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Yr 3 Med 2 > Renal Workshop (proteinuria & haematuria) > Flashcards

Renal Workshop (proteinuria & haematuria) Flashcards

1
Q

What is proteinuria?

A
  • Presence of cloudy ‘frothy’ urine (as has protein in
  • Normal variant up to 80mg ±20 equates to 0.1 PCI/1+ on dipstick
  • Balance between amount of protein filtered by glomerulus and amount reabsorbed by the proximal tubule
  • LMW proteins may be filtered but reabsorbed to <0.2 PCI

When patient has a catheter in then reading not that accurate as can be contaminated (e.g. urine sample)

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2
Q

Why is proteinuria important marker?

A
  • Marker of intrinsic renal disease ie. damage to the glomerular basement membrane
  • Risk factor for progression of renal disease
  • Independent risk factor for cardiovascular morbidity and mortality (as hypertension due to INCREASE RAAS system thus, INCREASE Na+)
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3
Q

Who is at risk of proteinuria and where should they be tested?

A

Where → GP practice

Who →

  • A GFR less than 60 mL/min/1.73 m2
  • Diabetes
  • Hypertension
  • Cardiovascular disease
    • Ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease
  • Structural renal tract disease, multiple renal calculi or prostatic hypertrophy
  • Multisystem diseases with potential kidney involvement
  • Family history of stage 5 CKD or hereditary kidney disease
  • Opportunistic detection of haematuria
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4
Q

Draw a nephron & its blood supply (how many nephrons in EACH kidney)

A
  • 1 million nephrons in EACH kidney total → 2 million (as 2 kidneys)
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5
Q

Draw a nephron

A
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6
Q

What is the difference between a normal and diseased glomerulus in transport across the glomerulus? (diagram)

A
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7
Q

What is meant by microalbuminuria?

A
  • Refers to albumin above the normal range (>30mg), but below the dipstick threshold of 300mg
  • Present in 1/3 of type 1 diabetics
  • Level correlates with glucose and hypertension control
  • Also correlates with cardiovascular risk as with all cause proteinuria
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8
Q

What is the difference between macroalbuminuria and microalbuminuria?

A

Macroalbuminuria → >70mg albumin in urine

Microalbuminuria → >30mg albumin in urine

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9
Q

What are the types of proteinuria?

A

Transient

  • UTI, fever, exercise, pregnancy, orthostatic, extreme cold, seizures, CCF, severe acute illness, factitious

Persistent

  • Primary renal disease
    • Associated with haematuria
    • Glomerular, tubular, overflow
  • Secondary renal disease
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10
Q

What are the causes of proteinuria? (& explain them)

A
  1. PRIMARY RENAL DISEASE
    1. Glomerular
      1. Disease of glomeruli
      2. Mainly albumin
      3. Otherproteins → immunoglobulins, macroglulins (1.5g/24hrs)
    2. Tubular
      1. Secretory (secreting proteins)
    3. Overflow
  2. PRIMARY GLOMERULAR DISEASE
    1. Malignant
    2. Benign
  3. SECONDARY RENAL DISEASE
    1. DM
    2. Amyloid
    3. Myeloma
    4. Infections → hepatitis/malaria
    5. Connective tissue diseases
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11
Q

History & examination clinical evaluation of someone with proteinuria?

A

History

  • Connective tissue diseases
  • Vasculitides
  • DM
  • CCF
  • Hypertension
  • Uraemic symptoms
  • Medications
  • FH

Examination

  • Nephrotic
  • SBE
  • CTD
  • Rheumatoid disease

Further evaluation

  • Ensure not diabetic or suffering from UTI
  • Fasting glucose
  • Baseline renal function
  • M,C and S urine and treat if evidence of bacteriuria
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12
Q

What would a protein-creatine ratio to protein excretion graph look like?

A
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13
Q

Why has ACR been recommended in preference to PCR and reagent strip analysis?

A
  • In patients with established disease, there may occasionally be clinical reasons for a specialist subsequently to use PCR instead of ACR to quantify and monitor significant levels of proteinuria (for example, in patients with monoclonal gammopathies)
  • Albumin is the predominant protein in the vast majority of proteinuric kidney diseases, including diabetes, hypertension and glomerular diseases
  • Albumin measurement offers greater sensitivity, and improved precision, for the detection of lower, but clinically significant, levels of proteinuria compared to PCR
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14
Q

What is a clinically significant ACR and what is the equivalent level of proteinuria?

