24 Non-Glomerular Hematuria Flashcards Preview

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Flashcards in 24 Non-Glomerular Hematuria Deck (33):
1

Non-Glomerular Causes of Hematuria:
DDx & Work-up

  • DDx
    • Cancer – until proven otherwise
    • Trauma
    • Stones
    • Infection
    • Iatrogenic
    • Miscellaneous
  • Work-up
    • Urinalysis
      • Upper vs. lower tract
    • CT scan
      • (-) Contrast or (+/-) contrast
      • [ Historical: Intravenous pyelogram (IVP)]
    • Cystoscopy
    • Retrograde urethrogram and cystogram
    • 90% of work up will be negative

2

Hematuria of Cancer

  • Gross hematuria common
  • Work-up as indicated and urine cytology
  • Bladder cancer- Transitional cell –Urothelial cell
  • Renal carcinoma
    • Detected incidentally, not usually from hematuria
  • Prostate cancer
    • Dectected by PSA and rectal exam, not hematuria
  • Urethral cancer
    • Only GU cancer more common in females
    • Urothelial cancer in proximal urethra
    • Squamous cancer in distal

3

Hematuria from Trauma

  • Blunt and penetrating renal trauma
  • Ureteral trauma
  • Blunt and penetrating bladder trauma
  • Rupture of the membranous urethra
  • Straddle trauma to the bulbar urethra
  • Injury to the penile urethra

4

Blunt Renal Trauma

  • Etiology
  • Grade
  • W/ microscopic hematuria
  • CT
  • Treatment

  • Etiology
    • Motor vehicle accident’s
    • Falls
    • Contact sports
  • Graded I - V
  • W/ microscopic hematuria
    • Work-up not necessary if hemodynamically stable
    • Except children or clinical suspicion
  • CT usually done for other injuries
  • Treatment
    • Observation
      • Until urine clear
    • Surgery
      • Grade V
      • Thrombosis of the main renal artery
      • Multiple major lacerations
      • Avulsion of the main renal artery and/or vein

5

Penetrating Renal & Bladder Trauma

  • Both
    • Stab or gun shot wound
  • Renal
    • 88% associated with other organ injury
    • After stabilization, surgical exploration
      • Rare to study
  • Bladder
    • Diagnostic studies only if stable
    • Surgical repair

6

Ureteral Trauma

  • Rare
  • Deceleration injury or penetrating trauma
  • Iatrogenic causes
  • Incidental congenital anomalies
    • Uretero-pelvic junction obstruction
  • Surgical repair

7

Blunt Bladder Trauma

  • Motor vehicle accident’s, deceleration injuries
  • Gross hematuria typically present
  • Types
    • Contusion
    • Extraperitoneal rupture
      • 10% of pelvic fracture
      • Treatment: bladder drainage
    • Intraperitoneal rupture
      • Surgical repair
  • Retrograde urethrogram first

8

Rupture of the Membranous Urethra

  • 10% pelvic fractures in males
  • GROSS BLOOD AT MEATUS
  • Retrograde urethrogram
  • Operative realignment
    • Open or endoscopic

9

Straddle Trauma to the Bulbar Urethra

  • Butterfly hematoma
  • Treatment: extended drainage
  • Long term: stricture disease

10

Injury to the Penile Urethra

  • Penetrating trauma or sexual activity
    • Fractured penis
  • Gross blood
  • Retrograde urethrogram
  • Open surgical repair

11

Kidney Stones:
Calculus Disease

  • One of the most common renal diseases of the Western World
  • Present in Egyptian mummies dated to 4800 B.C.
  • 2 to 4% of the American population are at risk of at least one stone episode
    during his/her life time
  • 50% of those will experience at least one further episode of stone formation over the ensuing 10 years
  • Stone disease accounts for 1 of every 1000 hospitalizations
    • 200,000 hospitalizations per year
    • Exceeding $400 million dollars annually

12

Kidney Stones:
3 Theories of Stone Formation

  • Matrix Theory
    • Organic matrix compounds present in all stones are causally related to stone formation
  • Inhibitor Theory
    • Deficiency in the urine of substrates which normally inhibit crystallization and growth
  • Crystalloid or Precipitation-Crystallization Theory
    • Supersaturation with respect to the stone-forming constituents
  • Reality: likely due to a combination of these theories

13

Kidney Stones:
Calcium Oxalate Monohydrate or Dihydrate:
Pathogenesis / Risk Factors

  • Idiopathic
  • Metabolic defects
    • Alkaline urine pH
    • Hypercalciuria
    • Hyperoxaluria
    • Hyperuricosuria
  • Family history
  • Dehydration
  • Diet or medications
    • Vitamins A, D, C
    • Acetazolamide
    • Antacid abuse

