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CRRAB II- Week 2 > Russ- Hematuria > Flashcards

Russ- Hematuria Flashcards

1
Q

What is the most common screening test for blood and protein in the urine?

A

Urine Dipstick Test

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2
Q

How does a urine dipstick test work?

A

A strip for blood uses Hydrogen peroxide which catalyzes a chemical reaction between Hb and the chromogen tetramethylbenzidine

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3
Q

What can cause false negative results on UDT?

A

Formalin

High urinary concentration of ascorbic acid

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4
Q

What can cause false positive results on UDT?

A 
Alkaline urine (pH> 9)
Contamination with oxidizing agents used to clean the perineum
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5
Q

What is abnormal hematuria in Adults? Children?

A

1 RBC/ high power field

5 RBC/ high power field

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6
Q

What are frequent causes of hematuria?

A
  1. transient unexplained- mCC
  2. UTI
  3. Stones
  4. Cancer (bladder, kidney, prostate)
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7
Q

what are less frequent causes of hematuria?

A 
Exercise (marathons)
trauma
endometriosis
sickle cell disease
PKD
Glomerular disease
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8
Q

What are risk factors for UT malignancy?

A 
>35
smoking hx
exposure to chemicals
obesity/htn
pelivic irradiation
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9
Q

How should you proceed if you have a patient with red urine?

A

Obtain a urine sample and spin it.

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10
Q

What does it mean if the urine sediment is red?

A

hematuria

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11
Q

What does it mean if the urine supernatant is red?

A

NOT Hematuria

Need to dipstick for heme

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12
Q

What can cause a red supernatant dipstick that is ALSO negative for heme?

A

Porphyria- abnormal metabolism of Hb

Phenzaopyridine- UT anesthetic to help with pain

Beets

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13
Q

What is beeturia?

A

14% of pts

increased intestinal absorption (colon) and urinary excretion of hte red pigment betalaine

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14
Q

What is betalaine?

A

Redox indicator that’s protected by REDUCING agents like oxalate.

DECOLORIZED by ferric ions, HCL acid and colonic bacteria.

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15
Q

In what pt populations does beeturia more predictably occur?

A

Pts that are IRON DEFICIENCT, ACHLORHYDRIC (pernicious anemia), or eat a diet rich in oxalate containing foods.

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16
Q

What can cause a red supernatant dipstick that is POSITIVE for heme?

A

Myoglobinuria- plasma clear

Hemoglobinuria- plasma red

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17
Q

Hematuria, pyuria, dysuria

A

UTI

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18
Q

Hematuria + recent URI

A

Ig nephropathy

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19
Q

hematuria + family hx of renal failure

A

Hereditary nephritis
thin basment membrane disease
familial hematuria

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20
Q

Hematuria+ unilateral flank pain w/ radiation to the groin

A

Kidney stone

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21
Q

hematuria + sxs of hesitancy and dribbling

A

prostatism

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22
Q

hematuria + vigorous exercise/trauma

A

not uncommon

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23
Q

cyclic hematuria in women

A

endometriosis

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24
Q

What are signs of GLOMERULAR bleeding?

A
  1. Red cell casts
  2. Proteinuria
  3. Dysmorphic appearing red cells (RBC enter tubules and water/salt changes way that RBC appear)
  4. Smokey brown or coca cola colored urine
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25
Q

What are clots significant for?

A

NEVER from glomerulus–> d/t urinary collecting system source

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26
Q

What radiological test should you do in a pt with hematuria?

A

CT scan of abdomen and pelvis*

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27
Q

What causes 50% of unexplained hematuria?

A

underlying glomerular disease

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28
Q

What are unusual causes of hematuria?

A

AV malformations
Fistulas
Loin pain- hematuria syndrome (abnormal glomerular basement membrane w/ a possible association w/ intratubular crystal formation)

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29
Q

What is seen with loin pain?

A

Blood in the urine + unilateral flank pain w/o evidence of obstruction/infection.

Biopsy–> abnormal GBM

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30
Q

How common is microscopic hematuria in children?

A

2-4% have pos dipstick for plood: 1% after SECOND UA

*NOT that uncommon

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31
Q

What are the MCC of persistent microscopic hematuria in children?

A
  1. Glomerulopathies
  2. Hypercalciuria
  3. Nutcracker syndrome
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32
Q

What are common glomerulonephropathies in children?

A

Ig A nephropathy
Alport’s syndrome
Thin basement membrane disease
Post-infectious glomerulonephritis

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33
Q

What causes hypercalciuria? What is it indicative of

A

Urine Ca/crea > .2

KS when they’re adults–ratio >2 is right environment for stones

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34
Q

What is nutcracker syndrome?

A

Left renal vein compression by the aorta and superior mesenteric a–> increased venous pressure and hematuria

*asian children

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35
Q

How do you evaluate microscopic hematuria in children that is asymptomatic and isolated (no protein)?

A

It’s usually benign so just observe it

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36
Q

How do you evaluate microscopic hematuria in children who also have asymptomatic proteinuria?

