DOCSLIB.ORG

This Case Is Nuts

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
This Case Is Nuts This Case Is Nuts PRESENTED BY: R LOGAN JONES, MD ACP – OREGON CHAPTER ANNUAL MEETING SALEM, OR; NOV 8TH 2018 New Patient to Clinic Chief Complaint : Right Flank Pain Generally healthy man in his 60s Non-substance user Proud Vegetarian CKD 3 without proteinuria Horseshoe kidney Recurrent oxalate renal stones Multiple procedures for nephrolithiasis No history of UTI Right CVA tenderness Recent CT with non-obstructive stones My Assessment RENAL COLIC SECONDARY TO RECURRENT NEPHROLITHIASIS “Pity the hurried practitioner” Reviewing outside records while staffing... Things get interesting! 24-Hour Urine Collection Urine Oxalate 460 mg/day EXTREME HYPEROXALURIA 460 mg/day “The Wise Counsel“The ofpractice the of “Extreme Hyperoxaluria” Specialistmedicine is requires Comforting”knowledge of basic science” Urology: • Impressed by magnitude of hyperoxaluira • Concerns for primary genetic disease – “Primary Hyperoxaluria” What now? Hyperoxaluria = Too Much Oxalate in the Urine Primary Hyperoxaluria • Too much endogenous oxalate production • Oxalate via collagen catabolism as a “dead-end” metabolic byproduct Secondary Hyperoxaluria Oxalate Primary Hyperoxaluria (PH) HEPATOCYTE PH 1 • Represents 80% of cases Peroxisome Cytosol • Usually presents in childhood • Nearly all are ESRD by 5th decade PH 2 • Represents ~10% of cases Mitochondria PH 3 • Presents during childhood/adolescence Cochat,P. N Engl J Med 2013; 369:649-658 Collagen Hydoxyproline Normal Physiology Glyoxylate Oxalate “PH” Related Glycolate Enzymes Glycine “HOMEOSTASIS” Cochat,P. N Engl J Med 2013; 369:649-658 Collagen Hydoxyproline DISEASE STATE Glyoxylate Oxalate “PH” Related Glycolate Enzymes Glycine PRIMARY HYPEROXALURIA Cochat,P. N Engl J Med 2013; 369:649-658 Hyperoxaluria = Too Much Oxalate in the Urine Primary Hyperoxaluria • Too much endogenous oxalate production • Oxalate via collagen catabolism as a “dead-end” metabolic byproduct Secondary Hyperoxaluria • Too much absorbed oxalate from exogenous sources • Mostly from plant-based foods Oxalate Secondary Hyperoxaluria Enteric Hyperoxaluria - Decreased Calcium & Increased Bile Acid Increased Total Oxalate Content - Oxalate Overload Bernadino,M, et al. CMAJ December 12, 2016 cmaj.151327 “Methodical examination leads to safe inductions” Recurrent Renal Stones: American Urologic Association Guidelines 1. Obtain a detailed medical and dietary history, serum chemistries and urinalysis 2. When a stone is available, clinicians should obtain a stone analysis at least once. 3. Clinicians should obtain or review available imaging studies to quantify stone burden. Pearle MS, et al. AUA. Medical Management of Kidney Stones. 2014. Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et al. World J Nephrol. May 6, 2015; 4(2): 235-244 Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90 mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et al. World J Nephrol. May 6, 2015; 4(2): 235-244 Progression of Primary Hyperoxaluria Stages of CKD by eGFR CKD 1-3 CKD 4-5 ESRD Cochat,P. N Engl J Med 2013; 369:649-658 Patient’s Imaging Example: Primary Hyperoxaluria Oxalosis • Oxalate crystal deposits in • Bone • Heart • Blood Vessels • Kidney 1. K. Sriram, Nitin S. Kekre, Ganesh Gopalakrishnan. Primary hyperoxaluria and systemic oxalosis. 2007 2. S. Strauss, et al. Pediatric RadiologyJanuary 2017, Volume 47, Issue 1, pp 96–103 1:800,000 live births 1:700,000 lifetime odds Risk of our patient developing adult onset Lifetime risk of being killed by an Primary Hyperoxaluria type 1 earth/space object collision (Alan Harris – Astronomer) Cochat,P. N Engl J Med 2013; 369:649-658 “Be satisfied with probabilities in diagnosis” Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90 mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et al. World J Nephrol. May 6, 2015; 4(2): 235-244 Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90 mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et al. World J Nephrol. May 6, 2015; 4(2): 235-244 “Listen to the patient, he is telling you the diagnosis” Detailed Patient History • I haven’t eaten meat in decades Family: Social: • Has one daughter,• I eat also a withbowl aof cashews• Recently and a bowlmoved of to Portland horseshoe kidney peanuts everyday• Does for proteinnot exercise • No history of end-stage kidney, liver, or heart disease • Lifelong vegetarian – eats mostly • I will also eat potatonuts chips, for protein and sometimes some veggies • He never smoked cigarettes, regularly consumed alcohol, or used illicit drugs. Our Patient’s Dietary Journal: Cumulative Daily Oxalate in milligrams 800 Our Patient’s Intake 700 600 500 400 300 Miligrams Miligrams Oxalateof 200 Average American Intake 100 0 0 1 2 3 4 5 6 7 8 9 Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90 mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et al. World J Nephrol. May 6, 2015; 4(2): 235-244 Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90 mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et al. World J Nephrol. May 6, 2015; 4(2): 235-244 Calcium Oxalate Monohydrate Calcium Oxalate Dihydrate (Whewhellite) (Weddelite) . Clouter,J et al. World J Urol. 2015; 33: 157–169 Daudon,M et al. Comptes Rendu Chemie. 19(11) · June 2016 Mixed stone: -80% calcium oxalate monohydrate - 20% calcium oxalate dihydrate. Clouter,J et al. World J Urol. 2015; 33: 157–169 Daudon,M et al. Comptes Rendu Chemie. 19(11) · June 2016 Approach to Hyperoxaluria Clinical feature Primary Hyperoxaluria Secondary Hyperoxaluria 24-hr Urinary Excretion > 90 mg per day < 90 mg per day -Usually before 5th decade -Recurrent renal stones -Recurrent stones Clinical Presentation -Occasional Nephrocalcinosis -Nephrocalcinosis -Occasional CKD and ESRD -ESRD or ESLD common Presence of Frequent part of the Less common Systemic Oxalosis presentation Family history is often History of GI tract disease or History suggestive with other affected dietary history may suggest relatives cause Composition of 95% calcium oxalate Mixed stones Renal Stones monohydrate (whewellite) (whewellite and weddellite) Adapted from: Bhasin,B, et
Load more

Recommended publications
  • A Dipstick Test Combined with Urine Specific Gravity Improved the Accuracy of Proteinuria Determination in Pregnancy Screening
    Kobe J. Med. Sci., Vol. 56, No. 4, pp. E165-E172, 2010 A Dipstick Test Combined with Urine Specific Gravity Improved the Accuracy of Proteinuria Determination in Pregnancy Screening NATSUKO MAKIHARA1, MINEO YAMASAKI1,2, HIROKI MORITA1, and HIDETO YAMADA1* 1Division of Obstetrics and Gynecology, Department of Surgery-related, and 2Division of Integrated Medical Education, Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan. Received 12 July 2010/ Accepted 20 August 2010 Key Words: dipstick test, pregnancy proteinuria, protein/creatinine ratio, urine specific gravity Proteinuria screening using a semi-quantitative dipstick test of the spot urine in antenatal clinic is known to have high false-positive rates. The aim of this study was to assess availability of a dipstick test combined with the urine specific gravity for the determination of pathological proteinuria. A dipstick test was performed on 582 urine samples obtained from 283 pregnant women comprising 260 with normal blood pressure and 23 with pregnancy-induced hypertension. The urine protein (P) and creatinine (C) concentrations, specific gravity (SG), P/C ratio were determined, and compared with dipstick test results. The P concentration increased along the stepwise augmentations in dipstick test result. Frequencies of the urine samples with 0.265 or more P/C ratio were 0.7% with − dipstick test result, 0.7% with the ± result, 3.3% with the 1+ result, and 88.9% with the ≥2+ result. However, if the urine specific gravity was low, frequencies of the high P/C ratio were 5.0% with ± dipstick test result and 9.3% with the 1+ result.
