Load Reagent" Routine.
Press the softkey under the display prompt of "ADVANCE" to advance the old reagent roll until it is
clear of the instrument readhead. Press "CONTINUE" when this is complete.
Enter the lot number identification (Lot ID) for the new roll of reagent.
Open the instrument doors, then remove the used reagent roll and discard. Clean the stationary rod
labeled "F" and reinstall on the instrument. Open the reagent compartment and remove the old packet of desiccant. Lower "B" by rotating the handle counterclockwise, then pressing down firmly on "B."
Carefully remove the foil lid from the new reagent canister. Notice the large packet of desiccant in
the center of the roll; leave the desiccant in place to maintain reagent stability after loading. Grasp the reagent roll, holding the desiccant packet in place, and lift it from the canister.
Partially insert the roll into the reagent compartment with the clear plastic leader unrolling over the top (counterclockwise) and the black stripe at the back side. Be sure the leader is positioned to the left of "A" (see the attached loading diagram).
While still holding the roll with one hand, remove the tape that secures the leader, then push the roll
the rest of the way into the reagent compartment.
Load the reagent through the instrument as follows and by referring to the loading diagram:
Guide the plastic leader on the reagent roll behind and under "A," under "C," through "D," over
Insert the end of the leader into the slot in "G." Hold the leader in the slot and rotate "G"
counterclockwise until the holes in the leader are engaged on the pins of "C."
Raise "B" by lifting up firmly on the handle, then rotate the handle fully clockwise until it is
secured in its notch. Press "CONTINUE" to begin advancing the reagent roll.
When the advancement stops, ensure that the holes in the plastic leader are engaged on the
pins of "E." Press "CONTINUE" again to advance the roll to the first reagent strip. The instrument will stop automatically when the first strip is detected.
Close and secure the reagent compartment door.
Empty the waste bottle and refill the rinse bottle and replace both. Close the instrument doors.
10. Proceed with the Calibration procedure, following the prompts on the display.
QUALITY CONTROL: For best results, performance of the reagent roll should be confirmed by routinely testing known negative and positive specimens or controls. Controls may also be randomly hidden in each batch of specimens tested. Water should NOT be used as a negative control. Each laboratory should establish its own goals for adequate standards of performance, and should question handling and testing procedures if these standards are not met.
CLINITEK ATLAS Control Strips provide a convenient basis for a urine chemistry quality control program.
These Control Strips are included in the CLINITEK ATLAS Calibration and Control Kit and are also available separately as Product No. 5019.
Due to its specificity for acetoacetic acid, the ketone reagent area may not react with commercial controls
other than CLINITEK ATLAS Control Strips. If questionable results are obtained with the ketone reagent area, reactivity should be checked with CLINITEK ATLAS Control Strips or by testing negative and positive clinical specimens that have been identified as positive or negative with a reference test method, such as ACETEST®* Reagent Tablets. RESULTS: Results with the CLINITEK ATLAS System are obtained in clinically meaningful units. Results may be displayed on the screen; they may also be transferred to a computer and/or printer. The values given by the instrument represent nominal values; actual values will vary around the nominal values. LIMITATIONS OF PROCEDURES:
As with all laboratory tests, definitive diagnostic or therapeutic decisions should not be based on any single result or method.