A
  1. QUANTITATE protein w/ a 1st void morning specimen for the urine total protein/creatinine ratio (normal refer to nephrology
37
Q

What are causes of symptomatic hematuria in children?

A
  1. glomerular disease
  2. interstitial/tubular disease
  3. Lower UT
  4. Nephrolithiaseis
  5. Tumor
  6. Vascular disease
  7. Gross hematuria: UT infeciton; trauma; irritation of meatus/perineum
38
Q

What percent of men and women develop symptomatic kidney stones by age 70?

A

12% men

5% women

39
Q

In what populations is the rate of urolithiasis increased?

A
  1. Elderly
  2. M> W
  3. W > B

*7-10/ 1000 hopsital admissions

40
Q

What percent of KS are calcium? Are they more commonly oxalate or phosphate?

A

80%

Oxalate > phosphate

41
Q

What are the sxs of kidney stones?

A

Pan that wax/wane

Higher stone–> flank pain
As stone moves done–> dilation of the ureter behind obstruction–> abdominal pain–> moves lower–> groin pain–> uretral/bladder junction–> testicle/labial pain

Gross/microscopic hematuria
N, V, dysuria, urgency

42
Q

How do you diagnose KS? What is commonly used in the ER?

A
  1. Abdominal plain film (KUB) used for Ca stone
  2. Ultrasound of hte kidneys- individual w/ hx of KS to decrease radiation
  3. CT scan of abdomen/pelvis (in ER if they hadn’t had KS before)
43
Q

How do you treat KS?

A

Pain medications
Hydration

Relax uretral smooth muscle:
Alpha blocker (tamsulosin)
Ca channel blocker (nifedipine)
44
Q

What is ureteroscopy?

A

Use a scope to ascend from the urethra> bladder > ureter

Use a basket, lithotripsy or laser

45
Q

What is extracorporeal shock wave lithotripsy?

A

Break up large stone so it passes w/ out obstruction

46
Q

What is endoscopic lithotripsy used for?

A

staghorn calculi (large)

47
Q

What does a calcium oxalate crystal look like?

A

dumbbell shape

or

under polarized light–> coarse, needle- shaped CaOxalate crystals

48
Q

What are risk factors for calcium stone formation?

A 
Hypercalciuria
hyperuricosuria
hypocitraturia 
Low urine volume
Increased oxalate excretion
49
Q

What does citrate do to calcium stones?

A

usually inhibits stone formation

50
Q

What is the most common cause of hypercalciuria?

A

Idiopathic hypercalciuria

51
Q

What causes idiopathic hypercalciuria?

A
  1. Absorptive hyperclaciuria- AD, elevated calcitriol levels–> increased Ca absorbed from kidneys
52
Q

What is fasting hypercalciuria?

A

Movement of Ca from bones to blood stream to urine

53
Q

What is renal hypercalciuria?

A

Renal leak (abnormal Ca reabsorption in the PT)

54
Q

What cause hypocitraturia?

A
  1. Chronic diarrhea
  2. Renal tubular acidosis
  3. Ureteral diversion (leads to bicarbonate loss–> metabolic acidosis)
  4. High protein diet–> acidic urine–> low citrate levels
  5. Topiramate
55
Q

What causes hyperoxaluria?

A
  1. Increased oxalate absorption: low Ca diet, absorptive hypercalicuria, enteric hyperoxaluria (malabsorption of FA and bile salts–observed w/ intestinal bipass surgery)
  2. Overproduction of oxalate: primary hyperoxaluria (genetic abnormality when there’s an overproduction of oxalate in the body, fairly unusual)
56
Q

How does Ca affect oxalate?

A

Ca is a primary binder of oxalate in the intestine–> more Ca ingested–> more oxalate binded –> more excreted in the urine

57
Q

What medical problems are associated with calcium stone formation?

A
  1. primary hyperparahtyroidism
  2. medullary sponge kidney
  3. distal renal tubular acidosis
58
Q

What is medullary sponge kidney?

A

Abnormality at end of UT as it enters the papilla> reflux of urine > puts people at risk for cyrstallizaiton at the tip of hte papilla > KS form more easily

59
Q

What causes distal renal tubular acidosis?

A

Pre-existing disorder that leads to KS formation

60
Q

What type of labs should you do to evaluate KS?

A
  1. Plasma Ca concentration (make sure they don’t have primary hyper PTH)
  2. PTH
  3. Electrolytes- acidosis
  4. Serum uric acid- excessive UA in serum
  5. 24 hr collection: volume, Ca, UA, citrate, oxalate, cr, pH, Na, phosphorus
61
Q

How do you tx KS?

A
  1. fluid- 2 L of water > dilute things that cause stones to form
  2. Salt-> drives Ca excretion; lower Ca excretion > low salt diet
  3. Protein> lower protein > limit acid load> drop citrate levels
  4. low ca > make oxalate more available and make problem worse
  5. Limit oxalate if high in urine
62
Q

What medications are used to treat KS?