A
  • At normal levels of protein loss, albumin is a minor component (approximately 10–20%) of total urinary protein. On average, when the total protein concentration is 1 g/L, approximately 70% of this will be accounted for by albumin.
  • In people without diabetes consider clinically significant proteinuria to be present when the ACR is 30 mg/mmol or more (this is approximately equivalent to PCR 50 mg/mmol or more, or a urinary protein excretion 0.5 g/24 h or more).
  • In people with diabetes consider microalbuminuria (ACR more than 2.5 mg/mmol in men and ACR more than 3.5 mg/mmol in women) to be clinically significant.
  • Heavy proteinuria should be considered present when the ACR is 70 mg/mmol or more (this is approximately equivalent to PCR 100 mg/mmol or more, or a urinary protein excretion 1 g/24 h or more).
  • For the initial detection of proteinuria, if the ACR is 30 mg/mmol or more but less than 70 mg/mmol this should be confirmed by a subsequent early morning sample.
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15
Q

How can you quantify proteinuria by a ACR/24hr sample?

A
  • >15 microalbuminuria
  • >300 nephrotic range
  • Consider further renal consult/investigations…
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16
Q

How do you investigate someone with proteinuria?

A
  • URINE DIPSTICK
    • First repeat two urine samples by dipstick to confirm persistent proteinuria
    • Do at least one week apart
      • NB can be false positive in alkaline urine (pH >8) or in concentrated urine (SG>1.025)
  • Bedside
    • BP, urine dip, MC&S, PCR/ACR
  • Bloods
    • U&Es, FBC, HbA1c
    • Specific (if older)– immunoglobulins, myeloma screen, vasculitis screen
  • Imaging
    • USS
    • CT/MRI
  • Special tests
    • Renal biopsy
17
Q

What is the management of proteinuria?

A
  • Guided as per underlying disease
  • Conservative
    • Patient education
    • DM control, BP optimisation, smoking cessation
  • Medical
    • ACE inhibitors (DECREASE BP)
    • Antihypertensives (DECREASE BP)
    • Immunosuppressants
  • Surgical
    • Access/fistulae for dialysis
    • Transplant
18
Q

How to check if an individual has haematuria? (& what is AVH)

A
  • Initial test is the urine dipstick
    • False positives: Myoglobin/haemoglobin
  • Worth repeating on at least two occasions
  • The presence of haematuria (VH or NVH) should not be attributed to anti-coagulant or anti-platelet therapy and patients should be evaluated regardless of these medications

AVH = Asymptomatic vascular haematuria

19
Q

What is the assessment of haematuria?

A
  • Often incidental finding
  • More than 2 red cells/high powered field
  • Significant haematuria is considered to be 1+ or greater
  • Trace haematuria should be considered negative
  • Can arise from anywhere in urinary tract unlike proteinuria
  • Define aetiology
    • Age <45>
    • Glomerular/non-glomerular
    • Benign vs malignant
20
Q

Explain the presence of monomorphic red cells in urine

A
21
Q

Explain red cell casts in urine

A
22
Q

What is the terminology used to describe haematuria?

A

Visible haematuria

  • Otherwise referred to as macroscopic or gross haematuria
  • Urine is coloured pink or red
    • (Or on occasion like cola in acute glomerulonephritis)
  • Symptoms reported by patient, or seen by health professional

Non-visible haematuria

  • Otherwise referred to as microscopic or dipstick positive haematuria
  • Symptomatic non-visible haematuria (s-NVH)
    • Symptoms such as voiding lower urinary tract symptoms (LUTS): hesitancy, frequency, urgency, dysuria
  • Asymptomatic non-visible haematuria (a-NVH)
    • Incidental detection in the absence of LUTS or upper urinary tract symptoms
23
Q

What is significant haematuria?

A
  • Any single episode of VH
  • Any single episode of s-NVH (in absence of UTI or other transient causes)
  • Persistent a-NVH (asymptomatic - NVH) (in absence of UTI or other transient causes)
    • Persistence is defined as 2 out of 3 dipsticks positive for NVH

IMPORTANT TO ASK IF IT WAS WITNESSED

24
Q

What are the major causes of haematuria by age and duration?

