26 - Hematuria and Proteinuria Flashcards
1
Q
Hematuria
A
- Blood in urine
- May be macroscopic or microscopic
- Can be benign or pathological
- Prerenal, renal, or post-renal
- Through history is important
2
Q
Benign hematuria
A
- Strenuous exercise
3
Q
Pathological hematuria
A
- Any disorder that erodes/ulcerates the mucosal surface or affects the vasculature of the urogenital system
4
Q
What are some prerenal causes of hematuria?
A
- Coagulopathy: primary or secondary
- IMHA: “pseudo hematuric patient”
5
Q
What are some renal cause of hematuria?
A
- Renoliths
- Pyelonephritis
- Renal cysts
- Perirenal pseudocysts
- Renal dysplasia
- Renal telangiectasia
- Renal neoplasia
- Idiopathic renal hematuria
- Trauma
6
Q
What are some postrenal causes of hematuria?
A
- Cystoliths, ureteroliths, urethroliths
- Cystitis
- Neoplasia
- Feline interstial cystitis
- **don’t forget about the genital tract
7
Q
**How can you differentiate blood from urinary system vs. genital tract?
A
- Could compare a urinalysis from a cysto sample and a free catch sample
o Will be good unless there is a lot of backflush - Imaging
8
Q
Hematuria: physical exam
A
- Any evidence of petechia and or ecchymosis
- Examine MM
- Do a rectal
o Pelvic urethra, trigone region of bladder and prostate - Examine genitalia
- Careful palpation of bladder and kidneys
9
Q
Hematuria: specific urogenital examination
A
- Inspect genitalia and urethral orifice
o Extrude penis from prepuce
o Digital vaginal exam (sterile procedure)
10
Q
Hematuria: observe micturition
A
- Observe them while during voiding to verify and confirm OR detect abnormalities such as dysuria/stranguria that could localize the source
- Stage at which blood appears may help to localize the origin
11
Q
If blood seen at beginning of urination or dripping independent of urination, which does it suggest?
A
- Genital or urethral source
12
Q
If blood at end of urination, what does it often indicate?
A
- Urinary bladder origin
13
Q
What if there is blood throughout micturition, what does it suggest?
A
- Kidney or urethral origin
- Bladder cannot be ruled out
14
Q
How can you distinguish between true hematuria and other causes of red urine?
A
- *Need to rule out pigmentary and bilirubinuria
- Urinalysis: USG and pH
- Dipstick occult blood test
- Urine sediment analysis
15
Q
Hematuria: urinalysis
A
- Essential part of evaluating them
- Cystocentesis UNLESS contraindicated
o Can compare to free catch to help localize the bleeding (proximal vs. distal urinary tract) - Protein, infectious organisms, WBCs, casts and crystals can help determine definitive on contributing causes of hematuria
16
Q
Hematuria: dipstick occult blood test
A
- Defects Heme compounds
- Blood, Hg, myoglobin and bilirubin give a positive
- False positive with oxidizing compounds in urine
- Small amounts of blood give strong positive
17
Q
Hematuria: urine sediment analysis
A
- Normal urine contains: 0-5RBCs/hpf
- Increased numbers indicate hematuria
- Account for sampling trauma
- *RBC may lyse in dilute urine or very alkaline urine
o Leads to DISCORDANT RESULTS b/w dipstick and sediment exam
18
Q
*Hematuria: how to rule out hemoglobinuria, myoglobinuria and bilirubinuria
A
- Spin the urine (doing it at a LOW speed): examine sediment and supernatant
o Pigments stay suspended but RBCs do NOT - Evaluation of plasma in a spun hematocrit tube
o Myoglobin is rapidly cleared from plasma so pink discolouration is NOT expected - Serum biochemistry may help
19
Q
Consider causes of pseudo-hematuria or intermittent hematuria
A
- Repeat UA if suspected it is intermittent
o Uroendoscopy when symptomatic may be required for intermittent - Ask about drug and diet history for pseudo-hematuria
o Pigments in concentrated urine, dyes from foods, toxins, inherited conditions
o Dipstick should be negative for RBCs/bilirubin with this
20
Q
Hematuria: urethral catheterization
A
- May be indicated in some cases to assess patency in dogs or cats when dysuria has been observed or reported
21
Q
Hematuria: minimum database (CBC, serum biochem, UA)
A
- CBC and serum biochem:
o systemic signs of illness
o palpable abnormalities in one or both kidneys, uterus or prostate
o *pay attention to platelet count, RBC count and azotemia
22
Q
Hematuria: coagulation panel/testing
A
- Might need to do it to rule out if they have a coagulopathy (primary vs. secondary)
23
Q
Hematuria: diagnostic imaging
A
- To track down site and cause
- Abdominal radiograph and US
o Examine for irregularities, masses, abnormalities in shape and size of structures, uroliths
24
Q
If hematuria is real, you need to try and localize the source/cause of bleeding?
