5243.Lecture 139a - Renal Syndromes and Urinalysis
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Transcript of 5243.Lecture 139a - Renal Syndromes and Urinalysis
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DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi ([email protected] 17, 2009 9am Anne Chin ([email protected] 1 of 6 Recorded, (Not) Corrected
Welcome to Unit 7. This hour serves primarily as an introduction to the world of nephrology. Basically, this lecture covers the exciting
topic of urine. The slides posted on WebCT are incorrect, but lucky for you, the ones in the syllabus are correct. Dr. Reddi finished this
first lecture on urinalysis in the 10am hour, so if youre looking for information on the last few slides, you must look elsewhere. As
usual, Dr. Reddi primarily stuck to reading off the slides. If you have any questions, he can be reached at extension # 6052.
Renal Syndromes and Urinalysis
INTRO TO THE KIDNEY
The kidney size really matters. The normal adult kidney is about 11-12 cm long,
5-7cm wide, and 2-3 cm thick, with a weight of 125-170g. Clinically, its useful to
know the normal size values of a kidney because size can give you a clue about the
underlying renal disease and helps you narrow your differential diagnosis. Size is
measured using renal ultrasound.
Large (>12cm) Small (
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DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi ([email protected] 17, 2009 9am Anne Chin ([email protected] 2 of 6 Recorded, (Not) Corrected
o Uremia (symptoms; fatigue, weakness, anorexia, bone or abdominal pain, poor appetite loss of appetite is often
the first symptom)
o Hypertension: volume dependent hypertension due to the inability to excrete Na+
o Renal colic
o Urinary tract infection (dysuria) more common in females
o Electrolyte disorders (hypo- or hypernatremia, hypo- or hyperkalemia, elevated creatinine and BUN (azotemia),
metabolic acidosis)
- Signs & Symptoms of Chronic Renal Failure:o Lethargy, fits, coma
o Anorexia, nausea, vomiting
o Hypertension, pericarditis, heart failure
o Pleurisy, dyspnea on exercise
o Nail changes
o Bone pain
o Edema
o Peripheral neuropathy, myopathy (muscle weakness)
o Amenorrhea, impotence, infertility
o Bruising, pruritic excoriations, sallow pigmentation, mucosal pallor (anemia), epistaxis
Now we will discuss specific abnormalities in a little more detail
Acute Nephritic Syndrome: acute illness
- Macroscopic or microscopic hematuria
o Microscopic hematuria = observation of RBCs under the microscope
- Edema (mostly periorbital and also generalized)
- Oliguria (urine volume
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DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi ([email protected] 17, 2009 9am Anne Chin ([email protected] 4 of 6 Recorded, (Not) Corrected
- Normal: pH = 4.5-6.5
- Clinical use:
o Renal tubular acidosis (RTA)
o Renal stones (uric acid and cystine stones precipitate in acid urine)
o Treatment of salicylate, phenobarbital ingestion and rhabdomyolysis (alkalinization of urine improves these
conditions)
o Urinary tract infection (UTI)
o Follow therapy in metabolic alkalosis (alkaline urine indicates improvement)
Glucose:
- Special reagent strips measure only glucose
- Clinical use:
o Detect uncontrolled diabetes mellitus
o Detect proximal tubular defect (Fanconi syndrome)
o Glucosuria occurs in normal pregnancy due to increased filtered load of glucose
Protein: Normal protein excretion is < 150mg/day
- Reagent strips (dipsticks) can detect albumin only
- Sulfosalicylic acid (SSA) detects or precipitates all proteins
o
Negative dipstick but positive SSA indicates proteins other than albumin (diagnostic for multiple myeloma andother plasma cell dyscrasias)
- Clinical use: detect proteinuric conditions
Ketones: there should be no ketones in the urine except during starvation conditions. Ketonuria can result from excess alcohol or
diabetic ketoacidosis.
- Ketones: Acetone, acetoacetic acid (AcAc), 3-beta hydroxybutyric acid (BHB)
- Dipstick sensitivity:
o AcAc: 4+
o Acetone: 2+
o BHB: 1+
- Clinical use: Diabetic ketoacidosis; starvation ketosis; alcoholic ketosis; recovery from ketosis
Blood:- Detects Hgb and myoglobin
- Clinical use: detect hematuria
- Dipstick positive urine, but no RBCs in sediment suggests hemoglobinuria or myoglobinuria (not frank blood) (diagnostic for
rhabdomyolysis)
o Differentiation by serum color
Hemoglobinuria: pink serum
Myoglobinuria: clear serum
Urinary Sediment:
- Includes such things as: cells, casts, crystals, bacteria, yeast, and miscellaneous particles as you can imagine these can get
pretty disgusting
- Cells:o Epithelial: squamous usually arise from the urethra and are not pathognomonic of anything
o Transitional: spindle or pear-shaped cells from the bladder these indicate cystitis if there are >5 transitional cells
per high power field
o Renal tubular: arise from the renal tubules indicate acute tubular necrosis if > 4 cells per high power field
o RBCs
o WBCs
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DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi ([email protected] 17, 2009 9am Anne Chin ([email protected] 5 of 6 Recorded, (Not) Corrected
- Casts: consist of Tamm-Horsfall proteins (mucus protein + cell debris often conforms to a cylindrical shape)
o Hyaline: pure Tamm-Horsfall proteins that have the same refraction constant as glass (thus the name) not
pathognomonic of any disease
o Granular: Tamm-Horsfall + albumin are of no clinical significance because they are found in both normal and
abnormal urine
o RTC (renal tubular cell): round, cells with eccentric nuclei - indicated acute tubular necrosis
o RBC: usually a very bad sign that indicates glomerulonephritis or severe hypertensive disease
Hemoglobincast hemolysis of red cells acute nephritic syndrome, low SG (same pathology as RBC
casts)
o WBC: indicates urinary tract infection, acute interstitial disease (TID)
o Waxy: enlarged ~2x indicate chronic kidneydiseaseo Broad: 2-3x the size of a normal cast indicative ofchronic kidney disease
o Fatty: fat, cholesterol, triglycerides appear as maltese crosses associated with nephrotic syndrome
Look a lot like RBC casts can be distinguished by proteinuria and clinical manifestations
A B C
D E F
GH I
Urinalysis Casts
A. Hyaline Cast B. Granular Cast C. WBC Cast D. RTC Cast E. RBC Cast F. Hemoglobin Cast G. Fatty Casts (maltese cross) H. Broad Cast I. Waxy Cast
A B C
A.Epithelial CellsB.Transitional CellC.Renal Tubular Cell (RTC)
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DPPT: Lecture 139a: Renal Syndromes & Urinalysis Dr. Reddi ([email protected] 17, 2009 9am Anne Chin ([email protected] 6 of 6 Recorded, (Not) Corrected
- Crystals:
o Calcium oxalate: envelope-like appearance nonpathognomonic (in normal urine)
Metabolite of ethylene glycol can help diagnose ethylene glycol ingestion associated with metabolic
acidosis, respiratory distress and increased osmolar gap
o Triple PO4 (NH4-Mg-PO4): coffin-lid appearance suggestive ofinfection (UTI)
o Uricacid: football shape (but can vary) - gout
o Cystine: looks like a benzene ring suggests cystinuria
~FIN~
A B
C
D
Urinalysis Crystals:
A.Calcium oxalate crystals nonpathognomonic or
metabolite of ethylene
glycol
B.Triple PO4 (NH4-Mg-PO4)crystal infection
C.Cystine crystal cystinuriaD.Uric acid crystals - gout
