the abnormal urinalysis - dalhousie university...objectives understand elements of the normal and...
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Abnormalities of the Urinalysis
and Serum ElectrolytesA Cased-Based Approach
S. Neil Finkle
Dalhousie Nephrology
Conflict of Interest
Nil to disclose
Objectives
Understand elements of the normal and abnormal
urinalysis
Recognize urinary findings in clinical syndromes
Proteinuria
Glomerulonephritis
Nephrotic Syndrome
Interstitial Nephritis
Understand the clinical approach to disorders of sodium
and potassium
Urinalysis
Collection
Clean, dry container
Patients should clean external genitalia
Indwelling catheter – don’t sample from the drainage bag
Interpret at room temp and within 2 hrs of collection
Can be refrigerated for short-term storage
Urinalysis
Gross Inspection
Turbidity – infection, crystals
Colour
Red/Brown – hemoglobin, myoglobin, beets, rhubarb, rifampin,
dilantin, senna, porphyria
White – pyuria, crystals, chyluria
Black – hemoglobin/myoglobin
Urinalysis - Dipstick
Heme – RBCs, hemoglobin, myoglobin
Leuk esterase – lysed neutrophils release
Nitrite albumin – GNRs elaborate nitrate reductase –converts nitrate to nitrite
Albumin – generally > 300 mg/day threshold detection
Glucose
0, 5.5, 14, 28, 55, >111 mmmol/l
Specific gravity
1.000 to 1.030
Urinalysis
Microscopic Analysis
Blood
Monomorphic
Dysmorphic
WBC’s
Casts
RBC Casts
WBC Casts
Granular Casts
Hyaline Casts
Bacteria
Crystals
Case 1
50 year-old female with HTN, DM2 and Gout
Recent flare gout, Rx Indomethacin 100mg bid for 3 days
Gout settled, but developed swelling feet and legs progressive
over 1 week
Gained 8 kg over past week
Feeling generally unwell
Urinalysis
>3 g/l protein, neg blood, trace glucose, LE neg
HgA1c 7.5, Cr 150 (baseline 80), Lytes normal
Case 1 Photo - swelling
Case 1
Questions
Does the patient have Nephrotic Syndrome?
Does the patient have AKI?
What’s the eGFR?
How did NSAIDs play a role in his presentation?
Case 1
Questions
Does the patient have Nephrotic Syndrome?
> 3g/24 hr protein - likely
Does the patient have AKI?
Yes, acute deterioration in renal function
What’s the eGFR?
Unreliable, needs steady state to quantify
NSAIDs
Caused the Nephrotic Syndrome which led to AKI
Case 2
67 year-old female
Hiatus hernia with GERD – marked
Rx Esomeprazole 40 mg OD with much relief
Routine labs – 3 months later
Cr 163 (68 last year), lytes normal
Urinalysis 1g/l protein, LE positive, 10 WBC/HPF with
WBC casts
Case 2
Does she have AKI?
What’s the most likely cause of the AKI?
Does she need a kidney biopsy?
How should we treat her?
Case 2
Does she have AKI?
Yes, acute deterioration renal function
What’s the most likely cause of the AKI?
Allergic Interstitial Nephritis from PPI
Does she need a kidney biopsy?
Yes
How should we treat her?
Trial steroids, stop PPI, consider H2RB
PPI related
Allergic Interstitial Nephritis
AIN 5-10% of causes of AKI
~60% drug-related
25% of these are due to PPIs
Relatively rare population-based
1:12,500 patient-years
J Nephrol (2016) 29:611–616
Case 3
33 year-old male has routine labs done for life insurance
purposes
CBC normal, LE’s normal, lytes normal, Cr 82
Urinalysis 1 g/l protein, 1+ blood, glucose negative, 10-
20 rbc’s/HPF, dysmorphic rbcs, few rbc casts
ACR 100 mg/mmol
800 mg protein on 24 hr urine
KDIGO Working Group
Case 3
Does he have AKI?
