6 - Hematuria And Proteinuria

Question 1

Hematuria definition?

Answer 1

> 3 RBC/HPF (high power field)

Question 2

Warning sign of hematuria?

Answer 2

Gross hematuria (hmm)
Sign of malignancy

Question 3

Besides malignancy hematuria can be?

Answer 3

Urinary calculi
UTI
Carcinoma of kidney or bladder

Question 4

Initial hematurea

Answer 4

Blood at beginning of stream

- penile/urethral source

Question 5

Terminal hematuria?

Answer 5

Blood at end of stream
- prostatic urethral or bladder neck source

• Posterior urethral polyps
• Vascular neck tumors

Question 6

Total hematuria?

Answer 6

Blood throughout
- bladder or upper tract source

• stone
• tumor
• TB
• nephrotic syndrome

Question 7

ROS for hematuria?

Answer 7

Are the following symptoms present?
– Dysuria
    • Painful intermittently (beginning/end of urination) 
    • Painful throughout
– Symptoms of bladder irritability
    • frequency, urgency, etc. 
– Urethral discharge? 
– Fever, pain 
– Trauma, menses

Get an abdominal/pelvic/rectal exam to r/o differential

Question 8

Renal or extra renal?

Answer 8

Renal
− Glomerular
− Non-glomerular
− Cysts
− Calculi
− Neoplasms

Extra-renal
– Benign prostatic
hyperplasia 
– Infections 
– Drugs 
– Calculi 
– Neoplasms 
– Blood disorders 
– Trauma 
– Pelvic radiation 
– Genital or anal bleeding

Question 9

DDX for hematuria?

PP ON THIS

Answer 9

• Period 
• Prostate, papillary necrosis 
• Obstructive uropathy 
• Nephritic syndrome 
• Trauma, tumor, tuberculosis, thrombosis
(renal vein) 
• Hematologic (blood disorder, sickle cell) 
• Infection/inflammation 
• Stones

Question 10

1st thing to do w hematuria?

Answer 10

Urinalysis
– 1st morning void is best
– Dipstick can detect as few as 2 RBC/HPF
– If positive → get 3 samples at least 1 wk apart for
confirmation

Question 11

False pos hematuria?

Answer 11

Myoglobinuria, hemoglobinuria, bacteria, oxidizing
agents, hydrochloric acid, concentrated urine,
menses, vigorous exercise, beets/rhubarb

Question 12

False neg hematuria?

Answer 12

High vitamin C/ascorbic acid levels

Question 13

If pos heme UA?

Answer 13

Confirm w microscopy

Culture and sensitivity

• ID and treat
• repeat 4-6 weeks

Cytology (if persistent)
- r/o cancer

Question 14

Imaging for hematuria?

Answer 14

CTU

Cystoscopy (urology)

Question 15

Referrals for hematuria?

Answer 15

Nephrology

Urology if:

• calculi
• ureteral, cystic, urethral origin

Question 16

“Flow” chart?

Answer 16

Get it “flow”

Slide 16

Question 17

Pseudohematuria?

Answer 17

Dipstick pos
Microscopic neg

Hemoglobinuria - black urine - (hemolysis, hemolytic
anemia, malaria) - dark from at extra-renal source

Myoglobinuria - rhabdo, trauma, sock, acute tubular necrosis

Foods

Food coloring

Drugs

Question 18

Pance peral

Answer 18

AN OLD PERSON W/ A HISTORY OF SMOKING (esp., male) PRESENTING W/ PAINLESS HEMATURIA HAS BLADDER CANCER UNTIL PROVEN OTHERWISE!!

Question 19

Definition of proteinuria?

Answer 19

150mg/24hrs

Question 20

Microalbuminuria?

Answer 20

30-300

> 300 dipstick will find it

Question 21

Nephrotic proteinuria?

Answer 21

> 3.5 g/day

Question 22

Glomerular proteinuria?

Answer 22

Effacement of epithelial cell foot processes and; altered glomerular permeability w/ ↑ filtration fraction of normal plasma proteins; heavy proteinuria
– Diabetic nephropathy

Basically a broken glomerulus

Question 23

Tubular proteinuria?

Answer 23

Faulty reabsorption of normally filtered proteins (i.e., beta-2-macroglobulin and immunoglobulin light chains) in proximal tubule
– ATN, toxic injury (lead, aminoglycosides), drug-induced interstitial nephritis, and hereditary metabolic disorders (Wilson disease and; Fanconi syndrome)

Broken reabsorption

Question 24

Overload proteinuria?

Answer 24

Overproduction of circulating, filterable plasma proteins (i.e., monoclonal gammopathies = Bence Jones proteins, myoglobin, or hemoglobin)
– Multiple myeloma, rhabdomyolysis, hemolysis

You just have too much protein for the kidney to handle

Question 25

Functional proteinuria

Answer 25

Benign - stressors - illness, exercise, orthostatic proteinuria #crossfitlife

Question 26

Microalbuminuria is important in?

Answer 26

Diabetics - DM nephropathy - annual screening HTN and other kidney disease

Question 27

Microalbuminuria is a risk factor for?

Answer 27

Cardiovascular disease

Question 28

Dipstick testing w pos proteinuria is usually?

Answer 28

Incidental pos (too much protein in diet etc) REPEAT in 24hrs w 1st morning void - no exercise

Question 29

Gold standard of proteinuria?

Answer 29

24hr collection Pts will hate you

Question 30

Spot samples?

Answer 30

UACR - urinary albumin creatine ration - instead of 24 hr - recommended for DM UPCR - urinary protein creatine ration - better for monitoring established proteinuria

Question 31

Eval of proteinuria?

Answer 31

``` Quantify - urine labs Serum Chem (CMP) - GFR, BUN, creatinine, serum albumin, lipids US Urinary electrophoresis Renal biopsy ```

Question 32

Clinical complications of proteinuria:

Answer 32

Acute renal failure • Generalized edema (due to hypoalbuminemia) • Pulmonary edema

Question 33

Proteinuria pts are at a higher risk for?

Answer 33

– bacterial infection (including spontaneous bacterial peritonitis) – arterial and venous thrombosis (including renal vein thrombosis [RVT]) – cardiovascular disease

Question 34

Tx for proteinuria?

Answer 34

Goal <0.5g/day Lower proteinuria >> lowering BP (CKD progression) ACE or ARB Baseline serum potassium and creatine Wt loss Protein restriction Nephrology referral

Question 35

ACE and ARBs show?

Answer 35

– ↓ intra-glomerular pressure – ↓ protein excretion – slow progression of renal disease

Question 36

Wt loss effect on proteinuria?

Answer 36

5% wt loss can decrease proteinuria up to 20-30%

Question 37

Now i lay me down to sleep, i pray to god my muscles peak

Answer 37

If i should die before i wake, i hope heaven has unlimited protein shakes