    [Show full text]
  • Proteinuria and Albuminuria: What’S the Difference? Cynthia A
    EXPERTQ&A Proteinuria and Albuminuria: What’s the Difference? Cynthia A. Smith, DNP, CNN-NP, FNP-BC, APRN, FNKF What exactly is the difference between TABLE Q the protein-to-creatinine ratio and the Persistent Albuminuria Categories microalbumin in the lab report? How do they compare? Category Description UACR For the non-nephrology provider, the options for A1 Normal to mildly < 30 mg/g evaluating urine protein or albumin can seem con- increased (< 3 mg/mmol) fusing. The first thing to understand is the impor- tance of assessing for proteinuria, an established A2 Moderately 30-300 mg/g marker for chronic kidney disease (CKD). Higher increased (3-30 mg/mmol) protein levels are associated with more rapid pro- A3 Severely > 300 mg/g gression of CKD to end-stage renal disease and in- increased (> 30 mg/mmol) creased risk for cardiovascular events and mortality in both the nondiabetic and diabetic populations. Abbreviation: UACR, urine albumin-to-creatinine ratio. Monitoring proteinuria levels can also aid in evaluat- Source: KDIGO. Kidney Int. 2012.1 ing response to treatment.1 Proteinuria and albuminuria are not the same low-up testing. While the UACR is typically reported thing. Proteinuria indicates an elevated presence as mg/g, it can also be reported in mg/mmol.1 Other of protein in the urine (normal excretion should be options include the spot urine protein-to-creatinine < 150 mg/d), while albuminuria is defined as an “ab- ratio (UPCR) and a manual reading of a reagent strip normal loss of albumin in the urine.”1 Albumin is a (urine dipstick test) for total protein.
    [Show full text]
  • Understanding What It Means to Have Protein in Your Urine Understanding What It Means to Have Protein in Your Urine
    UNDERSTANDINGUnderstanding WHAT ITYour MEANS TO HAVE Hemodialysis PROTEINAccess Options IN YOUR URINE 2 AAKP: Understanding What It Means to Have Protein in Your Urine Understanding What It Means to Have Protein in Your Urine The kidneys are best known for making urine. This rather simple description does not tell the whole story. This brochure describes other important functions of the kidneys; including keeping protein in the blood and not letting any of the protein in the liquid (plasma) part of blood escape into the urine. Proteinuria is when “Proteinuria” is when kidneys allow proteins to kidneys appear in the urine and be lost from the body. allow Proteinuria is almost never normal, but it can proteins to be normal - rarely - in some healthy, active appear in the urine children or young adults. and be The kidneys are paired organs located on either lost from the body. side of the backbone. They are located at the Proteinuria level of the lowest part of the rib cage. They are is almost the size of an adult fist (4.5 – 5 inches in length). never Together the two kidneys receive a quarter of normal, but it can the blood that is pumped from the heart every be normal minute. This large blood flow is needed in order - rarely - for the kidneys to do one of the kidneys’ main in some jobs: healthy, active • remove waste products in the blood every children day or young adults. • keep the body in balance by eliminating the extra fluids and salts we consume on a regular basis.