What’s the cause of his urinary abnormalities?
How will they affect his ability to get life insurance?
Does he need a kidney biopsy?
Case 3
Does he have AKI?
No, Cr normal
What’s the cause of his urinary abnormalities?
Probably glomerulonephritis, likely IgA Nephropathy
Does he need a kidney biopsy?
Probably not yet
Indicated if > 2g protein or worsening renal function
Affect of insurability
prohibitive
Case 4
78 year-old healthy non-smoking male presents
to ER with SOB
Present for 10 days, worsening
Cough productive green sputum
Hemoptysis for past day
Exam normal except for BP 180/100, scattered crackles
on respiratory exam and maculopapular rash on
forearms
Case 4
Labs
Lytes normal, Cr 375 (baseline 81)
Hg 81 g/l, WBC and Plts normal, ANCA + PR3, Anti GBM+,
ANA -, Hep B/C and HIV all negative
Urinalysis 2 g/l protein, 2+ blood, neg glc, LE neg
20-40 rbc/hpf, dysmorphic RBC’s, numerous RBC casts
Case 4
Does he have AKI?
What are the cause of the urinary abnormalities?
Does he need a kidney biopsy
How should we look at treating him?
Case 4
Does he have AKI?
Yes
What are the cause of the urinary abnormalities?
Glomerulonephritis, likely GPA and Goodpasture’s overlap syndrome
Does he need a kidney biopsy?
yes
How should we look at treating him?
BP control, pulse steroids, cyclophosphamide, rituxan, may need dialysis and/or pheresis if worsens
Case 5
71 year-old female
HTN, DM2, CHF
BP 170/81
Lytes normal, CBC normal, Cr 130 (progressive increase
over past 2 years)
ACR 110 mg/mmol
Urinalysis 2 g/l protein, neg blood, 1+ glucose
Case 5
Dose she have AKI?
What is the cause of her urinary abnormalities?
Does she need a kidney biopsy?
What’s her eGFR?
How should we look at treating her?
Case 5
Dose she have AKI?
No CKD
What is the cause of her urinary abnormalities?
Likely Diabetic Nephropathy
Does she need a kidney biopsy?
no
What’s her eGFR?
35 ml/min/1.73m2
How should we look at treating her?
ACEI or ARB, Canagaflozin, glc control
Case 6
80 y/o F HTN, IHD with previous anterior MI, RA
Fell at home R hip #
Na 115 preop
consult medicine preop ?etiology and mgmt hypoNa
Meds
HCTZ 50mg OD
MTX 7.5 mg weekly
Case 6
O/E 50 Kg, thin
P 80,R BP 140/90 JVP ASA
Chest/CVS/ABD normal
Features of RA
Na 115 K 3.8 HCO3 26 Cl 96
Urea 3 Cr 80 Glc 5 Sosm 250 mOsm/kg
Case 6
How would you approach this patient ?
What is the cause of her hyponatremia ?
Is it acute or chronic ?
How would you manage her ?
Hyponatremia - Approach
R/O pseudohyponatremia
Assess ECF volume
Assess diet and fluid intake
Assess serum tonicity
Hyponatremia
Hypovolemic
Normal response to hypovolemia
Hypovolemia with inappropriate fluid mgmt ie with D5W
or 1/2 NS replacement
Hyponatremia
Hypervolemic
Increased ECF volume but reduced effective circ blood
volume turns on ADH
CHF
Cirrhosis
Nephrotic syndrome
Renal Failure
Hyponatremia
Normovolemic
Thiazide diuretics (ADH indirect stim)
Adrenal failure
Hypothyroid
Malnutrition - beer potomania
Polydypsia
SIADH Pulmonary
CNS
Drugs (NSAIDs, Opiates, TCA’s)
Reset osmostat
Hyponatremia
ECF volume normal
Normal BP make adrenal failure less likely
Thiazide diuretic, NSAID
Toast and tea diet (250 mosm/d)
fluid intake 3L day
Hyponatremia
What further information required ?