14

Kidney Stones:
CaOx Features

  • Accounts for about 85% of all stones
  • Male to female ratio is 3-4:1
  • High incidence of stones in the South Eastern United States = Stone Belt [Texas to Virginia and south]
  • Hypercalciuria
    • > 300 mg/24 hr in males
    • > 250 mg/24 hr in females
  • Calcium homeostasis requires
    • Hormones: 1,25 vitamin D, PTH
    • Organs: bone, kidney, gut

15

Kidney Stones:
Hypercalciuria

  • Increased gut absorption of calcium
    • Increased 1,25 vit D (sarcoid, primary hyperparathyroidism)
    • Dietary calcium excess
    • Idiopathic
  • Increased bone reabsorption
    • Primary hyperparathyroidism
    • Distal RTA
    • Idiopathic
  • Increased renal excretion
    • Hypercalcemia of any cause
    • Distal RTA
    • Dietary sodium or protein excess
    • Idiopathic hypercalciuria
    • Renal leak

16

Kidney Stones:
Other Hypers

  • Hyperuricosuria
  • Hyperoxaluria

  • Hyperuricosuria
    • Uric acid crystals may serve as a nucleus for calcium salt precipitation
  • Hyperoxaluria
    • > 40 mg/24 hours
    • End product of metabolism
    • Forms an insoluble complex with calcium
    • NOT pH dependent
    • Causes:
      • Increased production
        • Congenital
        • Vitamic C (2 gm/day)
        • Ethylene glycol
      • Increased intestinal absorption
        • Dietary excess
        • Enteric hyperoxaluria
        • Dietary calcium restriction

17

Kidney Stones:
Enteric Hyperoxaluria

  • Malabsorption syndromes
    • Crohn's disease
    • Intestinal bypass
  • Pathophysiology
    • Fatty acid soaps bind calcium in the gut
    • Calcium prevented from complexing with oxalate
    • Oxalate then "free" to be absorbed in large quantities
  • Paradoxical treatment
    • Calcium or magnesium supplementation
    • Treat the underlying condition

18

Kidney Stones:
Calcium Oxalate Diagnosis & Treatment

  • Diagnosis
    • Stone analysis
    • Calcium oxalate crystals NOT diagnostic
    • 24 hour urine studies
  • Treatment
    • Decrease urinary calcium/sodium/oxalate/uric acid
    • Inhibitors
    • Fluids, treat underlying defect, education

19

Kidney Stones:
Calcium Phosphate

  • Pathogenesis/risk factors
  • Clinical features
  • Diagnosis
  • Treatment

  • Pathogenesis/risk factors
    • Hypercalciuria
      • Vitamin D intoxication
      • Hyperparathyroidism
      • Sarcoid
    • Alkaline urine
      • Urinary acidification defect
        • Distal, Type I RTA
      • Acetazolamide
      • Milk-alkali syndrome
        • Excessive intake of milk/antacids to control dyspepsia: results in hypercalcemia
  • Clinical features
    • Common minor constituent of garden variety calcium stones
    • Pure calcium phosphate stones are rare
  • Diagnosis
    • Stone analysis; crystals NOT diagnostic
    • 24 hour urine studies: hypercalciuria
    • Identify other causative risk factors
  • Treatment
    • Decrease calcium excretion
    • Fluids, Rx underlying defect, education

20

Kidney Stones:
Urate Nephropathy

  • Uric acid stones
    • Most common form of uric acid disposition in the urinary tract
  • Acute uric acid nephropathy
    • Particularly malignant form of uric acid precipitation
    • Chemotherapy for a lymphoma or leukemia
    • May obstruct of the urinary tubules by sludging
    • True crystals, or stones do not form
  • Chronic urate nephropathy
    • Unrelated to stone disease
    • Progressive disease occurring in a minority of gout patients
    • Precipitates in the interstitium and pyramids
      • Interstitial nephritis

21

Kidney Stones:
Uric Acid Calculi

  • Pathogenesis
  • Clinical features
  • Diagnosis
  • Treatment

  • Pathogenesis
    • Hyperuricosuria
      • gout
      • psoriasis
      • Lesch Nyhan syndrome
        • Juvenile gout: x-linked recessive deficiency in enzyme hypoxanthine-guanine phosphoribosyltransferase (HGPRT): resulting in elevated uric acid
      • obesity
      • Status post chemotx
    • Persistently acid, concentrated urine (pH < 5.5)
      • chronic diarrheal disease, esp. via ileostomy
    • Uric acid solubility decreases 10-20x when urine pH falls 7 to 5
  • Clinical features
    • 5-10% of all stones
    • Only truly radiolucent stone
  • Diagnosis
    • Stone analysis
    • Uric acid crystals in the urine NOT diagnostic
    • 24 hour urine studies: hyperuricosuria
  • Treatment
    • Very susceptible to solubility conditions
    • Alkalinization to reach urinary pH 6.5-7.0 (solubility product)
    • Fluids, treat underlying condition, education

