Cloudy with Occasional Chance of Crystals

1. Cloudy with Occasional Chance of Crystals What you can Learn from the Urine 18th Annual Family Practice Review Feb 8, 2013 Jeff Kaufhold, MD FACP Master Physician Ohio University Heritage School of Medicine Nephrology Associates of Dayton

2. Pre Test • Hematuria is a sign of all of the following EXCEPT: • 1. Bladder Tumor • 2. Urinary tract Infection • 3. Nephrotic syndrome • 4. Glomerulonephritis • 5. Kidney stones

4. Hematuria - Epidemiology • Definitions • Macroscopic - pink, red, or tea colored • Microscopic - >4 RBC’s per hpf of spun urine sediment • Prevalence • School aged - 4% (always check a 2nd specimen) • >35 y/o - 13% • PPV low, most useful in elderly men

5. Hematuria - Epidemiology • Specific • Glomerular causes - • Predominate in children and young adults • >40 y/o only 5% of cases • Neoplasm • >40 y/o, Urinary tract 15-20% of cases • Children: Wilm’s tumor, Rhabdomyosarcoma of bladder

6. Hematuria - Evaluation • History • Physical • Urinalysis

7. Hematuria - Evaluation

8. Hematuria - Evaluation • Urinalysis • Proteinuria - indicator of glomerular disease • can be up to 500 mg/24 hr in gross hematuria • RBC cast - must look at urine with your own eyes • Pyuria - look for UTI/STD • Crystals • Dysmorphic RBC’s

10. Hematuria • T • I • G • H • T • S

11. Hematuria • TUMOR • I NFECTION • G LOMERULONEPHRITIS • H EMATOLOGIC • T RAUMA • S TONE

12. HematuriaWorkup • TUMOR - Cytology • I NFECTION - Culture • G LOMERULONEPHRITIS • H EMATOLOGIC – CBC and Coags • T RAUMA – Xray • STONE - IVP

14. HEMATURIA • Glomerular Causes: • IgA (Berger’s) • Mesangioproliferative GN • Hereditary GN’s, including • Alport’s, Thin Basement Membrane • Hallmark of Glomerular Disease is RBC cast

18. Renal Calculi Types

19. Urate stone Cystine Stone

20. Calcium Oxalate stone Calcium Oxalate stone Formed on a Urate Nidus

21. Oxalate Crystals

22. Urine Sediment varies by pH

23. 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

24. 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

25. PROTEINURIA • Nephrotic 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 %

26. Nephrotic range PROTEINURIA Relative Frequency by Age.

27. Distribution of Glomerular Disease by Age

28. NEPHROLOGYDEFINITIONS • PROTEIN/CREATININE RATIO based on assumption of 1 Gmof creatinine excreted per 24 hours: • <0.2 = normal • >3.0 nephrotic

29. There are still always some surprises

30. Billing codes and Reimbursement • CPT code for • Urinalysis without microscopy • Dipstick 81000 • Automated 81002 • Medicare reimbursement: $3.16 • UA with microscopy • Dipstick 81015 • Automated 81001 • Reimbursement: $4.45

31. Billing codes and Reimbursement • Covered Diagnoses: • CKD 585. • UTI 590. • Kidney stone 592. • Other disorder of kidney 593.9 • Diabetes 250.00

32. 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?

33. Lindsey’s Nails

34. Atrophic Kidneys on CT

35. Post Test • Hematuria is a sign of all of the following EXCEPT: • 1. Bladder Tumor • 2. Urinary tract Infection • 3. Nephrotic syndrome • 4. Glomerulonephritis • 5. Kidney stones

36. Summary • RIFLE 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