A
  1. thiazide diuretics> decrease Ca excretion in urine
  2. K citrate or bicarbonate > alkalinize urine to increase citrate excretion
  3. Orthophosphate> absorptive hypercalcuria> reduces Ca in intestine
  4. Allopurinol/febuxostat> decrease UA production > pts w/ high UA level and Ca stones
  5. Ca carbonate> used to bind oxalate in stomatch > prevents it from being absorbed
63
Q

What stone most commonly occurs in hot arid climates? What does it look like on radiologic evaluation

A

Uric acid urolithiasis (40%)

5-10% of stones in US/Europe

Non-opaque

No demonstrable abnormality in uric acid metabolism

64
Q

What causes uric acid urolithiasis?

A
  1. High conc of UA in urine

2. Acidic urine pH– more insoluble in acidic urine

65
Q

How do you diagnose uric acid urolithiasis?

A

Analysis of stone material recovered

Indirectly by demonstrating increased urine UA excretion

66
Q

How do you treat UA urolithiasis?

A

Allopurinol/febuxostat

Alklainize the urine

Urine output to be > 2 L /day

67
Q

What’s another name for struvite stones?

A

Magnesium ammonium phosphate stones

Infection stones

68
Q

What do struvite stones look like?

A

Coffin lid crystals

69
Q

What conditions lead to struvite stones? What organism causes these conditions?

A

increased ammonia production

increased urine pH (decreased solubility of phosphate)

Urease producing organism (PROTEUS AND KLEBSIELLA) that breaks down urea to ammonia

70
Q

What pts often get struvite stones?

A

Pts w/ chronic indwelling foley catheters

71
Q

How do you tx struvite stones?

A
  1. chronic admin of antibiotics
  2. acetohexemic acid- urease inhibitor (slows down production of ammonia)
  3. ESWL/Percutaneous nephrolithotomy
72
Q

What do cystic stone crystals look like?

73
Q

What causes cystinuria? What type of trait is cystinuria?

A

Impairment of cystine transport>
decreased proximal tubular re-absorption and increased cystine excretion

Autosomal recessive

74
Q

What are the cystinuria subtypes and what are they characterized by?

A

Characterized by the amts of cystine excreted by parents phenotypes (usually asymptomatic heterozygotes)

1/1 parents excrete a NORMAL mat of cystine (mut on chrom 2)

II/II parents excrete LARGE amts

III/III parents excrete intermediate amts

75
Q

What do cystic stones look like on x-ray?

A
  1. radio-OPAQUE (d/t density of sulfur containg molecules)
  2. fuzzy gray appearance–less radio-opaque than Ca
  3. usually discrete but staghorn can occur
76
Q

How do you diagnose cystic stones?

A
  1. family hx
  2. hexagonal cystien crystals on urinalysis
  3. measurement of cystine excretion
77
Q

What is medical therapy for cystic stones?

A
  1. High fluid intake >3 L/day
  2. Alkalinization of urine (pH > 7)
  3. Restriction of Na–> more reabsorption of cyteine
78
Q

What medications complex cysteine molecules and make it more soluble and are used to treat cystic stones?

A

Penicillamine
tiopronin
captopril

79
Q

What type of invasive therapy is used for cystic stones?

A
  1. irrigation of renal pelvis via catheter w/ penicillamine or actylcystine
  2. RESISTANT to ESWL
  3. Percutaneous nephrolithotomy/ultrasonic lithotripsy (soft so not as affective)
80
Q

What can cure cystic stones?

A

Renal transplant> no longer have genetic abnormality in the kidney

81
Q

When is medical treatment indicated after a first kidney stone?

A

ONLY in pts w/ metabolically active stone disease

Need to demonstrate:
formation of new stones
enlargement of old stones
passage of gravel
multiple stones at presentation
82
Q

What is the rick of a symptomatic 2nd stone? Who is more at risk for a second, stone men or women?

A

15% at one year
35-40% at 5 yrs
50% at 10 yrs

MEN

83
Q

How do you evaluate a first kidney stone?

A
  1. Plasma Ca x 2-> make sure they don’t have a parathyroid adenoma
  2. increase fluid intake (over 2 L/d)
  3. Consider CT scan w/ IV contrast (look for medullary sponge kidney)
  4. dietary hx
84
Q

What percent of asymptomatic stones pass?

85
Q

What are complications associated wtih ESWL?

A

Obstruction

Reversibly damage blood vessels and tubules

New HTN

Impaired renal fucntion

86
Q

Does a complain of red urine equate to blood in the urine?

A

Not necessarily!

Lab > centrifuge> supernatant vs. urine sediment

87
Q

Does painless hematuria help narrow the differential diagnosis?

A

YES!

UTI/KS are usually symptomatic

88
Q

What is kidney function and does it help in the differential diagnosis?

A

Normal > suggests that theres no obstruction that keeps kidneys from draining properly

89
Q

What significance is there in the lack of proteinuria?

A

Lack> NOT form glomerulus

CRRAB II- Week 2 (9 decks)

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