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Renal I > Nephrology: Proteinuria and Hematuria ( Lect. 1/2) > Flashcards

Nephrology: Proteinuria and Hematuria ( Lect. 1/2) Flashcards

1
Q

List the cellular layers that a protein must traverse to reach the proximal tubule if it starts within an afferent arteriole ?

A

Capillary endothelium: has fenestrations(pores) that are large enough for protein molecules to traverse, however under normal conditions they do not.

Capillary endothelium basement membrane: typically negatively charged due to glycocalyx, heparin sulfate and other - charged proteins. This helps stop the outflow of plasma proteins into Bowmans Space.

Podocyte: Has foot processes that wrap around the capillary. Aids in filtration and helps select out larger molecules so that they do not go into Bowmans space.

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2
Q

What is the normal 24 hr protein excretion ?

A

60-150 mg (so its false that all proteins cannot be filtered, there is some filtration just of smaller particles)

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3
Q

What percent of daily protein excretion is albumin ?

A

15% (10-20 mg)

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4
Q

What are the more frequently excreted proteins found in the urine ?

A

Small molecular weight
Light Chain
Immunoglobulins

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5
Q

Which proteins are not filtered ?

A

Tamm-Horsfall proteins (if these are present it is indicative of pathology)

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6
Q

Colorimetric reaction based on the chemical interaction between Tetrabromophenol Blue in citric acid buffer with urinary albumin. What is a positive and negative reading on this dipstick ?

A

Green –> Negative

Blue–> Positive

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7
Q

What is the only protein measured by Tetrabromophenol blue ?

A

ALBUMIN ! The dipstick is only useful for reading this !

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8
Q

Describe the Number Scale used for quantifying amount of albumin in the urine

A

Trace 10 – 20 (30?) mg/dl (only truly important in diabetes and heart disease unless persistent.)

1+ 30 (100?)mg/dl
2+ 100 (200?) mg/dl
3+ 300 mg/dl
4+ 1000 mg/dl

To estimate the 24 hr protein concentration of the urine, multiply the number scale value by 10. Ex. If you have a 2+ dipstick value then you know that you have a 100 mg/dl, So 100 x 10 = 1000 mg/Day.

There is some discrepancy between Slide 11 and 12 on what the Number value coo relations are, which is why I put these in parentheses.

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9
Q

Why is hematuria a confounding problem in urinalysis of albumin ?

A

When RBC’s are lost into the urine there is inevitably going to be excess albumin lost with it. This will skew your reading to be higher then it should be.

The reading for albumin in albuminuria with concurrent hematuria will be always be higher (than without )unless there is a true loss of albumin not linked to hematuria.

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10
Q

What is the level of protein in the urine which delineates between microalbuminuria and macroalbuminuria ?

A

> 300 mg/day !

30-300 mg/day is microalbuminuria, anything above this is macro.

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11
Q

If the urine dipstick is positive what do you automatically have ?

A

Macroalbuinuria ( Trace 10-30 mg/dl. 30 x 10 =300)

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12
Q

Despite 24 hr collection being the “Gold Standard” for Urinalysis. What technique is becoming more useful ?

A

Spot Random Collection (protein/Creatinine ratio)

Should do this earlier in the morning rather than in the afternoon.

Proven to be just as efficacious as 24 hr collection.

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13
Q

What are the four classifications of proteinuria ?

A

Tubular
Overflow
Orthostatic
Glomerular

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14
Q

Tubular

A 
Amount: .5-2 mg
Type of Protein: B2-microglobulin, albumin
HTN: None
Renal Failure: Mild
Hematuria:no
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15
Q

Overflow

A 
Amount: .5- > 3g 
Type of Protein:Light chain immunoglobulin (kappa- delta)
HTN: None
Renal Failure: Marked 
Hematuria: No
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16
Q

Orthostatic

A 
Amount: .5-2g
Type of Protein: Albumin
HTN: No
Renal Failure: No
Hematuria: No
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17
Q

Glomerular

A 
Amount: > 3.5 mg
Type of Protein: Albumin
HTN: VERY HIGH
Renal Failure: Moderate 
Hematuria: Moderate
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18
Q

All patients with proteinuria must have what labs/diagnostics done ?

A

Serum creatinine

Urine microscopy

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19
Q

Fatty Casts and oval bodies are indicative of which syndrome ?

