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CRRAB 2 > 2: Hematuria > Flashcards

2: Hematuria Flashcards

1
Q

Does red urine = blood in urine?

A

Spin it down: if sediment is red = hematuria, if supernatant is red, it is not hematuria (need to dipstick for heme)

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2
Q

Does painless hematuria narrow DDx?

A

Absolutely. UTIs and stones generally symptomatic. Cancer may be painless.

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3
Q

WIS lack of proteinuria with hematuria?

A

No proteinuria = unlikely to be a glomerular issue (it is extraglomerular)

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4
Q

Frequent causes of hematuria (4)

A

Transient/unexplained, UTI, stones, cancer (bladder, kidney, prostate)

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5
Q

Less frequent causes of hematuria (6)

A

Exercise, trauma, endometriosis, sickle cell, PCKD, glomerular disease

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6
Q

Risk factors for urinary tract malignancy

A

> 35 years of age, smoking, occ exposure (benzene, aromatic amines), history of: gross hematuria, chronic cystitis, pelvic radiation, cyclophosphamide, chronic indwelling FB, analgesic abuse, obesity, HTN. EtOH may be protective.

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7
Q

Causes of red supernatant dipstick negative for heme (3)

A

porphyria, phenazopyridine, beets

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8
Q

Red supernatant dipstick positive for heme ddx

A

myoglobinuria (plasma clear) or hemoglobinuria (plasma is red)

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9
Q

What does urine dipstick test for?

A

proteinuria or hematuria

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10
Q

What might cause a false negative urine dipstick test?

A

presence of formalin or high [ascorbic acid]

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11
Q

Cause of urine dipstick false positive

A

pH > 9 or contamination w oxidizing agents used to clean perineum

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12
Q

What constitutes hematuria in children and adults?

A

RBC/high power field: 5 in children or 2 in adults

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13
Q

What UA findings point to glomerular (4) vs extraglomerular (1) source of hematuria?

A

Glomerular: red cell casts, proteinuria, dysmorphic RBCs, smokey brown or coca-cola color
Extraglomerular: clots (possible papillary necrosis)

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14
Q

How is angiography used with hematuria?

A

Investigate bleeding not defined by CT, can occlude causative blood vessels

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15
Q

What percent of hematuria is due to glomerular disease? How is this diagnosed?

A

50%, kidney biopsy

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16
Q

Unusual causes of hematuria

A

Arterio-venous malformations, fistulas, loin pain - hematuria syndrome

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17
Q

What is loin pain - hematuria syndrome

A

Abnl GBM + assoc w/ intratubular crystal formation. usually presents with flank pain w/o infection or obstruction

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18
Q

What is Nutcracker syndrome? What population is it most frequently found in?

A

Asian children. Left renal vein compression by aorta and superior mesenteric artery.

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19
Q

Evaluating microscopic hematuria in an asymptomatic child. What’s next?

A

Determine presence of protein. None: benign/ observe. Present: quantify w 1st void morning spec. Total protein/creat ratio (nl <0.3) refer if above

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20
Q

What percent of men and women develop a symptomatic stone by age 70?

A

12% of men and 5% of women, rate increases with age

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21
Q

What % of stones are calcium? What are they usually precipitated with?

A

80%. Oxalate > phosphate.

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22
Q

What type of stones are known as infection stones?

A

Struvite

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23
Q

Which stones are caused by a genetic abnormality? What is the defect and pattern of inheritance?

A

Cysteine. Autosomal recessive impairment of cystine transport -> dec prox tubular reabs

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24
Q

Presentation of pain with stone

A

flank, abdominal, testicular or labial, tends to wax and wane. May have assoc n/v, dysuria, urgency, hematuria

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25
Q

What causes the pain associated with a stone?

A

Dilation of ureter behind stone due to back up.

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26
Q

What type of stones can be visualized on XR (KUB)?

A

Calcium= most radiopaque. Cystine visible but less opaque (discrete or staghorn)

27
Q

What imaging technique is generally used for a patient with known hx stone?

A

US

28
Q

What medications are helpful with stones?

A

Alpha blocker (tamsulosin) or Ca channel blocker (nifedipine) relaxes ureteral muscles allowing the stone to pass more easily

29
Q

When does a pt with a stone require hospitalization?

A

When unable to maintain hydration and urine output, need IV fluids.

30
Q

What shape are calcium oxalate crystals?

