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ComPbms.GU

Proteinuria, Hematuria, UTI

QuestionAnswer
Proteinuria; What Urinary protein excretion of more than 150mg per day an is a hallmark of renal disease. Microalbuminuria is defined as excretion of 30-50mg per day of protein and is an early sign of renal disease, especially in patients with DM.
Proteinuria; Classifications Transient Temporary change in glomerular hemodynamics which cause excess protein. These are self limiting or benign.
Proteinuria; Classifications Persistent Defined as 1+ protein on a standard dipstick on 2 or more occasions over 3 months.
Transient Proteinuria Causes Orthostatic proteinuria . Dehydration. Fever. Exercise induce proteinuria. CHF, Seizure disorders can cause transient proteinuria.
Persistent Proteinuria Causes Drug induced (lithium, NSAIDS) . Hereditary i.e.: polycystic kidney disease, Medullary kidney disease. Immune disorders i.e. drug allergies, collagen vascular disorders, sarcoidosis. Infection: TB.
Persistent Proteinuria Causes Metabolic imbalances: hyperuricemia, hypocalcaemia. Vascular disorders: DM, HTN, Sickle Cell disease.
Proteinuria Risk Assessment Proteinuria may help to predict risk assessments for renal disease in DM, HTN which is the leading cause of ESRD. Ethnic Groups at greater risk; African American, Native American, Hispanic American, Pacific Islanders.
Proteinuria Physical and Diagnostic Assessment Complete H&P to include a thorough: FMH, PMH, Social Hx, Surgical Hx, Recent Diagnostics which may have included dye. Complete physical assessment of the vascular system.
Proteinuria Diagnostic Testing: Urine dipstick, UA with culture and sensitivity, CMP, CBC with differential, Calcium and Phosphorus if not on CMP, Urine for Bence Jones Protein, Lipid profile, Consider 3 early am serial UA’s, 24 hour creatinine clearance.
Proteinuria Referral The NP may begin the initial work-up but the more intricate testing for specific protein and or other diagnostic tests will be directed by the urologist or renal specialist.
Proteinuria NP Role NP role: identify early risk factors, treat chronic disease states that lead to renal disease.
Hematuria; What? 3 or more red blood cells per high powered field. Two classifications: Transient: hematuria which occurs on occasion. Persistent: hematuria present on 2 or more consecutive occasions.
Hematuria; Epidemiology Usually non-pathologic in men under 33, and post menopausal women. However, men >50 has higher rate of malignancy. So, do more work up with men over 50.
Hematuria; Meaning Rarely due to systemic disease. It is related to renal disease. Bacterial infections are the most common cause of hematuria. Proteinuria and hematuria is suggestive of glomerular or interstitial nephritis.
Hematuria: PE and Clinical Presentation A thorough hx must be obtained: PMH. FMH. Social history including sexual hx, illicit drug use. Urinary patterns, urine color, timing of hematuria (beginning of urination, end or throughout). Pain presence and location. Acute and chronic medication
Heamturia: PE Travel to areas with endemic schistosomiasis – this is a parasitic infection caused by a fluke found in contaminated fresh water and is acquired via contact and the leading cause for hematuria worldwide.
Heamturia: Diagnostics UA with culture. UA for cytology. CBC. CMP. PT/PTT. 24 hour urine for calcium and uric acid. STD testing. Imaging: Ultrasound of kidney, ureter, bladder. CT scan or MRI- these have nearly replaced the IV pyelogram due to better imaging.
Hematuria: Mgmt Referral to urologist if biopsy or cystoscopy is indicated. Dx of underlying conditions and definitive tx of the illness or condition with monitoring for future episodes.
UTI; Physical findings Physical findings may include any of the following or all of the following: Dysuria. Frequency. Urgency. Fullness or incomplete bladder emptying. CVA tenderness or flank pain. Suprapubic pain.
UTI Complicated: Hx of underlying anatomic abnormalities i.e. polycystic kidney disease, neurogenic bladder. Hx of nephrolithiasis. Recent instrumentation. Indwelling Foley catheter or intermittent cauterization.
UTI Complicated: Polynephritis may start with a simple UTI but has progressed to a more serious infection involving the kidney, with fever, nausea, vomiting, CVA tenderness.
UTI: Physical Assessment and Tx of UTI Complete PMH, FMH and sexual Hx. Complete VS. Assess for CVA and suprapubic pain. Urine for dipstick and UA with culture from a clean catch urine specimen. The presence of nitrate and leuks on dipstick is 90% accurate for bacterial infection.
UTI; Physical Assessment and Tx of UTI The culture helps determine resistance to antibiotics.
UTI; Pharm Tx First line antibiotic is still TMP-SMX (bactrim). It is cheap, and effective if pt has not had frequent UTI’s. Bactrim DS bid x3 is effective, should use for 7 days if pt has had symptoms more than a few days or has had UTI in past.
UTI; Pharm Tx Ampicillin, Amoxicillin, Augmentin, and first generation cephlosorins all have efficacy in treating UTI’s but also have 10-20% resistance rates. Fluoroquinolones (ciprofloxacin, levofloxacin) are effective and may be used for 3-7 day course.
UTI; Medical Tx Polynephritis may require up to 14 days of treatment and a fluoroquinolone is preferred. Patients may also require IV hydration.
UTI; Medical Tx Complicated UTI’s need a culture to determine any resistance and more serious infection from a noscomial infection in institutionalized patients.
Created by: DianaB
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