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Cloudy with Occasional Chance of Crystals. What you can Learn from the Urine 18 th Annual Family Practice Review Feb 8, 2013. Jeff Kaufhold, MD FACP Master Physician Ohio University Heritage School of Medicine Nephrology Associates of Dayton. Pre Test.
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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
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
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
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
Hematuria - Evaluation • History • Physical • Urinalysis
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
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
HEMATURIA • Glomerular Causes: • IgA (Berger’s) • Mesangioproliferative GN • Hereditary GN’s, including • Alport’s, Thin Basement Membrane • Hallmark of Glomerular Disease is RBC cast
Renal Calculi Types
Urate stone Cystine Stone
Calcium Oxalate stone Calcium Oxalate stone Formed on a Urate Nidus
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
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 %
NEPHROLOGYDEFINITIONS • PROTEIN/CREATININE RATIO based on assumption of 1 Gmof creatinine excreted per 24 hours: • <0.2 = normal • >3.0 nephrotic
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
Billing codes and Reimbursement • Covered Diagnoses: • CKD 585. • UTI 590. • Kidney stone 592. • Other disorder of kidney 593.9 • Diabetes 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?
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
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