A
25
Q

Explain the types of microscopic haematuria

A

Glomerular

  • Associated with acanthrocytes/anisocytosis
  • Associated with proteinuria and red cell casts
  • IgA/thin membrane disease/hereditary nephritis (Alport’s)

Non-glomerular

  • Papillary necrosis
  • Nutcracker phenomenon → RARE, with abdominal pain, link with psychiatric distress (left renal vein is being compressed due to vertebrae)
  • AVMs
  • Neoplasms – bladder, urethral, prostate
  • Hyperuricosuria
  • Hypercalciuria
  • Tropical – SCD, malaria, schistosomiasis
  • Nephrocalcinosis
  • Cystic diseases – PKD, medullary sponge kidney
26
Q

What are the 2 types of haematuria & the causes?

A

Benign

  • Drugs
  • UTIs
  • High INR/VWD
  • Menstrual contamination
  • Mild trauma
  • Sexual intercourse
  • Vigorous exercise
  • Fictitious

Malignant

  • Renal cell carcinoma
  • Bladder cancer
  • Herbal weight loss preparations
  • Cyclophosphamide
  • Smoking
  • Dyes, rubber and leather manufacturers
27
Q

When test & what tests for prostate cancer?

A
  • Consider prostate-specific antigen (PSA) test & PR exam
  • When to test someone:
    • Any UTI symptomse.g. nocturia, polyuria, hesitency
    • Erectile dysfunction
    • Visible haematuria

REFER down cancer pathway if their PSA levels are high

28
Q

When test & what tests for bladder cancer?

A
  • Go down cancer pathway if they are 45 and over and have:
    • unexplained visible haematuria without UTI
    • Persistent visible haematuria with treated UTI
  • Aged 60 and over and have:
    • Non-visible haematuria & either dysuria OR raiseed
29
Q

When test & what tests for renal cancer?

A

Refer cancer pathway if:

  • Aged 45 and over and have:
    • Unexplained visible haematuria without UTI
    • VISIBLE haematuria that persists/recurs after successful treatment of UTI
30
Q

Who should be referred to urology?

A
  • All patients with visible haematuria (any age)
    • Some patients <40 yrs with cola-coloured urine and an intercurrent (usually upper respiratory tract) infection will have an acute glomerulonephritis, and a nephrology referral may be considered more appropriate if clinically suspected
  • All patients with symptomatic non-visible haematuria (any age)
  • All patients with asymptomatic non-visible haematuria ≥45 years (usually through screening)
31
Q

Who should be referred to renal?

A
  1. Evidence of declining GFR (usually only 1ml/min lost every year but, here accelerated loss of GFR)
    1. By >10ml/min at any stage within the previous 5 years, or by >5ml/min within the last 1 year
  2. Stage 4 or 5 CKD (eGFR <30ml/min)
  3. Significant proteinuria (ACR ≥30mg/mmol or PCR ≥50mg/mmol)
  4. Isolated haematuria
    1. Ie. in the absence of significant proteinuria with hypertension in those aged <45
  5. Visible haematuria coinciding with intercurrent (usually upper respiratory tract) infection
32
Q

What should you monitor long-term with patients with haematuria of undetermined aetiology?

A
  • Voiding LUTS
  • Visible haematuria
  • Significant or increasing proteinuria
  • Progressive renal impairment (falling eGFR)
  • Hypertension
    • Noting that the development of hypertension in older people may have no relation to the haematuria and therefore not increase the likelihood of underlying glomerular disease

Further management

  • If creatinine abnormal in presence of confirmed haematuria and PCR of >0.3 then refer to renal
  • If glomerular source ruled out, need to image upper tract with:
    • USS
    • CT → better than IVU in studies
  • Renal biopsy with isolated haematuria in the absence of proteinuria not backed by evidence
    • Study 75 people – 36% thin membrane disease, 23% IgA – what would it change in management?
  • If upper tract imaging unhelpful needs lower tract imaging with:
    • Cystoscopy (which is usually more fruitful in males)
    • CT/cytology

Yr 3 Med 2 (8 decks)

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