Hematuria ~ Tyler Flashcards
Distinguish between macroscopic (gross) hematuria and microscopic hematuria relating specific laboratory parameters in defining each.
Risk factors for bladder cancer include…
Risk factors for bladder cancer include cigarette smoking, occupational exposure to chemicals used in certain industries (leather, dye, and rubber or tire manufacturing), heavy phenacetin use, past treatment with high doses of cyclophosphamide, and ingestion of aristolochic acid found in some herbal weight-loss preparations.
All patients with even a single episode of gross hematuria should receive a thorough history and physical examination followed by urologic or nephrologic evaluation unless a self-limited, transient cause is identified (e.g. trauma, infection, menses, exercise induced). Even in patients with transient causes, if there are significant risk factors for malignancy (see Alarm Features), further evaluation should be considered. A careful history should also be performed in all patients with microscopic hematuria. Most experts recommend additional evaluation only if one or more repeated urinalyses confirm microscopic hematuria. However, there is no evidence to suggest that an isolated episode is less serious than recurrent episodes. Thus, some authors recommend that unless a self-limited cause is found, a complete evaluation should be undertaken, especially in men over the age of 40 and those with risk factors for significant disease (Figure 2).
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What are the alarm symptoms associated with hematuria?
Alarm Symptoms associated with Hematuria: • Increased age (particularly age older than 40–50 years) and male sex are associated with an increased incidence of neoplasm. • Constitutional symptoms (weight loss, appetite loss, chronic malaise, or fatigue) suggest malignancy or chronic infection. • A variety of factors in the personal and social history may increase the likelihood of a malignancy, including a heavy smoking history, exposure to aniline dyes in leather, tire, or rubber manufacturing industries; previous treatment with cyclophosphamide or pelvic irradiation; and ingestion of herbal weight loss preparations containing aristolochic acid. • A positive family history of deafness or renal disease suggests familial disease, e.g. Alport syndrome
• Hematuria in patients receiving anticoagulation therapy should not be attributed solely to the anticoagulant. • Blood in the urine can be an irritant and may cause dysuria, even in the absence of urinary tract infection or kidney stone disease. • Because older men with microscopic or gross hematuria are more likely to have a genitourinary malignancy, diagnostic evaluation should be pursued even in the presence of nocturia, polyuria, and decreased force of urinary stream (symptoms suggestive of benign prostatic hypertrophy). • Given significant overlap in microscopic and gross hematuria, it is suggested that adding an approach to determining glomerular versus non-glomerular causes of hematuria is important to help define a patient’s diagnosis more accurately.
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Identify glomerular causes of hematuria.
Identify non-glomerular causes of hematuria.
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What are the pivotal points that help distinguish glomerular hematuria from non-glomerular hematuria?
Pivotal points that help distinguish glomerular hematuria from non-glomerular hematuria include dysmorphic RBCs (acanthocytes), red cell casts, new or acutely worsening hypertension or proteinuria, and increased creatinine. while these abnormalities may also be seen in some of the interstitial and vascular causes of hematuria, they will not be found when hematuria is caused by a renal structural abnormality or an abnormality distal to the kidneys.
Visible blood clots, which are never due to a ______ cause, are another pivotal point, indicating a what kind of source?
Visible blood clots, which are never due to a glomerular cause, are another pivotal point, indicating a lower urinary tract source of the hematuria.
What are the essentials of diagnosis for RCC?
• Essentials of Diagnosis o Gross or microscopic hematuria o Flank pain or mass in some patients o Systemic symptoms such as fever, weight loss may be prominent o Solid renal mass on imaging
what are the familial dz associations of RCC?
o Familial: von Hippel-Lindau syndrome, hereditary papillary renal cell carcinoma, hereditary leiomyoma-renal cell carcinoma, Birt-Hogg-Dube syndrome o Association: dialysis-related acquired cystic disease
Sx and signs of RCC?
