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
