RENAL- Hematuria

Question 1

What amount will change the color of urine?

Answer 1

1ml/L of blood
**RARE danger byitself

Other symptoms
Systemic illnesses causing renal insult or renal end-organ damage
Hypertension
Diabetes
Coagulopathies
Autoimmune
Rash (petechiae/purpura): fatigue, edema, joint pain/swelling, bleeding/bruising
Fecal- or pneumo-uria**

Non-urinary tract diseases
Hepatitis – tea colored
Glomerular Dz – brown, cola colored
Rhabdomyolysis –Brown urine
Foods, food dyes
Contamination- epithelial Menstruation, fictitious

Not always blood
Hydration status
Meds - Pyridium, vitamins

Question 2

What conditin is MC at age >50 ? At what age and condition should u be concered about malignant?

Answer 2

Age >50 – UTI stones
Painless hematuria
Transient or persistent, no other diagnosis

Age <40 - malignancy rare
UTI, stones, VC
Primary glomerular Dz MC
Simple UTI/cystitis in males: rare, not simple!

Question 3

PT c/o the following, what should you consider?
Drops, pink urine, Hurts
Urinating frank blood

Answer 3

Drops, pink urine, Hurts-infection
Urinating frank blood-Infection, stones
Renal parenchymal Dz, glomerular Dz
Malignancy

Clots? excludes glomerular Dz

Question 4

PT c/o the following, what should you consider?

Painful, Dysuria or abd/flank pain,

Answer 4

Infection, stones, trauma

Painless?
Malignancy*
Glomerular causes
Meds - anticoagulants, etc
Prostate, endometriosis, menses
Exercise 
Hereditary - polycystic kidney, nephritis, sickle cell

Question 5

PT c/o the following, what should you consider?
Transient
Persistent

Answer 5

Transient, benign hematuria MC
     Fever, infection, trauma, exercise, post menopausal 
     women
Persistent (both gross and microscopic)
     work-up, Older patient

Question 6

What illness or medical devices can cause hematuria?

Answer 6

Poststreptococcal glomerulonephritis
Recent tx UTI, pyelonephritis -Finish treatment? Tx failure?
Endocarditis, impetigo
Catheter, diagnostic testing
Stents

Question 7

Which meds l/t - tubulointerstitial nephritis -> hematuria

Answer 7

Many antibiotics, 
NSAIDS, 
diuretics
Dilantin, Allopurinol (gout)
Anticoagulants
CAM, Herbal meds

Question 8

What medical dz -> hematuria?

Answer 8

Polycystic kidney disease
Nephritis-Alport’s syndrome
ESRD teenagere, early adults, eye, ear, and hematuria is key

Coagulopathies
SCD
Bladder, renal or prostate cancer

Question 9

What events l/t hematuria?

Answer 9

Travel
TB - microscopic hematuria, sterile pyuria
Parasitic infection - schistosomiasis,(TX Praziquantel) etc

Ironman level-Gross, transient

Question 10

Centrifuge result showed the following…
Sediment clear, supernatant red/brown
Supernatant dip heme positive

Answer 10

Myoglobinuria- Rhado

Other causes
Supernatant red/brown, dip heme negative
Meds, porphyria, beets

Other lab – situation dependent
Urine culture & sensitivity
Urine pregnancy test
Chem panel - BUN/creat, Na, K, glucose
CBC: H&H, platelets - blood loss, chronic dz
STI test
Special tests: Sed rate, ANA, RA, PPD

24hr urine collection-Glomerular vs. tubal dz, FENa

Question 11

How Urine micro RBC is needed for significance?

Answer 11

RBC’s >3/hpf = significant

Dysmorphic RBC’s = glomerular origin

WBC’s >0-3 men, >0-5 women = pyuria

Women – Consider cath
ANy Squamous epithelial cells = contamination

Question 12

Describe each casts?
Red cell casts ->

White cell casts ->

Fatty casts = proteinuria

Granular/Waxy casts ->

Hyaline casts =

Answer 12

Red cell casts ->Glomerular Dz

White cell casts ->Pyelo-, interstitial nephritis

Fatty casts = proteinuria

Granular/Waxy casts -> Advanced renal Dz

Hyaline casts = non-specific -

Question 13

Pt is DX with a stone based of what imaging? at what Stage?

