Download - Cloudy with Occasional Chance of Crystals
![Page 1: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/1.jpg)
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
![Page 2: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/2.jpg)
Pre TestHematuria is a sign of all of the following
EXCEPT:1. Bladder Tumor2. Urinary tract Infection3. Nephrotic syndrome4. Glomerulonephritis5. Kidney stones
![Page 3: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/3.jpg)
![Page 4: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/4.jpg)
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
![Page 5: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/5.jpg)
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
![Page 6: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/6.jpg)
Hematuria - EvaluationHistory
Physical
Urinalysis
![Page 7: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/7.jpg)
Hematuria - Evaluation
![Page 8: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/8.jpg)
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
![Page 9: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/9.jpg)
![Page 10: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/10.jpg)
Hematuria
T
I
G
H
T
S
![Page 11: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/11.jpg)
Hematuria
TUMOR
I NFECTION
G LOMERULONEPHRITIS
H EMATOLOGIC
T RAUMA
S TONE
![Page 12: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/12.jpg)
HematuriaWorkup
TUMOR - Cytology
I NFECTION - Culture
G LOMERULONEPHRITIS
H EMATOLOGIC – CBC and Coags
T RAUMA – Xray
STONE - IVP
![Page 13: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/13.jpg)
![Page 14: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/14.jpg)
HEMATURIAGlomerular Causes:
IgA (Berger’s)
Mesangioproliferative GN
Hereditary GN’s, including
Alport’s, Thin Basement Membrane
Hallmark of Glomerular Disease is RBC cast
![Page 15: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/15.jpg)
![Page 16: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/16.jpg)
![Page 17: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/17.jpg)
![Page 18: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/18.jpg)
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
![Page 19: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/19.jpg)
Urate stoneCystine Stone
![Page 20: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/20.jpg)
Calcium Oxalate stoneCalcium Oxalate stone Formed on a Urate Nidus
![Page 21: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/21.jpg)
Oxalate Crystals
![Page 22: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/22.jpg)
Urine Sediment varies by pH
![Page 23: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/23.jpg)
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
![Page 24: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/24.jpg)
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
![Page 25: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/25.jpg)
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 %
![Page 26: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/26.jpg)
Nephrotic range PROTEINURIA Relative
Frequency by Age.
![Page 27: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/27.jpg)
Distribution of Glomerular Disease by Age
![Page 28: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/28.jpg)
NEPHROLOGY
DEFINITIONS
PROTEIN/CREATININE RATIO based on assumption of 1 Gm of creatinine excreted per 24 hours:
<0.2 = normal
>3.0 nephrotic
![Page 29: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/29.jpg)
There are still always some surprises
![Page 30: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/30.jpg)
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
![Page 31: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/31.jpg)
Billing codes and Reimbursement
Covered Diagnoses:CKD 585.UTI 590.Kidney stone 592.Other disorder of kidney 593.9Diabetes 250.00
![Page 32: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/32.jpg)
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?
![Page 33: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/33.jpg)
Lindsey’s Nails
![Page 34: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/34.jpg)
Atrophic Kidneys on CT
![Page 35: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/35.jpg)
Post TestHematuria is a sign of all of the following
EXCEPT:1. Bladder Tumor2. Urinary tract Infection3. Nephrotic syndrome4. Glomerulonephritis5. Kidney stones
![Page 36: Cloudy with Occasional Chance of Crystals](https://reader036.vdocuments.us/reader036/viewer/2022062804/56814a15550346895db73db1/html5/thumbnails/36.jpg)
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