A
- Pre-renal, renal, post-renal
- Observe micturition
- Ruling out coagulopathy
- Medical imaging
25
Normal urine; protein
- Contains little to no protein
26
*When proteinuria exists, what does accurate assessment involve (4 key elements)?
- Localizing the source
- Quantifying the magnitude
- Documenting persistence
- Tracking trends in response to treatment of underlying disease
27
How can proteinuria be classified?
- Physiological/benign
o Usually mild and transient (ex. fever and strenuous exercise)
- Pathologic
o Prerenal, renal, post-renal
28
How can pathological prerenal causes of prerenal proteinuria be ruled out?
- History
- Normal serum protein
- Lack of hemoglobinemia, myoglobinemia, hemogloboniuria, myoglobinuria
29
Prerenal proteinuria: physiological/benign
- Strenuous exercise
- Seizures
- Fever
- Extreme heat or cold stress
30
Prerenal proteinuria: pathological
- Paraproteinemias
o Multiple myeloma
o Lymphomosarcoma
o Leukemia
o Chronic infections
- Hemolytic anemia
- Rhabdomyolysis
- *NOT ALBUMIN BEING LOST
31
Post renal proteinuria
- Inflammation or hemorrhage in LUT
o Cystitis, metritis prostatitis, neoplasia
o “active”: urine sediment expected
o Occult UTI: cushings, DMs, other causes of PU/PD
32
Renal proteinuria
- Disorders of glomeruli
o Loss of albumin (smaller proteins)
o Larger MW proteins prevented (globulins)
- Disorders of glomeruli
o Mild
o Low molecular weight proteins (polypeptides and AAs)
- *urine protein electrophoresis can be used to differentiate
- *QUANTIFICATION IS ESSENTAL
33
What is the hallmark of glomerular disease?
- Proteinuria in face of “inactive sediment”
o No WBCs, bacteriuria, hematuria
34
What are the sequalae’s of glomerular diseases?
- Chronic renal failure
- Nephrotic syndrome
- Hypercoagulability: thrombosis
- Systemic hypertension
35
What are the 4 components of nephrotic syndrome?
- Proteinuria
- Hypoalbuminemia
- Hypercholesterolemia
- SC edema or body cavity effusions
36
Proteinuria: dipstick analysis
- If protein is 1+ or more with USG <1.035
- If protein is 2+ or more with USG >1.035
- *strips only detect albumin concentration >30mg/dl (takes a bit)
- Can use sulfosalicylic acid turbidity (SSA) to detect lower levels
37
What are some dipstick false positive results (proteinuria)?
- Very alkaline urine
- Very concentrated urine: CATS
o Made for human urine
- Blood contamination or other cellular contaminants: sperm, pyuria
- Some medications: penicillin
38
What are some dipstick false negative results (proteinuria)?
- In presence of non-albumin proteins OR in acidic urine
39
Proteinuria: UPCR
- Used to quantify magnitude or protein loss
- ONLY done once results of complete UA have been evaluated
- Should be done on a cysto sample
- Random sample of urine or pooled samples
- CANNOT BE USED to differentiate patients with glomerulonephritis from renal amyloidosis
o Amyloidosis: is much worse (need to biopsy the kidney)
40
*****EXAM*****What are the normal ranges of UPCR ratio in dogs and cats?
- UPC ration <0.2=normal
- Grey zone: >0.2-0.5 (dogs) and >0.2-0.4 (cats)
- Abnormal: >0.5 (dogs) and >0,4 (cats)
41
Proteinuria: USG
- If acute glomerular disease=normal
- If chronic glomerular disease=isothenuric range
- *presence of concentration urine does NOT rule out the possibility of significant glomerular disease
o USG 1.035 with 3+ proteinuria is highly significant if inactive sediment
42
What might medullary amyloidosis result in, in terms of USG?
- Isosthenuria w/o proteinuria due to physical disruption of medullary concentrating gradient
43
What is cylindruria?
- Hyaline or protein casts seen with glomerular disease
44
Proteinuria: serum biochem panel
- AZOTEMIA
- Dehydration
- HYPOALBUMINEMIA and hypercholesterolemia (if sufficient magnitude)
- Nonregenerative anemia, hyperphosphatemia, mild hypocalcaemia, metabolic acidosis
45
Coagulation abnormalities
- Glomerular disease can be associated with hypercoagulability and thromboembolism
- Decreased plasma concentration of antithrombin III
- Increased platelet aggregation
46
Renal imaging: proteinuria
- May be normal or increased in size with acute glomerulonephritis or renal amyloidosis
- Small, irregular: chronic glomerulonephritis
47
What are the causes of glomerulonephritis?
- Infectious causes
- Inflammatory/immune diseases
- Neoplasia
- Idiopathic
- Metabolic
- Familial
- Drug induced
- *similar things cause amyloidosis
48
Renal biopsy: proteinuria
- ONLY way to differentiate glomerulonephritis from amyloidosis
o Amyloidosis=usually progressive and fatal disease