Answer 13

POSTRENAL
Ureter, bladder, urethra or prostate
Cystitis (UTI)
Stones – renal or ureteral
Urethritis
Prostatic obstruction/hypertrophy
Tumor (bladder, prostate)
Instrumentation, urethral trauma
Exercise

Renal ultrasound
Cystoscopy, CT urography for bladder CA - urologist

Question 14

What are the DZ under Nephritic syndromes (Nephritic = glomerular)?

Answer 14

Renal Glomerular Dz
Postinfectious 
IgA nephropathy
Henoch-Schonlein Purpura 
Rapidly progressive (SLE, Wegener’s)
Goodpasture’s syndrome (lung/kidney)
Glomerular basement membrane Dz
Chronic glomerular disease

Work up
Chem panel for renal function
Urine microalbumin (protein studies)
24 hour urine 
Renal ultrasound
Early referral to nephrologist
Renal biopsy 

TX
Search for underlying cause, correct it
Control hypertension, diabetes

Question 15

Pt has the following s/s?
Fever, rash, acute renal insufficiency
arthralgia, eosinophillia, hematuria,
Proteinuria, white cell casts
Medication related or infectious

What are the Renal Non-glomerular dz?

Answer 15

Interstitial nephritis – hematuria plus:

Renal Non-glomerular
Pyelonephritis
Trauma
Renal tumor, cysts, medullary sponge
Renal infarct

PMH, PE***
Renal ultrasound for masses
Intravenous pyelogram (IVP, ULS, CT) for medullary sponge kidney
CT W/ contrast for renal tumors, trauma

Question 16

What do you do with Microscopic hematuria - no obvious Dx?

Answer 16

Repeat UA micro x2 over 3-4 weeks.
Chem panel
Persistent? R/O glomerular causes
24hr urine, renal ULS (uterosacral ligament suspension) are first steps

Cystoscopy first high risk for bladder CA (age, Hx)
Young? Renal ultrasound, IVP or CTU(urography)
Older? Renal ULS, CT, IVP, +/-urine cytology

Question 17

At what size and condtion do you refer to Urologist?

Answer 17

Urologist-Stones >6mm or bilat/multiple
Cancer
Men with UTI

Nephrologist
glomerular Dz
renal parynchemal Dz
Familial renal Dz
Renal mass/tumor

Question 18

Pt it 23 is M has persistent, gross hematuria, +/- mild proteinuria after recent URI.

Answer 18

IgA nephropathy: most common cause of primary glomerulonephritis in developed countries.
Any age, peaks 2nd-3rd decade,
2:1 male predominance
Dx with renal biopsy.
Associated with cirrhosis, celiac dz and HIV.

Young male with progressive hematuria – think IgA nephropathy.

Question 19

Pt is 8yo girl palpable purpura, buttocks, face, colicky abdominal pain, arthritis, gross hematuria, no proteinuria.

Answer 19

Henoch-Schonlein Purpura:
Most common systemic vasculitis in children.
90% kids, usually self-limiting.
Clinical diagnosis – biopsy skin lesions for atypical presentations. Platelets and prothrombin time must be normal for diagnosis
Good prognosis, may recur.

Kids with purpura, hematuria and abd/joint pain – think HSP.

Question 20

PT is 28y F whites with fatigue, fever, arthrialgias, abd pain. Nasal and/or oral ulcers (chronic sinusitis, otitis, cough, dyspnea, hemoptysis, and abnormal CXR, microscopic/ gross hematuria w/o clots, active sediment with red cell casts, renal failure.

Answer 20

Wegener’s granulomatosis: Immune-mediated, small vessel vasculitis. Antineutrophil cytoplasmic antibody (ANCA) associated vasculiities.
All ages,
both genders equal,
whites.
Dx –ANCA antibodies, renal or lung biopsy.
Tx – immunosupression therapy.

Constitutional sx’s, oral/nasal sores, pulmonary sx’s w/ hematuria – think Wegener’s.

Question 21

PT is 30 y F acute renal failure, hematuria, red cell casts with dysmorphic RBC’s, proteinuria; dyspnea, hemoptysis. .

Answer 21

Goodpasture’s: Anti-GBM (glomerular membrane dz) antibody dz. Syndrome = rapidly progressive glomerulonephritis with pulmonary hemorhage. 
Older children, young adults (male > female, more severe dz), 
older adults (female > male). 

Presentation: acute renal failure, hematuria, red cell casts with dysmorphic RBC’s, proteinuria; dypnea, hemoptysis.

Dx: renal biopsy.

Tx: plasmapheresis, immunosupression early - dialysis, renal transplant possible.

Hematuria, rapidly progressive renal failure and hemoptysis – think Goodpasture’s.