A

Monohydrate: dumbbell, needle
Dihydrate: envelope

31
Q

What is the effect of citrate excretion on stone formation?

A

Citrate inhibits stone formation

32
Q

What are the 3 types of hypercalciuria?

A
  1. Absorptive: autosomal dom -> inc Calcitrol 2. Fasting (resorptive): bone loss 3. renal: defective Ca reabsorp in prox tubule
33
Q

Sources of hypocitraturia

A

Almost anything that gives you a metabolic acidosis. Chronic diarrhea, renal tubular acidosis, high protein diet, Topiramate (anti-seizure med). Ureteral diversion (surgical)

34
Q

Sources of excreted oxalate

A

Glycine metabolism (40%), ascorbic acid metab (40%), diet (10%)

35
Q

How do oxalate and calcium interact in the intestine?

A

Bind each other. If Ca is decreased or complexed with fatty acids/bile acids -> more free oxalate -> absorbed

36
Q

What is medullary sponge kidney?

A

Abnormal medullary papilla -> reflux of filtrate -> risk for crystallization

37
Q

How does salt affect Ca level?

A

Dec salt -> inc % reabsorption of Na -> Ca follows (less excreted = less likely to form stones)

38
Q

If someone gets a Ca stone, should they reduce their Ca intake?

A

No. Dec Ca -> more oxalate absorbed from GI tract -> more stones.

39
Q

Mech of thiazides in reducing stone formation

A

Dec Ca excretion in urine, used esp for absorptive hypercalciuria

40
Q

Potassium citrate and bicarbonate mech of reducing stone formation

A

For pts w Ca-oxalate stones, alkalinizes urine reducing formation

41
Q

Orthophosphate MOA w regard to stone formation

A

reduces Ca in urine

42
Q

Febuxostat MOA

A

Decreases uric acid prod by inhibiting xanthine oxidase (as does allopurinol)

43
Q

Calcium carbonate MOA

A

binds oxalate in stomach preventing absorption

44
Q

What % of stones in US are uric acid? When are these more frequent?

A

5-10% though they make up 40% of stones in hot arid climates (low urine volume and acidic)

45
Q

Typical serum uric acid level for someone forming a uric acid stone

A

Normal serum level

46
Q

Prevention options for uric acid stones (3)

A

Urine output >2L/d
Alkalinization of urine (req 3-4 doses/d)
Allopurinol/Febuxostat (easiest, just 1x/d)

47
Q

What type of crystals form only in alkaline urine? What shape?

A

Struvite, coffin lid shaped.

48
Q

Struvite stone composition

A

magnesium ammonium phosphate

49
Q

What are the 2 requirement for struvite stone formation? When are these conditions met most commonly?

A

Inc ammonia prod and inc urine pH. Satisfied by urease pos UTI (proteus or klebsiella)

50
Q

How does increased urine pH facilitate struvite stone formation?

A

Decreases solubility of phosphate

51
Q

What drug acts as a urease inhibitor?

A

Acetohexemic acid

52
Q

Why might a patient prone to urease pos UTI with a chronic indwelling catheter be given chronic abx?

A

Goal: get rid of urease-producing organisms but not others, allowing the less harmful ones to colonize

53
Q

Shape of cystine crystals?

A

Hexagonal, essentially pathognomonic for cystinuria.

54
Q

Cystinuria subtypes

A

Based on parents cystine excretion, can be combo

I/I: normal, II/II: large, III/III: intermediate

55
Q

Rec fluid intake for cystine stone formers?

A

3L/day

56
Q

Med therapy for cystine stone formers

A

Alk of urine, dec Na intake -> inc prox tub cystine reabs. Chelators: Penicillamine, Tiopronin, Captopril

57
Q

In what type of stone is ESWL less effective? Why?

A

Cystine, a softer stone

58
Q

Rate of stone recurrence over 10 years

A

50%, men > women

59
Q

What percent of pts require intervention vs pass stones spontaneously?

A

50/50

60
Q

ESWL complications

A

Obstruction by broken off chunks, reversible damage to blood vessels and tubules depending on # and energy of shocks, new HTN (renin release?)

61
Q

Long term ESWL complication

A

impairment of renal fx, prob from scar formation. Changes present at 4 years.

62
Q

Which stones have a particularly high incidence of stone formation from residual calculi after ESWL?

A

Struvite

63
Q

Do residual stone particles after ESWL matter?

A

Yes, nidus for further formation

CRRAB 2 (12 decks)

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