    [Show full text]
  • Storm in a Pee Cup: Hematuria and Proteinuria
    Storm in a Pee Cup: Hematuria and Proteinuria Sudha Garimella MD Pediatric Nephrology, Children's Hospital-Upstate Greenville SC Conflict of Interest • I have no financial conflict of interest to disclose concerning this presentation. Objectives • Interpret the current guidelines for screening urinalysis, and when to obtain a urinalysis in the pediatric office. • Interpret the evaluation of asymptomatic/isolated proteinuria and definitions of abnormal ranges. • Explain the evaluation and differential diagnosis of microscopic hematuria. • Explain the evaluation and differential diagnosis of gross hematuria. • Explain and discuss appropriate referral patterns for hematuria. • Racial disparities in nephrology care 1. APOL-1 gene preponderance in African Americans and risk of proteinuria /progression(FSGS) 2. Race based GFR calculations which have caused harm 3. ACEI/ARB usage in AA populations: myths and reality Nephrology Problems in the Office • Hypertension • Proteinuria • Microscopic Hematuria • Abnormal Renal function The Screening Urinalysis • Choosing Wisely: • Don’t order routine screening urine analyses (UA) in healthy, asymptomatic pediatric patients as part of routine well child care. • One study showed that the calculated false positive/transient abnormality rate approaches 84%. • Population that deserves screening UA: • patients who are at high risk for chronic kidney disease (CKD), including but not necessarily limited to patients with a personal history of CKD, acute kidney injury (AKI), congenital anomalies of the urinary tract, acute nephritis, hypertension (HTN), active systemic disease, prematurity, intrauterine growth retardation, or a family history of genetic renal disease. • https://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on- nephrology-and-the-american-society-of-pediatric-nephrology/ Screening Urinalysis: Components A positive test for leukocyte esterase may be seen in genitourinary inflammation, irritation from instrumentation or catheterization, glomerulonephritis, UTIs and sexually transmitted infections.
    [Show full text]
  • Hematuria in the Child
    Hematuria and Proteinuria in the Pediatric Patient Laurie Fouser, MD Pediatric Nephrology Swedish Pediatric Specialty Care Hematuria in the Child • Definition • ³ 1+ on dipstick on three urines over three weeks • 5 RBCs/hpf on three fresh urines over three weeks • Prevalence • 4-6% for microscopic hematuria on a single specimen in school age children • 0.3-0.5% on repeated specimens Sources of Hematuria • Glomerular or “Upper Tract” – Dysmorphic RBCs and RBC casts – Tea or cola colored urine – Proteinuria, WBC casts, renal tubular cells • Non-Glomerular or “Lower Tract” – RBCs have normal morphology – Clots/ Bright red or pink urine The Glomerular Capillary Wall The Glomerular Capillary Wall Glomerular Causes of Hematuria • Benign or self-limiting – Benign Familial Hematuria – Exercise-Induced Hematuria – Fever-Induced Hematuria Glomerular Causes of Hematuria • Acute Glomerular Disease – Poststreptococcal/ Postinfectious – Henoch-Schönlein Purpura – Sickle Cell Disease – Hemolytic Uremic Syndrome Glomerular Causes of Hematuria • Chronic Glomerular Disease – IgA Nephropathy – Henoch-Schönlein Purpura or other Vasculitis – Alport Syndrome – SLE or other Collagen Vascular Disease – Proliferative Glomerulonephritis Non-Glomerular Hematuria • Extra-Renal • UTI • Benign urethralgia +/- meatal stenosis • Calculus • Vesicoureteral Reflux, Hydronephrosis • Foreign body • Rhabdomyosarcoma • AV M • Coagulation disorder Non-Glomerular Hematuria • Intra-Renal • Hypercalciuria • Polycystic Kidney Disease • Reflux Nephropathy with Renal Dysplasia •
    [Show full text]
  • Blood Or Protein in the Urine: How Much of a Work up Is Needed?
