RENAL-UA Flashcards
Pt states his urine is foamy and he is swollen, recent wt gain swollen eyes in am, ankles at night. Weak and tired.
UA dipstick protein >150mg/24 hrs. What is condition?
Proteinuria defined
asymptomatic until severe
UA (dipstick)
Miscellaneous Causes Exercise Fever, systemic stress, concentrated urine, UTI Orthostatic - Split urine test, during day and first morning sample - normal when supine Preeclampsia - >20wks
Which protein is is restricted by glomerular capillaries?
Albumin – relatively high molecular weight (smaller)
Multiple types, all are filtered by the glomerulus and reabsorbed PCT
Sick glomeruli = increased permeability
Tubular proteinuria results
Who gets it Glomerular Proteinuria?
Inc permeability of GM
Albumin +, MOD- (AKA microabluminuria)
Large amounts for DX 300-500mg/day
Diabetics – mod. albuminuria*** earliest diabetic nephropathy
Non-diabetic CKD (HTN)
Conditions causing the Nephrotic Syndrome
Orthostatic proteinuria - benign
<30yo, <2g/day, nl CrCl, >upright, 16hr collection
Exercise - benign
Pt describes long terms use of NSAIDs and recent ABX d/t car accident and sever blood loss. She was septic and also and CT w/ contrast. FH of Wilson DZ adn Faconi syndrome. U/A Dip NEG. What is MOST likely conditions?
Tubular Proteinuria
Small light chain proteins d/t Tubular dysfx
Acute (and chronic) interstitial nephritis (AIN)
Acute tubular necrosis (ATN)
Myoglobinuria - rhabdomyolysis
Trauma, hemolysis, sepsis, low perfusion ischemia
Toxic injury – drugs (OD’s), contrast dye (ATN)
Hereditary disorders
Wilson’s Dz- rare, copper excretion into bile
Kayser-Fiesher ring cornea
KID w/ Proteinuria and Pysche is Key
Fanconi- PCT injury, unable to resor gluc, phos, bicarb. Dehydration. Protein. Kids, Adult-amionglycosides. RENAL TUBULAR Acidosis
Pt was diagnosed with Multiple Myeloma d/t Bence Jones proteins. PHM of OD and stones, rhabdomyoiss, and hemolysis. What is the condition?
Multiple Myeloma (overproduction) Plasma cell malignancy 25% - “Myeloma kidney” Bence Jones proteins present Causes tubular toxicity and obstruction Back pain and chest Anemias Inc. Ca+ Waxy cast Osteolytic lesion-fx, weak bone PET scan Tx- chemo, bone marrow transplant Older PT bone pain, proteinuria, inc Ca, ARF is key
Rhabdomyolysis (overload from ATN)
Hemolysis (overload from ATN)
What is the first step in DX fo proteinuria?
Dipstick-Indicates presence only ***
Trace to 4+ - rough estimates, not good for true or type 1+ = <100mg/dL 2+ = 100 to 300mg/dL 3+ = 300 to 1000mg/dL 4+ = >1000mg/dL
albumin but not small amounts; positive at ~300-500mg/24hrs
Positive = glomerular etiology
Early diabetic nephropathy is not reliably detected on dipstick
Does not detect small, light chain proteins
Pt 1 has Dipstick positive but no Sx’s or risks? What is the status? and next step?
Pt 2 has the follow but no risk What is the status?and next step.
Pt1 -Transient Urine micro (casts), if dipstick 2+ or > repeat 1 month
Pt2 Persistent
UA micro, chem panel, esp if with hematuria
Culture for amount and type
Consider urine protein immunoelectrophoresis for light chain proteins IF Sx’s, Family Hx suggest Myeloma
Risks? Diabetic, HTN, CHF?
Screen all for albuminuria early, monitor
Persistent proteinuria reflects underlying renal or systemic disorder – work it up
What is important prognostic indicator for secondary glomerular disease = end-organ damage?
AMOUNT
Moderately increased albuminuria:
30-300mg/day of albumin
Benign, isolated proteinuria <1-2 gm/day; dipstick +
Foamy urine? >2 gm protein/24hrs
Nephrotic range >3 grams/24hrs
Diabetic nephropathy
Hypertensive nephropathy – proteinuric, non-diabetic chronic kidney disease (CKD)
Which one is which…
>30 abnormal
> 0.2 abnormal
Urine microalbumin (random sample): first test
AKA: urinary albumin-to-creatinine ratio (UACR): >30 abnormal
Screening for diabetic nephropathy
HTN, glomerular Dz
UPCR: urine protein-to-creatinine ratio
>0.2 abnormal
What does Moderately increased albuminuria Dx relies on?
1-Spot urine microalbumin (albumin-to-creatinine ratio)
>30mg albumin to 1g creatinine = microalbuminuria likely
2-Timed albumin excretion rate (24hr or 10hr urine collection)>30micrograms/minute = microalbuminuria likely
confirm it with repeat testing
2 of 3 specimens over 3-6 month period for diagnosis
Type 1 DM – test after 5yrs (rare prior) or at puberty
Type 2 DM – at diagnosis and yearly
HTN – yearly, q6mos if poor control
What is the non compliant gold standard, used less, difficult as outpatient?
24 hour urine protein studies
> 30 mg/min - moderately increased albuminuria
> 2g/24hrs likely glomerular type
> 3g/24hrs nephrotic range (glomerular problem)
<2g/24hrs likely tubular or overflow
Both can be >2g/24hrs if severe
Next: urine protein immunoelectrophoresis
What if Pt has Acute renal failure with negative dipstick?
tubular or overflow proteinuria
SSA-sulfosalicytic acid turbidity testing
Measures all proteins
Excess light chain proteins form casts making
supranatant turbid
Identifies Bence Jones proteins
Tx Peristent Proteinuria
Tight control diabetes, HTN
Early recognition, tx can slow/reverse dz
Proteinuria/CKD = increased cardiovascular risk
ACE inhibitors and ARB’s – best if poor control
Monitor renal function (BUN, creatinine) q 3mos
Renal ultrasound for structural abnormalities
Refer to nephrologist for renal biopsy (glomeruli), worsening renal function & bad proteinuria
Pt has the following present... Proteinuria-urine is foamy, >3.5 grams per 24hrs Edema HYPOalbuminemia HYPErlipidemia Dipstick +
Nephrotic Syndrome
Glomerular proteinuria -Albumin is the principal urinary protein
How does Hypoalbuminemia contribute to edema in Nephrotic Syndome?
produces dec in plasma/capillary osmoid/oncotic pressure - fluid seeps OUT of vessels into interstitial space. (plasm fluid {High}-moves to low)
Renal Na+ retention and fluid into ECF
Both lead to decreased intravascular volume**. HIGH ECF
Pitting, peripheral; dependent areas first
Can progress to anasarca - total body edema - ascites, scrotal, sacral, pleural/cardiac effusions
Albumin is dumped into the urine
Serum albumin <3g/dL (N 3.5-5.5g/dL)
Total serum protein <6g/dL (N 6.0-8.0g/dL)