Substances that cause abnormal urine color, such as drugs containing azo dyes (e.g., Pyridium®*, Azo
Gantrisin®*, Azo Gantanol®*), nitrofurantoin (Macrodantin®*, Furadantin®*), and riboflavin, may affect the readability of reagent areas on urinalysis reagent strips. The color development on the reagent pad may be masked, or a color reaction may be produced on the pad that could be interpreted by the instrument as a false positive. Color: Because of the inherent differences between the perception of the human eye and the optical system of the instrument, there may be differences between the color that is perceived visually and that reported by the instrument, especially when there are low levels of a color present. Glucose: Ascorbic acid concentrations of 30 mg/dL or greater may cause false negatives for specimens containing small amounts of glucose (100 mg/dL). Nitrites and ketone bodies do not interfere with this test. Bilirubin: Metabolites of Lodine®* (etodolac) may cause false positive or atypical results; ascorbic acid concentrations of 15 mg/dL or greater may cause false negatives. Since very small amounts of bilirubin may be found in the earliest phases of liver disease, the user must consider whether the sensitivity of CLINITEK ATLAS System to bilirubin is sufficient for the intended use. When very small amounts of bilirubin in urine are sought (e.g., earliest phase of viral hepatitis), ICTOTEST®* Reagent Tablets should be the method of choice. Protein: False positive results may be obtained with highly buffered or alkaline urines. Contamination of the urine specimen with quaternary ammonium compounds (e.g., from some antiseptics and detergents) or with skin cleansers containing chlorhexidine may also produce false positive results. pH: No known interfering substances. Blood: Elevated specific gravity may reduce the reactivity of the blood test. Capoten®* (Captopril) may also cause decreased reactivity. Certain oxidizing contaminants, such as hypochlorite, may produce false positive results. Microbial peroxidase associated with urinary tract infection may cause a false positive reaction. Levels of ascorbic acid normally found in urine do not interfere with this test. Ketone: False positive results (Trace) may occur with highly pigmented urine specimens or those containing large amounts of levodopa metabolites. Compounds such as mesna (2-mer-captoethane sulfonic acid) that contain sulfhydryl groups may cause false positive results or an atypical color reaction. Urobilinogen: The reagent area may react with interfering substances known to react with Ehrlich's reagent, such as p-aminosalicylic acid and sulfonamides. False negative results may be obtained if formalin is present. Strip reactivity increases with temperature; the optimum temperature is 22?26癈. The test is not a reliable method for the detection of porpho-bilinogen. The absence of urobilinogen cannot be determined with this test. Nitrite: A positive nitrite result suggests the presence of 105 or more organisms per mL, but color development is not proportional to the number of bacteria present. A negative result does not in itself prove that there is no significant bacteriuria. Negative results may occur when urinary tract infections are caused by organisms that do not contain reductase to convert nitrate to nitrite; when urine has not been retained in the bladder long enough (four hours or more) for reduction of nitrate to nitrite to occur; or when dietary nitrate is absent, even if organisms containing reductase are present and bladder incubation is ample. Ascorbic acid concentrations of 75 mg/dL or greater may cause false negative results with specimens containing small amounts of nitrite ion (0.1 mg/dL or less). The presence of colored precipitates may cause a false positive result. Leukocytes: Elevated glucose concentrations (≥ 3 g/dL) or high specific gravity may cause decreased test results. The presence of cephalexin (Keflex®*), cephalothin (Keflin®*), or high concentrations of oxalic acid may also cause decreased test results. Tetracycline may cause decreased reactivity, and high levels of the drug may cause a false negative reaction. Any substance that causes abnormal urine color may obscure the color reaction, resulting in an inaccurate interpretation of the leukocyte reading by the instrument. EXPECTED VALUES: Expected values for the "normal" healthy population and the abnormal population are listed below for each reagent area. Color: The normal color of urine is pale yellow to dark yellow.3 Glucose: Small amounts of glucose are normally excreted by the kidney.4 These amounts are usually below the sensitivity level of this test but on occasion may produce a color that may be interpreted by the instrument as a Trace. Trace amounts (100 mg/dL) may