22

Kidney Stones:
Struvite Stones

  • Pathogenesis / risk factors
  • Clinical features
  • Diagnosis
  • Treatment

  • Pathogenesis / risk factors
    • Urinary tract infection with urea-splitting organism
      • Proteus - most common
      • Klebsiella
      • Serratia
      • Enterobacter
    • Markedly alkaline urine (pH 7.5-8.0)
    • Supersaturation with magnesium-ammonium phosphate
  • Clinical features
    • Accounts for about 20% of stones
    • Most common cause of staghorn calculi
    • Most common stone in women and paraplegics
    • Recurrent UTIs
      • Bacteria reside in stone (i.e. coral)
    • 40% of struvite stones are mixed calculi
    • Sequela
      • Progressive renal insufficiency
      • Urosepsis or perinephric abscesses
      • Obstruction
  • Diagnosis
    • Stone analysis
    • Struvite crystals diagnostic of UTI with urea splitting organism
      • NOT necessarily struvite stone
    • Urinary pH 8 suspect struvite stones
  • Treatment
    • Antibiotics
    • Percutaneous surgery/lithotripsy
    • Fluids, treat underlying disease, education

23

Kidney Stones:
Cystine Calculi

  • Pathogenesis / risk factors
  • Clinical features
  • Diagnosis
  • Treatment
  • Drugs

  • Pathogenesis / risk factors
    • Cystinuria
      • Autosomal recessive genetic defect in dibasic amino acid transport in renal tubule and gastric mucosa
        • COLA = cystine, ornithine, lysine, arginine
      • Only amino acid to cause clinical disease
    • 1% of all stones
  • Clinical features
    • Onset often in childhood or early adolescence
    • Family history
    • Staghorn calculi can form, mildly radio-opaque
    • Progression to renal failure
      • Renal parenchymal damage
  • Diagnosis
    • Stone analysis
    • Cystine crystalluria
      • Hexagonal crystals
    • Cyanide-nitroprusside test
      • Qualitative
    • 24 hour urine studies
      • Quantitative
      • Homozygous vs. heterozygous
  • Treatment
    • High fluid intake (4L/d)
    • Patient education- compliance
    • Resistant to ESWL
    • Meds
  • Drugs
    • Alkali therapy – Potassium Citrate
      • Increase in cystine solubility at urine pH > 7.5
    • d-Penicillamine
      • Covalently bonds to cystine, making a soluble complex
      • Toxic -- glomerulonephritis, Lupus syndrome, marrow depression
    • Tiopronin (Thiola)—similar action to penicillamine but better tolerated

24

Kidney Stones:
Inhibitors

  • Deficient in urine of stone-former
  • Citrate
    • Forms a soluble Ca+2-citrate complex
    • Increases urinary pH
    • Hypocitraturia occurs in states of chronic metabolic acidosis (distal RTA, chronic real failure, acetazolamide therapy), K+ depletion and idiopathic cases
    • Presumably raises the formation product of all types of calcium stones

25

Kidney Stones:
Clinical Features & Treatment Options

  • Dull ache in the loin from distention of the renal capsule
  • Renal "colic" from acute or transient obstruction
    • Lumbar area and radiates around and down into groin, testis, labia or thigh
    • Pain changes as calculus moves
    • Patient cannot get comfortable
  • Nausea, vomiting, abdominal distention
  • Hematuria - gross or microscopic—does not have to be present
  • Frequency and urgency
  • Fever/chills

26

Kidney Stones:
Acute Management

  • Diagnostic Procedures
  • Treatment
  • Surgery

  • Diagnostic Procedures
    • History and physical examination
      • Risk factors, associated medical conditions, medications
    • Urinalysis: pH, rbc, wbc, culture, crystals
      • Not all crystals are diagnostic of stone disease
    • Spiral CT without contrast
      • Current diagnostic test of choice
      • Patients unable to have contrast agents
  • Treatment
    • 90% of stones less than 5 mm in diameter will pass spontaneously
    • Increase fluid intake
    • Strain all urine to catch stone for analysis
    • Steroid, alpha-blocker, antibiotic
    • Indications for surgical intervention
      • Infected system
      • Obstruction persists >4 weeks
      • Intractable pain or nausea
      • Stone unlikely to pass due to size
  • Surgery
    • If small calculus in the lower or middle third of the ureter
      • Ureteroscopy with basket or ESWL
      • May need to be fragmented to remove
        • Laser, pneumatic, or electrohydraulic
    • If large calculus and/or in the pelvis of the kidney, or upper third of the ureter
      • Ureteroscopy, percutaneous removal or ESWL