TSH 3 mU/L
Cortisol
0800 700 nmol/l
0830 1000 nmol/l (after 250 mcg ACTH)
UNa 30 Uosm 400
Hyponatremia
Therapy
D/C Thiazide
D/C NSAID
Feed
Fluid restrict 1.5 L / day
Case 7
80 y/o M HTN, DM II on OHA, Dementia OA, IHD
(angina - class 2)
Recent UTI (urinary incontinence)
Prostate Ca (Stage B) for TURP
Meds
Septra DS 1 PO BID
Metoprolol 50 mg PO BID
Iburpophen 400 mg PO BID
Glyclizide 80 mg PO OD
Case 7 O/E
P 100,R BP 100/60 T37C
Not oriented to place or time
JVP 2cm Below SA
Chest clear, CV exam normal, no edema
ABD exam normal
No active joints
I/O
30 cc U/O per hr X 24
Case 4 Na 135 K 7.5 Cl 105 HCO3 25
Urea 20 Cr 200 Glc 15
Hgb 130 WBC 10 Plts 250
Ca 2.1 Phosphate 1.1 Albumin 30
EKG
NSR 70 bpm poor R wave progression, peaked T waves, QRS 0.2 msec
U/A 1+ Blood 2+ Protein 2+Glc No WBC
Case 7
How would you manage this patient?
Case 7 Management
IV access
CaCl 1g IV push over 5 min X 2
NaHCO3 50 cc IV push
Insulin IV 5u bolus, followed by gtt 1u/hr
Kayexelate 60g PO, Lactulose 30 cc PO
NS 2 l over 10 hr
Continuous EKG monitoring (ICU step-down)
Cancel OR
D/C septra & ibuprophen
Hyperkalemia
Treatment
Protect myocardium
Shifting maneuvers
Remove K from ECF
diuretics
cation exchange resins (Kayexalate)
dialysis
Hyperkalemia
How do you approach hyperkalemia (in terms
of defining etiology)?
What is the cause of this patient’s
hyperkalemia?
Hyperkalemia
Etiology
Pseudohyperkalemia
hemolysis
thrombocytosis
leukocytosis
Hyperkalemia Etiology
Increased K release from cells
Metabolic acidosis
Insulin deficiency
Hyperosmolality (hyperglycemia)
Tissue catabolism (TLS, Burns, rhabdomyolysis, GI bleed)
B2 blockers
Exercise
Periodic Paralysis - AD defect in skel muscle voltage dependent Na channels
Succinylcholine - depolarizes membrane potential with K release
Hyperkalemia Etiology
Reduced Renal K Excretion
GFR - any etiology
Tubular flow - any etiology (ECBV)
Ureterojejunostomy
reabsorption urine K by jejnum
K secreting defect
TIN
Obstructive uropathy
distal RTA with Na reabs & secondary K and H secretion
Hyperkalemia Etiology
Reduced Renal K Excretion
Hypoaldosteronism
Hyporeninemic
Hyperreninemic
Pseudohypoaldosteronism
Hyperkalemia
Diagnostic Approach
Detailed assessment
Identify causes for shift & any offending drugs
Assess ECF volume and renal function
Case 7 Course - 24 hrs
K 4 Cr 150 Urea 10
Glc normalized, diabeta dose increased
JVP ASA
U/O 60 cc/hr
TURP uneventful
Contributors hyperkalemia
Volume depletion
Drugs (NSAID, Septra, BB)
Hyperglycemia
Hypoaldosteronism (diabetes)
Objectives Achieved
Understand elements of the normal and abnormal
urinalysis
Recognize urinary findings in clinical syndromes
Proteinuria
Glomerulonephritis
Nephrotic Syndrome
Interstitial Nephritis
Understand the clinical approach to disorders of sodium
and potassium