Hematuria (Tyler)

Question 1

After centrifuging if there is red sediment with RBC on microscopy present then

Answer 1

it’s gross hematuria

Question 2

if the supernatant is positive for hemoglobin by urine dipstick

Answer 2

hemoglobinuria (intravascular hemolysis)
or
myoglobinuria (muscle breakdown)

Question 3

if the supernatant is not positive for hemoglobin by urine dipstick and is red

Answer 3

beet or blackberry ingestion
drugs
phenazopyridine 
rifampin
phenothiazines
sulfasalazine

Question 4

if the supernatant is not positive for hemoglobin by urine dipstick and is brown or black

Answer 4

liver disease
acute porphyria
ochronosis
malignant melanoma

Question 5

Gross hematuria is defined as

Answer 5

> 3500 RBC per high power field

Question 6

microscopic hematuria is defined as

Answer 6

2-3 RBC per high power field

Question 7

DDx for hematuria

Answer 7

RCC
Glomerulonephritic (like IgA)
Medullary sponge kidney

cystitis 
urinary calculi
BPH (microscopic)
transitional cell carcinoma
PCKD
anticoag use
prostate cancer
papilalry necrosis
renal infarction 
interstitial nephritis 
radiation
atrophic vaginitis
schistosomiasis
menses

Question 8

when should you not workup a single episode of gross hematuria

Answer 8

confirmed transient case such as
trauma/infection/menses/exercise induced

alarm features still should show concern for malignancy

Question 9

is there evidence that suggested isolated episode is less serious than recurrent episodes of hematuria?

Answer 9

nope therefore work people up if there isn’t a self-limiting cause identified

Question 10

hematuria in Pts with anticoagulation therapy

Answer 10

do not attribute only to the therapy!

Question 11

blood in urine may cause

Answer 11

dysuria even in absence of UTI

Question 12

in older men microscopic hematuria

Answer 12

should always be investigated due to increased risk of malignancy

Question 13

nonglomerular lower urinary tract source should think

Answer 13

urethritis/prostatitis 
BPH
cystitis 
bladder carcinoma
prostate carcinoma 
exercise induced

Question 14

nonglomerular upper urinary tract source should think

Answer 14

ureteral calculus
renal calculus
hydronephrosis 
pyelonephritis 
polyscystic kidney disease
renal trauma
papillary necrosis 
interstitial nephritis
sickle cell
renal infarction
renal TB
infection with schistosoma
renal vein thrombosis

Question 15

primary glomerulonephritis should think

Answer 15

IgA nephropathy
Postinfectious
Idiopathic

Question 16

secondary glomerulonephritis

Answer 16

SLE
Wegener’s
other vasculitides

Question 17

what are the familial causes of hematuria

Answer 17

thin basement membrane disease

alport syndrome (hereditary nephritis)

Question 18

alarm symptoms with hematuria

Answer 18

increased age (40-50) and male

constitutional symptoms

social Hx that increases risk of neoplasia

positive family history of deafness or renal disease suggests familial disease like alport

Question 19

if a urine dipstick is positive for blood and microscopic exam does not show RBC then

Answer 19

myoglobinuria and hemoglobinuria should be considered

Question 20

true macroscopic hematuria

Answer 20

is always pathological

Question 21

microscopic hematuria may be

Answer 21

transient

Question 22

all pts with hematuria should

Answer 22

have a urine culture performed

Question 23

essentials of diagnosis of RCC

Answer 23

Gross or microscopic hematuria

Flank pain or mass in some patients

Systemic symptoms such as fever, weight loss may be prominent

Solid renal mass on imaging

Question 24

Demographics of RCC

Answer 24

peak incidence in 6th decade

M:F 2:1

cause unknown

cigarette smoking risk factor

Von hippel-lindau syndrome is major familial risk factor

hereditary papillary renal cell carcinoma, hereditary leiomyoma-renal cell carcinoma, Birt-Hogg-Dube syndrome also risk factors

dialysis related acquired cystic disease also major concern (10% incidence)

Question 25

signs and symptoms of RCC

Answer 25

Hematuria (gross or microscopic) in 60% of cases Flank pain or an abdominal mass in ~30% Triad of flank pain, hematuria, and mass in ~10–15%, often a sign of advanced disease Fever occurs as a paraneoplastic symptom Symptoms of metastatic disease (cough, bone pain) in ~20–30% at presentation Often detected incidentally

Question 26

DDx with RCC

Answer 26

``` o Angiomyolipomas (fat density usually visible by CT) Renal pelvis urothelial cancers (more central location, involvement of the collecting system, positive urinary cytology) ``` Renal oncocytomas (indistinguishable from renal cell carcinoma preoperatively) Renal abscesses Adrenal tumors, certain types

Question 27

lab tests for RCC

Answer 27

hematuria in 60% paraneoplastic syndromes erythrocytosis from increased EPO in 5% (anemia is actually more common though)

Question 28

imaging studies for RCC

Answer 28

CT and MRI are most valuable Chest radiographs for pulmonary metastases Bone scans for large tumors, bone pain, elevated alkaline phosphatase levels MRI and duplex Doppler ultrasonography can assess for the presence and extent of tumor thrombus within the renal vein or vena cava in selected patients

Question 29

prognosis for RCC

Answer 29

Tumors confined to the renal capsule (T1–T2) demonstrate 5-year disease-free survivals of 90–100% after radical nephrectomy Tumors extending beyond the renal capsule (T3 or T4) and node-positive tumors have 50–60% and 0–15% 5-year disease-free survival, respectively For patients with solitary resectable metastases, radical nephrectomy with resection of the metastasis has resulted in 5-year disease-free survival rates of 15–30%

Question 30

When to refer for RCC

Answer 30

Refer patients with solid renal masses or complex cysts to a urologist for further evaluation Refer patients with renal cell carcinoma to a urologic surgeon for surgical excision Refer patients with metastatic disease to an oncologist

Question 31

IgA nephropathy

Answer 31

primary renal disease with IgA deposition in mesangium can be primary or secondary most common glomerular disease worldwide especially in ASia usually in children and young adults M:F 2:1 or 3:1 rarely nephrotic

Question 32

secondary IgA nephropathy

Answer 32

Hepatic Cirrhosis Celiac Disease HIV infection CMV

Question 33

where is gross hematuria common/uncommon

Answer 33

uncommon in intrinsic kidney disease but is common in IgA nephropathy and cyst rupture as well as ADPCKD

Question 34

is IgA nephropathy entirely benign

Answer 34

nope | 40% of patients will reach ESRD after 20ish yrs

Question 35

episodic hematuria with URI should suggest

Answer 35

IgA nephropathy

Question 36

MEST classification for IgA nephropathy

Answer 36

Mesangial hypercellularity Endocapillary hyperceullularity Segmental glomerulosclerosis Tubular atrophy/interstitial fibrosis

Question 37

y lab tests for IgA

Answer 37

Urinalysis variably demonstrates protein, red blood cells, and red blood cell casts. Serum creatinine may be elevated. Urine protein-to-creatinine ratio reveals mild increases in proteinuria. Serum IgA is elevated in only 50% of patients and supports the diagnosis but has little clinical utility.

Question 38

Medullar Sponge Kidney genes/chromosome

Answer 38

MCKD1 on 1 | MCKD2 on 16

Question 39

CT shows what in MSK

Answer 39

Cystic dilatation of the distal collecting tubules A striated appearance in this area Calcifications in the renal collecting system

Question 40

is MSK benign

Answer 40

yes, usually but is associated with increased calcium phosphate and oxalate stones these pts also exhibit reduced kidney concentrating ability with incrased frequency of UTI