cloudy with occasional chance of crystals

Cloudy with Occasional Chance of

CrystalsWhat you can Learn from the Urine18th Annual Family Practice Review

Feb 8, 2013

Jeff Kaufhold, MD FACPMaster Physician Ohio University Heritage School of MedicineNephrology Associates of Dayton

Pre TestHematuria is a sign of all of the following

EXCEPT:1. Bladder Tumor2. Urinary tract Infection3. Nephrotic syndrome4. Glomerulonephritis5. Kidney stones

Hematuria - Epidemiology

DefinitionsMacroscopic - pink, red, or tea coloredMicroscopic - >4 RBC’s per hpf of spun urine

sediment

PrevalenceSchool aged - 4% (always check a 2nd

specimen)>35 y/o - 13%PPV low, most useful in elderly men

Hematuria - EpidemiologySpecific

Glomerular causes - Predominate in children and young adults>40 y/o only 5% of cases

Neoplasm>40 y/o, Urinary tract 15-20% of casesChildren: Wilm’s tumor,

Rhabdomyosarcoma of bladder

Hematuria - EvaluationHistory

Physical

Urinalysis

Hematuria - Evaluation

Hematuria - EvaluationUrinalysis

Proteinuria - indicator of glomerular diseasecan be up to 500 mg/24 hr in gross hematuria

RBC cast - must look at urine with your own eyesPyuria - look for UTI/STDCrystalsDysmorphic RBC’s

Hematuria

T

I

G

H

T

S

Hematuria

TUMOR

I NFECTION

G LOMERULONEPHRITIS

H EMATOLOGIC

T RAUMA

S TONE

HematuriaWorkup

TUMOR - Cytology

I NFECTION - Culture

G LOMERULONEPHRITIS

H EMATOLOGIC – CBC and Coags

T RAUMA – Xray

STONE - IVP

HEMATURIAGlomerular Causes:

IgA (Berger’s)

Mesangioproliferative GN

Hereditary GN’s, including

Alport’s, Thin Basement Membrane

Hallmark of Glomerular Disease is RBC cast

Renal CalculiTypes

Composition

% Radio-opaque

Appearance Pathogenesis

Calcium oxalate

60 +++ Small, smooth or spiky

Hyperparathyroidism, hypercalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria

Calcium phosphate

20 +++ Slightly larger more friable

Distal renal tubular acidosis

Uric acid <10

- May be large

Low urinary pH, Hyperuricosuria

Struvite <10

++ Staghorn Infection with urease-producing microorganisms

Cystine <5 + Pale yellow, may be large

Cystinuria

Urate stoneCystine Stone

Calcium Oxalate stoneCalcium Oxalate stone Formed on a Urate Nidus

Oxalate Crystals

Urine Sediment varies by pH

NEPHROLOGY

HEMATURIA - DIFFERENTIAL TIGHTS TUMOR, INFECTION GN’s, HEMATOLOGIC TRAUMA AND STONE

PROTEINURIA - normal up to 150 mg/24 h made up of tubular protein (Tamm Horsfal) ABnormal = albumin, >150 mg

PROTEINURIA

LESS THAN 300 mg - normal

300 to 1200 think orthostatic or

interstitial

1200-3000 mg talk to the patient

OVER 3 Gm Consider Biopsy

PROTEINURIANephrotic syndrome: Over 3 GM protein, Edema,

hyperlipidemia, hypOalbuminemia

Due to Diabetes , Amyloidosis, or primary Glomerular disease.

Glomerular Causes:Minimal Change Disease - 25 %Focal Segmental Glomerulo Sclerosis

FSGS - 30 %Membranous - 30 %

Nephrotic range PROTEINURIA Relative

Frequency by Age.

Distribution of Glomerular Disease by Age

NEPHROLOGY

DEFINITIONS

PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours:

<0.2 = normal

>3.0 nephrotic

There are still always some surprises

Billing codes and Reimbursement

CPT code for Urinalysis without microscopy

Dipstick 81000Automated 81002

Medicare reimbursement: $3.16

UA with microscopyDipstick 81015Automated 81001

Reimbursement: $4.45

Billing codes and Reimbursement

Covered Diagnoses:CKD 585.UTI 590.Kidney stone 592.Other disorder of kidney 593.9Diabetes 250.00

How do you differentiate ARF from CRF.

What physical exam finding tells you the pt has Chronic Kidney Disease?

What Would you see on renal Imaging for a pt with CKD?

Lindsey’s Nails

Atrophic Kidneys on CT

Post TestHematuria is a sign of all of the following

EXCEPT:1. Bladder Tumor2. Urinary tract Infection3. Nephrotic syndrome4. Glomerulonephritis5. Kidney stones

SummaryRIFLE Criteria for ARF

CKD Stages and features

Nephrologists approach to Hypertension

What you can learn from the urine

Features which differentiate acute from chronic kidney disease