A

Nephrotic Syndrome ( nephrOtic = Oval bodies, Fat Casts (fat people are round like and O))

You may also see Cholesterol Crystals in nephrotic syndrome.

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20
Q

RBC casts and dysmorphic RBC’s are indicative of which condition ?

A

Glomerulonephritis

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21
Q

Leukocytes, PMN’s and White blood cell casts indicate what condition ?

A

Infection

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22
Q

Leukocytes and eosinophils indicate what condition ?

A

Interstial Nephritis

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23
Q

Foamy urine ?

A

Protein in it –> Albuminuria

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24
Q

What is a Fatty Cast ? (Starred)

A

Cholesterol deposit on Tamm-Horsfall Protein

Remember: Fatty Cast = nephrOtic syndrome

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25
Q

What is an Oval Fat Body ? (Starred)

A

Cholesterol on Renal Tubular Cells

Remember Oval Fat Body = nephrOtic syndrome

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26
Q

Which two conditions diagnosed by bloodwork are often seen in Nephrotic Syndrome ?

A

Hypoalbuminemia ( due to loss in the urine)

Hypercholesteremia (Cholesterol is present in Fatty Casts and in Oval Bodies)

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27
Q

What is the protein level and/or protein:creatinine needed in order to diagnose Nephrotic Syndrome ?

A

Protein level : > 3.5 mg/ day

Protein:Creatinine: >3.5 or higher

28
Q

What are the 5 kinds of Nephrotic Syndrome( Proteinuria) ?

A 
Minimal Change 
Membranous 
Focal Segmental Glomerular Sclerosis (FSGS)
Membranoproliferative 
IgA Neuropathy.
29
Q

What age group should you think of when people say “Minimal Change” Nephrotic Syndrome ?

A

Children (75% who have this are children)

30
Q

What age group should you think of when you say “Membranous” Nephrotic Syndrome ?

31
Q

What are two reasons why Nephrotic Syndrome includes/causes Hyperlipidemia ?

A
  1. Reduced oncotic pressure stimulates the production of Apoproteins (High LDL and VLDL) by the liver
  2. There may be reduced clearance of lipids due to decreased Lipoprotein Lipase production or decreased receptor clearance.
32
Q

How would you treat Nephrotic Syndrome associated hyperlipidemia ?

33
Q

What molecules are altered that lead to hypercoagualability in patients with Nephrotic Syndrome ?

A

Pro-coagulants are up-regulated :fibrinogen, Factor V, Factor VIII, von Willebrand Factor

Anti-coagulants are down regulated:Factor IX, Factor XI, Factor XII,Anti-thrombin III, Plasminogen, alpha-1 antitrypsin (anti-coagulants).

34
Q

Hypercoagulability in Nephrotic Syndrome may lead to Renal Vein Thrombosis. Which kind of Nephrotic Syndrome will you see this in most often ?

A

Membranous.

This complication rarely leads to renal impairment however.

Embolic complication may be present in 20% (Venous embolism more common then Arterial)

35
Q

Nephrotic Syndrome must be evaluated in which type of patients ? Why ?

A

Diabetics

Indicative of advanced renal disease.
Usually does not require biopsy

36
Q

In a patients without diabetes who presents with nephrotic syndrome (proteinuria) , what must be screened ?

A

Autoimmune
Infective
Malignancies

Often requires biopsy

37
Q

Although Tubular Proteinuria is considered a Nephrotic Proteinuria, what is unusual about it ?

A

the protein seen in it is .5-2 mg/ day meaning that it is below the 3.5 mg/day threshold for Nephrotic Proteinuria.

38
Q

Which portion of the tubule is affected in Tubuluar Proteinosis ?

A

The Proximal tubule

39
Q

In Tubular Proteinuria, the basement membrane is intact making it difficult for albumin to leak out. What protein typically is found in the urine ?

A

B2-microglobulin

40
Q

What are diseases that will lead to tubular damage and thus Tubular proteinuria ?

A

Heavy metals ingestion
Antibiotic usage
Interstitial nephritis.

41
Q

Is Orhtostatic Proteinuria in Nephrotic range for proteinuria ?

A

Nope ! .5-2.5 g/day

42
Q

How must urine for orthostatic proteinuria be collected to diagnose this condition ?

