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