27

Kidney Stones:
Diagnostic Procedures

  • CT Scan without contrast
  • More Diagnostic Procedures

  • CT Scan without contrast
    • “Renal colic CT”
    • “Kidney stone protocol CT”
      • CT abd/pelvis without contrast, low dose protocol
    • Rapid and specific
  • More Diagnostic Procedures
    • IVP = intravenous pyelogram
      • Previously best first test
      • Evaluation for obstruction and location
    • Ultrasound
      • May diagnose obstruction
      • Locate radio-opaque calculi
      • Limited in ureteral calculi
    • KUB = x-ray of the abdomen with pelvis
      • Kidney, Ureter, Bladder

28

Bladder Stone Surgery

  • Extracorporeal Shock Wave Lithotripsy - ESWL
  • Staghorn Calculi

  • Extracorporeal Shock Wave Lithotripsy - ESWL
    • Effective and safe procedure
    • Revolutionized the treatment of all types of stone disease
    • Typically first line therapy
    • Minimal anesthesia
    • Outpatient
  • Staghorn Calculi
    • Percutaneous surgery alone or with ESWL
    • Recurrence reported at 10-40%

29

Percutaneous Nephrolithotomy:
Chronic Management

  • Metabolic Work Up
  • Treatment

  • Metabolic Work Up
    • Blood chemistry: calcium, phosphate, bicarbonate, uric acid, BUN, creatinine
    • 24 hour urine collections on "normal" diet
      • calcium nl to 300 mg in M, 250 mg in F
      • uric acid nl to 800 mg in M, 750 mg in F
      • sodium desired 100-125 mEq
      • volume desired >2000 ml
      • citrate nl 300-900 mg
      • oxalate nl < 40 mg
      • cystine nl < 100 mg
    • Stone analysis
  • Treatment
    • Fluid intake 24 hours/day > 2-3 L/day
    • Dietary modification
    • Regulate urinary pH
      • Alkalinization: uric acid and cystine stones
      • Acidification almost never indicated
        • Cranberry juice NOT indicated

30

Percutaneous Nephrolithotomy:
Drug Therapy

  • Citrate
    • Alkalinization also for calcium phosphate stones
  • Thiazide diuretic
    • Decreases urinary calcium for calcium stones
  • Sodium cellulose phosphate
    • Binds calcium in the gut for absorptive hypercalciuria
  • Allopurinol
    • Decreases urinary uric acid for uric acid and calcium stones
  • Antibiotics
  • D-penicillamine
  • Thiola

31

Percutaneous Nephrolithotomy:
Prostate

  • Benign Prostatic Hyperplasia
  • Photovaporization of the Prostate

  • Benign Prostatic Hyperplasia
    • Common cause hematuria: turbulent flow
    • Symptoms determine therapy, not size!
    • Meds: alpha blockers, 5-alpha reductase inhibitors
    • Surgery
      • Minimally invasive
        • Microwave, laser, radiofrequency
      • Endoscopic Resection – transurethral resection of prostate (TURP)
      • Open surgery
  • Photovaporization of the Prostate
    • Equivalent results to TURP
    • Less side effects

32

Renal Cystic Disease

  • Simple Renal Cysts
  • Adult Polycystic Renal Disease

  • Simple Renal Cysts
    • Not cause of hematuria
    • Definition
      • Homogeneous throughout
      • Smooth walls
      • Posterior enhancement (Ultrasound)
  • Adult Polycystic Renal Disease
    • 1 in 500
    • Cause end-stage renal disease
    • Autosomal dominant
    • Involves nephron
    • Other organs
      • Pancreas, spleen, lungs
    • Hypertension common
    • Flank pain
    • No treatment necessary to cure, treatment symptoms

33

Renal Cystic Disease

  • Infectious Causes
  • Miscellaneous Rare Causes

  • Infectious Causes
    • Cystitis
    • Urethritis
    • Prostatitis
    • Pyelonephritis
    • Examine urinalysis & culture
      • White blood cell’s, nitrate positive, leukocyte esterase positive
  • Miscellaneous Rare Causes
    • Instrumentation
    • Foreign body
    • Anticoagulation
      • Remember: something is bleeding
    • Chemotherapy
      • Cyclophosphamide