A

Split at two times
One overnight Supine specimen.
One upright daytime specimen (should have a significantly higher protein concentration)

43
Q

Is Overflow Proteinuria in the Nephrotic range ?

A

Yes ! .5 - >3.5 g/ day

44
Q

Describe the glomerular structure in Overflow Proteinuria ?

A

The structure is normal ! However, there is an overproduction of small MW proteins which “overflows” the kidneys ability to filter/reabsorb –> loss in the urine

45
Q

Which disease leads to increased production of Kappa-Delta particles –> Overflow proteinuria?

A

MULTIPLE MYELOMA !

46
Q

Again, what is the normal albumin loss in urine per day ?

A

10-20 mg/ Day

47
Q

What is an abnormal Spot Collection Urinary Albumin: Urine Creatinine ?

48
Q

Microalbuminuria (<3 g/day) is indicative of what process in diabetics ? (Starred) !

A

Incipient Diabetic Nephropathy in 85% of patients

must be measured in all Type I Diabetics after 5 years of onset and in all Type II Diabetics upon initial presentation !!!!
A1C, Urinalysis and Microalbimurina screen

49
Q

What 3 diseases are associated with microalbuminuria in patients w/o diabetes ?

A

Peripheral Vascular Occlusive disease
Coronary Artery disease
L Vent. Hypertrophy

However, this has little correlation with renal disease.

50
Q

In a routine helathy individual who’s dipstick is positive for proteinuria, what must be done in follow up ?

A

Urine protein/Creatinine

51
Q

In HTN and diabetics with a negative dipstick, what should be done in follow up ? Positive ?

A

Spot urine Albumin/Creatinine

Protein/Creatinine

52
Q

Do Hematuria dipsticks measure whole RBC’s or free hemoglobin ?

A

Free Hemoglobin

The chemical on the dipstick will lead to lysis of RBC –> free hemoglobin

53
Q

What is the normal RBC count in the urine ?

A

less than 3 RBC’s.

54
Q

What condition may skew a Hematuria dip stick ?

A

Rhabdomyolysis (since dipstick can also be sensitive to myoglobin)

If you have + Dipstick but no RBC’s on microscopy think Rhabdo !

55
Q

Review the Slides for Normal and Dysmorphic RBC’s (Starred)

A

Slide 48 and 51

56
Q

How are dysmorphic RBC’s formed ?

A

By squeezing through the Basement membrane and fenestrations in in the endothelium. Causes their shape to distort and no longer be spheroid.

57
Q

What constitutes a RBC cast ?

A

RBC’s + Tamm Horsfell proteins

Remember this is indicative of Glomerulonephritis

58
Q

Nephritic Syndrome Glomerulonephritis can be summed up with the pneumonic PHAROH. What are the constituents of this ?

A

P: Proteinuria (< 3.5 g , less than nephrotic range)
H: Hematuria
A: Azotemia (High Levels of Nitrogen within the blood, either urea or creatinine)
R: RBC Casts
O: Oliguria
H: Hypertension

59
Q

What will you see in Nephritic syndrome that you will not see in Nephrotic

A

Dysmorphic RBC’s
WBC’s
RBC cast
Granular Casts

60
Q

What are the most common cases of isolated hematuria ?

A

Contamination (menstral cycle)
UTI
Urethritis
Exercise (runners Hematuria from irritation of the trigone)

61
Q

TICS (For Isolated Hematuria)

A

Trauma ,Tumor, Toxin
Infection,Inflammation (glomerulonephritis)
Cyst
Stones, Sickle Cell, Surgery

62
Q

What will be seen in the urine of an individual with Familial Thin Basement Membrane ?

A

blood but no protein or (renal failure)

63
Q

What are the common glomerular diseases associated with hematuria ?

A 
Familial Thin Basement Membrane
IgA Neuropathy 
Alports disease
SLE
Vasculitis
64
Q

What is the typical work up for hematuria ?

A

Urine Cytology
Imaging on GU tract
Cystoscopy

65
Q

If you see hematuria with proteinuria, what should you think ?

A

Presence of co-existent proteinuria should raise an immediate concern for renal parenchymal disease

66
Q

What should you think of persistent isolated hematuria

A

A urogenital mass lesion should be suspected in any patient with persistent isolated hematuria

Renal I (8 decks)

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