If protein loss is... \ 3.5 gm/day = ?

\ 3.5 gm/day = nephrotic syndrome

Urinalysis CIS From Freemont-Smith Flashcards by Stephen Schaffner

If urine specific gravity is less than 1.005 then the patient is?

Hydrated

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If the urine specific gravity is greater than 1.010 then the patient is?

Water conserving, up to 1.035

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If a patients urine specific gravity is greater than 1.035 then the patient is?

In a non-physiologic state (possibly due to x-ray dyes or other)

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In siadh will urine sg increase with H20 deprivation?

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If the kidney has a problem reabsorbing bicarb, what type of RTA is likely?

RTA type 2

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If a patient has problems excreting H+ ions into the collecting duct, then what type of RTA is likely?

Type I RTA

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What is type IV RTA due to?

Insufficient aldosterone production or insufficient response in the tubules. (resistance)

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+1 glucose equals roughly how much? What is normal?

• 1+ dipstick ≈ 250 mg/dL plasma glucose

(normal < 140 mg/dL)

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What proteins are measured by the dipstick?

Albumin only

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So can you detect multiple myeloma on dipstick?

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What are the gold standard and routine standard practice for urinalysis?

gold standard is 24 hour urine protein
routine practice uses spot urine albumin to creatinine ratios

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If protein loss is…

< 150 mg/day = ?
150-300 mg/day = ?
300mg- 3.5 gm/day = ?
> 3.5 gm/day = ?

< 150 mg/day = normal
150-300 mg/day = microalbuminuria
300mg- 3.5 gm/day = macroglobulinemia
> 3.5 gm/day = nephrotic syndrome

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You should follow up the dipstick with complete renal function testing, what does this include?

urine sediment morphology (blood, casts)
Serum albumin (if low, then serious urine loss)
quantitative measure of urine protein loss
eGFR (corrects for age, sex and weight)
imaging

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What are the steps in the investigation of proteinuria?

Rule out transient proteinuria (fever/exercise)
Rule out orthostatic proteinuria
obtain urin sediment
1. If normal, get quantitative urine protein

1. < 150 mg/day reassure patient
1. 150-300 mg/day microalbuminemia
1. >300 mg/day macroalbuminemia

If abnormal, determine primary vs. secondary glomerular disease

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When do you ignore a dipstick test for a female?

Within 5 days of menstruation

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What is the approach to the patient with red/brown urine?

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Walk me through the algorithm for hematuria!

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What are common mimics of primary hematuria?

menstruation

pigments (eg beets)
anticoagulation

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The most reliable indicator of glomerular disease in hematuria without rbc casts is proteinuria. If…

< 2 gm /24 hr: ?
2-4 gm/24 hr: ?
> 3.5 gm/24 hr: ?

< 2 gm /24 hr: tubulointerstitial
2-4 gm/24 hr: glomerular
> 3.5 gm/24 hr: nephrotic

dipstick bilirubin is positive when what kind of bilirubin is increased?

Negative when?

Direct (conjugated) bilirubin

negative in hemolysis

Urobilinogen is a water-soluble metabolic product of bilirubin absorbed from gut and filtered. When is it increased?

Do you see this with obstructive jaundice (no bilirubin to gut)?

•Increased in hemolytic anemia (↑production) and liver disease ( ↓metabolism)

Not seen in obstructive jaundice

Nitrites are specific for bacteria, but not sensitive. What sort of organisms is it good at detecting?

most gram (-) (E. coli, Klebsiella) and some gram (+) (Staph)

What is leukocyte esterase (LE) sensitive for? Specific for?

Sensitive for infection

Specific for pyuria (does not equal infection… he seemed to really get off on this point. Watch for a TQ here)

What does Dr. Freemont-smith consider the three key analytes in the dipstick test?

Proteinuria: confirm with P/C ratio, sediment, eGFR
Hematuria: R/O menses , urology versus nephrology
Infection (LE/nitrite)

A 26 year old newly married woman presents a 1 day history of burning on urination, urgency and frequency * Urine sediment: 12 pmn/hpf, 3 rbc/hpf * Urine dipstick: Spec Gravity: 1.020 pH 6.4 Glucose neg Protein 1+ Blood trace Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite 3+ Leuk Esterase 3+ Diagnosis? Organism?

Acute Cysticis - perhaps Staph. Saprophyticus

A 32 year old single female presents with a 2 day history of burning on urination. * Urine sediment: 6 pmn/hpf * Urine dipstick: Spec Gravity: 1.015 pH 6.4 Glucose neg Protein 1+ Blood Neg Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase 3+ Diagnosis?

Pyuria & dysuria from urethritis (not UTI)…? Maybe bacteria that does not react and is nitrite neg

A 24 year old afebrile female presents to your office with 3 day history of back pain after heavy lifting * Urine sediment: NDA * Urine dipstick: Spec Gravity: 1.015 pH 6.4 Glucose Neg Protein Neg Blood Neg Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite 3+ Leuk Esterase Neg Diagnosis?

Bactururia from poor transport (defective collection procedure)

A 52 year old male presents with a 3 hour onset of severe colicky right-sided flank pain radiating into his groin * Urine sediment: 5 rbc/hpf * Urine dipstick: Spec Gravity: 1.025 pH 6.4 Glucose Neg Protein 1+ Blood 2+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase 1+ Diagnosis?