• Symptoms and Signs o Hematuria (gross or microscopic) in 60% of cases o Flank pain or an abdominal mass in ~30% o Triad of flank pain, hematuria, and mass in ~10–15%, often a sign of advanced disease o Fever occurs as a paraneoplastic symptom o Symptoms of metastatic disease (cough, bone pain) in ~20–30% at presentation o Often detected incidentally
DDx of RCC?
o Angiomyolipomas (fat density usually visible by CT) o Renal pelvis urothelial cancers (more central location, involvement of the collecting system, positive urinary cytology) o Renal oncocytomas (indistinguishable from renal cell carcinoma preoperatively) o Renal abscesses o Adrenal tumors, certain types
What type of imaging is needed to dx RCC?
o Solid renal masses on abdominal ultrasonography or CT o CT and MRI scanning are the most valuable imaging tests; they confirm character of the mass, stage the lesion o Chest radiographs for pulmonary metastases o Bone scans for large tumors, bone pain, elevated alkaline phosphatase levels o 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
In regards to RCC, what are the most valuable imaging tests; they confirm character of the mass, stage the lesion?
CT and MRI scanning are the most valuable imaging tests; they confirm character of the mass, stage the lesion
What is the prognosis of RCC?
o Tumors confined to the renal capsule (T1–T2) demonstrate 5-year disease-free survivals of 90–100% after radical nephrectomy o 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 o 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%
When to refer patients for RCC?
o Refer patients with solid renal masses or complex cysts to a urologist for further evaluation o Refer patients with renal cell carcinoma to a urologic surgeon for surgical excision o Refer patients with metastatic disease to an oncologist
IgA Nephropathy important characteristics
• Primary renal disease with IgA deposition in the glomerular mesangium • Inciting cause unknown • Can be a primary (renal-limited) disease • Can be secondary to o Hepatic cirrhosis o Celiac disease o HIV infection o Cytomegalovirus infection • Most common primary glomerular disease worldwide, particularly in Asia • Usually occurs in children and young adults • Males affected 2–3 times more often than females • Gross hematuria, frequently associated with a mucosal viral infection such as an upper respiratory tract infection • Urine becomes red or smoky-colored 1–2 days after illness onset • Can present anywhere along the nephritic spectrum from asymptomatic microscopic hematuria to rapidly progressive glomerulonephritis • Rarely, a nephrotic syndrome can be present as well • Proteinuria: minimal to nephrotic range • Glomerular hematuria: microscopic is common; macroscopic (gross) can occur after infection • Positive IgA staining on kidney biopsy
Gross hematuria (red urine) is uncommon with intrinsic kidney diseases but is commonly encountered in ____ nephropathy and cyst rupture in ______ _______ _____ _____ ______ _______,
Gross hematuria (red urine) is uncommon with intrinsic kidney diseases but is commonly encountered in IgA nephropathy and cyst rupture in autosomal dominant polycystic kidney disease.
Is IgA nephropathy a benign condition?
IgA nephropathy is not an entirely benign condition, even when microhematuria is the only clinical presentation. Nearly 40% of patients reach end-stage kidney disease after 20 yr.
Episodic gross hematuria that occurs during upper respiratory infections is a classic presentation for…
Episodic gross hematuria that occurs during upper respiratory infections is a classic presentation for IgA nephropathy.
What is the MEST classification?
o M esangial hypercellularity o E ndocapillary hypercellularity o S egmental glomerulosclerosis o T ubular atrophy/interstitial fibrosis.
What is the prognosis and specific lab tests for IgA nephropathy?
• Prognosis is excellent with normal function and low proteinuria; accordingly, kidney biopsy is restricted to patients with sustained proteinuria >1 g/day or worsening kidney function. • Laboratory Tests o Urinalysis variably demonstrates protein, red blood cells, and red blood cell casts. o Serum creatinine may be elevated. o Urine protein-to-creatinine ratio reveals mild increases in proteinuria. o Serum IgA is elevated in only 50% of patients and supports the diagnosis but has little clinical utility.
What is medullary sponge kidney?
• A relatively common and benign disorder • Present at birth and not usually diagnosed until the fourth or fifth decade • Caused by autosomal dominant mutations in the MCKD1 or MCKD2 genes on chromosomes 1 and 16, respectively • Kidneys have a marked irregular enlargement of the medullary and interpapillary collecting ducts