be significantly abnormal if found consistently. CLINITEK ATLAS results of 250 mg/dL or greater should always be interpreted as abnormal. Bilirubin: Normally, no bilirubin is detectable in urine by even the most sensitive method. Positive bilirubin results (Small or greater) should be considered abnormal and should be investigated further. When confirming positive results, or when minute amounts of bilirubin are suspected, the urine specimen should be retested using ICTOTEST Reagent Tablets. Protein: Normally, no protein is detectable in urine, although a minute amount is excreted by the normal kidney. CLINITEK ATLAS results of 30 mg/dL or greater indicate significant proteinuria. For urines of high specific gravity, the Analyzer may indicate a result of Trace, even though only normal concentrations of protein are present. Clinical judgment is needed to evaluate the significance of Trace results. pH: The normal and abnormal urinary pH range is from 5 to 9. Blood: The significance of the Trace reaction may vary among patients, and clinical judgment is required for assessment in an individual case. Blood is often, but not always, found in the urine of menstruating females. This test is highly sensitive to hemoglobin and thus complements the microscopic examination. Ketone: Normal urine specimens ordinarily yield negative results with this reagent. Detectable levels of ketone may occur in urine during physiological stress conditions such as fasting, pregnancy and frequent strenuous exercise.5-7 In ketoacidosis, starvation or with other abnormalities of carbohydrate or lipid metabolism, ketones may appear in urine in large amounts before serum ketone concentrations are elevated.8 Urobilinogen: The normal urobilinogen range obtained with this test is 0.2 to 1.0 mg/dL (1 mg/dL is approximately equal to 1 Ehrlich Unit/dL).3 A result of 2.0 EU/dL represents the transition from normal to abnormal, and the patient and/or urine specimen should be evaluated further. Nitrite: Normally, no nitrite is detectable in urine. The proportion of positive nitrite results in cases of significant infection depends on how long the urine was retained in the bladder prior to collection. Identification of known positive cases with the nitrite test ranges from as low as 40%, when little bladder incubation occurred, to as high as approximately 80%, when a minimum of four hours of bladder incubation occurred. Leukocytes: Normal urine specimens generally yield negative results; positive results (Small or greater) are clinically significant. Individually observed Trace results may be of questionable clinical significance; however, Trace results observed repeatedly may be clinically significant. Positive and repeated Trace results indicate the need for further testing of the patient and/or urine specimen, according to medically accepted procedures for pyuria. Positive results may occasionally be found with random specimens from females due to contamination of the specimen by vaginal discharge. SPECIFIC PERFORMANCE CHARACTERISTICS: Specific performance characteristics are based on clinical and analytical studies. In clinical specimens, the sensitivity depends upon several factors, including specific gravity, pH, and the presence or absence of inhibitory factors typically found in urine (see LIMITATIONS OF PROCEDURES section). Because the color of each reagent area changes as the analyte concentration increases, the percentage of specimens detected as positive will increase with the analyte concentration. The performance data provided for each reagent were obtained in studies using fresh product.
Each instrumental display result represents a range of values. Because of specimen and reading
variability, specimens with analyte concentrations that fall between nominal levels may give results at either level. Results at levels greater than the second positive level for the glucose, protein, ketone, and urobilinogen tests will usually be within one level of the true concentration.
The following table lists the generally detectable levels of analytes in contrived urines; however, because
of the inherent variability of clinical urines, lesser concentrations may be detected under certain conditions.