Calculus

A 28 year old man has been in the ICU for 2 weeks following a motorcycle accident. He has had an indwelling bladder catheter for the 2 weeks. Repeated urine cultures have been negative * Urine sediment: 4 PMN/hpf, 3 rbc/hpf * Urine dipstick: Spec Gravity: 1.015 pH 6.4 Glucose Neg Protein 1+ Blood 1+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase 2+ Diagnosis?

Pyuria/hematuria from mechanical cause

A 66 year old female with atrial fibrillation is seen in your office for routine follow-up of her Warfarin therapy (anti-coagulation). Prothrombin time = 68 sec (11-15) with INR 6X upper limit * Urine sediment: 6 rbc/hpf * Urine dipstick: Spec Gravity: 1.020 pH 6.4 Glucose Neg Protein 1+ Blood 3+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg Diagnosis?

Hematuria from coagulation defect

A 54 year old asymptomatic male comes to your office after a dipstick for an insurance physical revealed blood. * Urine sediment: 5 rbc/hpf * Urine dipstick: Spec Gravity: 1.020 pH 6.4 Glucose Neg Protein Neg Blood 2+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg Diagnosis?

Bladder Tumor

A 6 year old boy presents with an acute onset of shaking and chills, with marked change in the color of his urine ## Footnote •Urine sediment: - after centrifugation - no rbc's seen on microscopy •Urine dipstick: Spec Gravity: 1.020 pH 7.4 Glucose Neg Protein Neg Blood 4+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg Diagnosis?

Intravascular hemolysis

Which is hematuria and which is hemoglobinuria?

A: hematuria, as it centrifuges clear B. Hemoglobinuria (intravascular hemolysis)

An 18 year old high school athlete presents for evaluation for an endurance event. She is mid-cycle. •Urine dipstick: Spec Gravity: 1.020 pH 6.4 Glucose Neg Protein Neg Blood 1+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg • Urine sediment: 4 rbc/hpf (normal \< 3 cells/hpf) Diagnosis?

Thin basement membrane disease (apparently)

A 32 year old, previously well male presents complaining of swelling of his face in the morning and swelling of his legs in the afternoon. •Urine dipstick: Spec Gravity: 1.030 pH 6.4 Glucose Neg Protein 4+ Blood Neg Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg • Urine sediment: waxy casts, oval fat bodies Diagnosis?

Minimal Change disease I believe. Can hit in middle age also.

A 64 year old insulin-dependent diabetic is in for routine monitoring. He has had the disease for 2 decades •Urine dipstick: Spec Gravity: 1.005 pH 6.4 Glucose Neg Protein trace Blood Neg Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg • Urine sediment: waxy casts Diagnosis?

Diabetic Nephropathy - urine is not concentrated (isothenuria)

Albuminuria is present when? and is a marker for?

Albuminuria is present when UACR is greater than 30 mg/g and is a marker for CKD.

What disease process caused this? Nephrotic or nephritic? What will the basement membrane look like on EM?

Diabetes, these are kimmelsteil wilson nodules. Nephrotic. Basement membrane will be thickened. (see attached image)

A 24 year old male presents with gross hematuria 72 hours after the onset of acute pharyngitis •Urine dipstick: Spec Gravity: 1.025 pH 7.4 Glucose Neg Protein 3+ Blood 4+ Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg • Urine sediment: rbc: TNTC, rbc casts Diagnosis?

Berger Disease

Describe what you will see in IgA nephropathy on both light Microscopy and IF.

Light Microscopy: Mesangial proliferation IF: Granular pattern of fluoresence

What is the mesangium in direct contact with?

The plasma. He has this scattered through his ppt. about three or four times.

Put the following in order from least to most common progression to ESRD by 10 years. Membranous nephritis Lupus Nephritis IgA nephropathy FSGS Membranoproliferative How can you slow this progression?

* IgA nephropathy 10% * Lupus nephritis 20% * Membranous nephritis 25% * Membranoproliferative 40% * Focal and segmental 80% Slow the process by use of ACE inhibitors

A 76 year old female with known IgG kappa multiple myeloma presents with progressive renal failure •Urine dipstick: Spec Gravity: 1.035 pH 6.4 Glucose Neg Protein Neg Blood Neg Bilirubin Neg Ketones Neg Urobilinogen Neg Nitrite Neg Leuk Esterase Neg Urine sediment: waxy casts Diagnosis?

Light chain nephropathy (amyloidosis)

A 7 year old male with recurrent episodes of E. Coli cystitis presents with fever and right CVA pain * Urine sediment: 9 wbc/hpf, * Urine dipstick: Spec Gravity: 1.025 pH 7.4 Glucose Neg Protein 1+ Blood Neg Bilirubin Neg Ketones 1+ Urobilinogen Neg Nitrite 2+ Leuk Esterase 2+ Diagnosis?

Acute pyelonephritis secondary to uretric reflux

Autopsy of an eight year olds kidneys reveal the findings shown in the images. You determine that this child had a high anion gap metabolic acidosis. What was the cause of the structures shown in the images?

Ethylene glycol poisoning (antifreeze/brake fluid) ## Footnote ( Pearl: Kids- tastes sweet-green)