Reagent Area Sensitivity Color: Several studies showed good agreement between results obtained visually and instrumentally. Glucose: Positive results with this test were obtained in at least 90% of clinical specimens containing ≥ 76 mg/dL glucose as determined by the hexokinase assay. The reagent area is specific for glucose; no substance excreted in urine other than glucose is known to give a positive result. The test is not influenced by urine pH, hemoglobin or high concentrations of ketone bodies. The reagent area does not react with lactose, galactose, fructose nor reducing metabolites of drugs (e.g., salicylates and nalidixic acid). This test may be used to determine whether the reducing substance found in urine is glucose. Reactivity may be influenced by urine specific gravity and temperature. The test is more sensitive than the copper reduction test (e.g., CLINITEST®* Reagent Tablets). Bilirubin: When urines were contrived with at least 0.8 mg/dL bilirubin, positive results were obtained in at least 90% of the specimens using this test. The test is less sensitive than ICTOTEST Reagent Tablets. Protein: The test is more sensitive to albumin than to globulin, hemoglobin, Bence-Jones Protein or mucoprotein; a negative result does not rule out the presence of these other proteins. At least 89% of the results were positive when urines were tested that had been contrived to levels of 15 mg/dL or greater albumin. pH: At least 90% of the pH results, as measured on the CLINITEK ATLAS Analyzer, were within 0.5 unit of the pH meter value using 669 clinical specimens. pH readings are not affected by variations in the urinary buffer concentration. Blood: Positive results were obtained in at least 90% of urines contrived with ≥ 0.015 mg/dL hemoglobin. The sensitivity of this test may be reduced in urines with high specific gravity. The test is equally sensitive to myoglobin as to hemoglobin. Because of the optical systems of urine chemistry instruments, the sensitivity to intact erythrocytes is lower than can be perceived visually. (Hemoglobin concentration of 0.062 mg/dL is approximately equivalent to 20 intact red blood cells per microliter.) Ketone: The reagent area reacts with acetoacetic acid in urine. It does not react with acetone or β -hydroxybutyric acid. When negative clinical specimens were contrived with acetoacetate at levels of ≥ 5 mg/dL, positive results were obtained in at least 90% of the specimens. Some high specific gravity/low pH urines may give results of Trace. Clinical judgment is needed to determine the significance of a Trace result. Urobilinogen: This test area will detect urobilinogen in concentrations as low as 0.2 mg/dL (approximately 0.2 EU/dL) in urine. The absence of urobilinogen in the specimen cannot be determined. Nitrite: The test is specific for nitrite and will not react with any other substance normally excreted in urine. In urines contrived with nitrite levels of 0.1 mg/dL or higher, at least 90% of the results were positive. Leukocytes: The leukocyte test detects enzymes with esterase activity. These enzymes are not normally present in urine, and the only known source is granulocytic leukocytes.9-10 Therefore, the test can be considered to be chemically specific for leukocytes in urine. At least 90% of the specimens were positive when urines were contrived with esterase equivalent to 5 cells or greater/high power field. The analytical sensitivity of this test is 5-15 cells/high power field in patient urines, determined by evaluations at a number of clinical sites. AVAILABILITY: CLINITEK ATLAS Reagent Pak is available as Product No. 5017. *TRADEMARKS ACETEST®, ICTOTEST®, and CLINITEST® are registered trademarks of Bayer Corporation. Pyridium® is a registered trademark of Parke-Davis. Azo Gantrisin® and Azo Gantanol® are registered trademarks of Roche Laboratories. Macrodantin® and Furadantin® are registered trademarks of Procter & Gamble Pharmaceuticals, Inc. Lodine® is a registered trademark of Wyeth-Ayerst Laboratories. Capoten® is a registered trademark of E.R. Squibb & Sons, Inc. Keflex® is a registered trademark of Dista Products Company. Keflin® is a registered trademark of Eli Lilly and Company. BIBLIOGRAPHY:
Free, A. H. and Free, H.: Urinalysis, Critical Discipline of Clinical Science. CRC Crit. Rev. Clin. Lab. Sci.
Kark, R. M. et al.: A Primer of Urinalysis, 2nd ed. New York: Harper and Row; 1963.
Henry, J.B. et al.: Clinical Diagnosis and Management by Laboratory Methods, 18th ed. Philadelphia:
Schersten, B. and Fritz, H.: Subnormal Levels of Glucose in Urine. JAMA 201:129-132; 1967.
McGarry, J. D.: Lilly Lecture, 1978: New Perspectives in the Regulation of Ketogenesis. Diabetes28:
Williamson, D. H.: Physiological ketoses, or why ketone bodies? Postgrad. Med. J. (June Suppl.):
Paterson, P. et al.: Maternal and Fetal Ketone Concentrations in Plasma and Urine. Lancet:862-865;
Fraser, J. et al.: Studies with a Simplified Nitroprusside Test for Ketone Bodies in Urine, Serum, Plasma
and Milk. Clin.Chim. Acta 11:372-378; 1965.
Oneson, R. and Gr鰏chel, D. H. M.: Leukocyte Esterase Activity and Nitrite Test as a Rapid Screen for
Significant Bacteriuria. Am. J. Clin. Path.83:84-87; 1985.
10. Kusumi, R. K., Grover, P. J., and Kunin, C. M.: Rapid Detection of Pyuria by Leukocyte Esterase Activity.
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