    Blood or Protein in the Urine: How much of a work up is needed? Diego H. Aviles, M.D. Disclosure • In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturers of the products or providers of the services discussed in my presentation • This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA Screening Urinalysis • Since 2007, the AAP no longer recommends to perform screening urine dipstick • Testing based on risk factors might be a more effective strategy • Many practices continue to order screening urine dipsticks Outline • Hematuria – Definition – Causes – Evaluation • Proteinuria – Definition – Causes – Evaluation • Cases You are about to leave when… • 10 year old female seen for 3 day history URI symptoms and fever. Urine dipstick showed 2+ for blood and no protein. Questions? • What is the etiology for the hematuria? • What kind of evaluation should be pursued? • Is this an indication of a serious renal condition? • When to refer to a Pediatric Nephrologist? Hematuria: Definition • Dipstick > 1+ (large variability) – RBC vs. free Hgb – RBC lysis common • > 5 RBC/hpf in centrifuged urine • Can be – Microscopic – Macroscopic Hematuria: Epidemiology • Microscopic hematuria occurs 4-6% with single urine evaluation • 0.1-0.5% of school children with repeated testing • Gross hematuria occurs in 1/1300 Localization of Hematuria • Kidney – Brown or coke-colored urine – Cellular casts • Lower tract – Terminal gross hematuria – (Blood
    [Show full text]
  • Proteinuria and Nephrotic Syndrome
    Proteinuria and Nephrotic Syndrome Rebecca Hjorten, MD Division of Nephrology Speaker Disclosures • Relevant Financial Relationships: No disclosure. • Relevant Nonfinancial Relationships: No disclosure. • I have no actual or potential conflict of interest in relation to this program/presentation. Division of NephrologyDivision of Nephrology Urine Dip Concern for Positive for Urine Positive for Glomerulonephritis Protein Protein AND Blood (GN) …PIGN, MPGN, IgA, HSP Lupus, ANCA vasculitis, Urine Positive for Anti-GBM Asymptomatic Protein AND NORMAL Concerning Ex. Nephrotic Syndrome False Positive Symptoms Non-Significant Levels Persistent of Urine Protein Asymptomatic Consider Proteinuria Further Orthostatic Proteinuria Evaluation and Referral to Transient Proteinuria Pediatric Nephrology Division of Nephrology Urine Dip Concern for Positive for Urine Positive for Glomerulonephritis Protein Protein AND Blood (GN) …PIGN, MPGN, IgA, HSP Lupus, ANCA vasculitis, Urine Positive for Anti-GBM Asymptomatic Protein AND NORMAL Concerning Ex. Nephrotic Syndrome False Positive Symptoms Non-Significant Levels Persistent of Urine Protein Asymptomatic Consider Proteinuria Further Orthostatic Proteinuria Evaluation and Referral to Transient Proteinuria Pediatric Nephrology Division of Nephrology Objectives • Asymptomatic Proteinuria without Hematuria • Identification of transient and orthostatic proteinuria • Initial workup and referral or persistent proteinuria • Nephrotic syndrome • Early recognition of nephrotic syndrome • Initiation of management •
    [Show full text]
  • Interpretation of Urine Analysis
    UNDERSTANDING URINALYSIS Slides __________________________________________________________________________________________________________ Urine Analysis Interpretation of • Appearance or color • Specific gravity • pH Urine Analysis • Leukocyte esterase March 2015 • Nitrites • Urobilinogen • Bilirubin • Glucose • Ketones • Protein • Blood • Microscopic examination Denise K Link, MPAS, PA-C The University of Texas Southwestern Medical Center [email protected] Proper Specimen Collection Routine Urine Analysis Appearance Chemical tests (dipstick) • Teach every patient how to collect proper specimen • pH 1. Clean-catch midstream • Protein 2. In patients with indwelling urinary catheters, a • Glucose recently produced urine sample should be obtained • Ketones (directly from the catheter tubing) • Blood 3. Best examined when fresh. Chemical composition • Urobilinogen of urine changes with standing and formed • Bilirubin elements degenerate with time • Nitrites • Leukocyte esterase 4. Refrigerated is best when infection is suspected • Specific gravity 5. First voided morning urine is ideal when evaluating suspected glomerulonephritis Microscopic examination of spun urinary sediment Urine Analysis with Microscopy Dipstick Methodology • Paper tabs impregnated with chemical reagents • Reagents are chromogenic • Reagents are timed developed • Some rxns are highly specific • Other are sensitive to the presence of interfering substances or extremes of pH • Rapid, semiquantitative assessment of urinary characteristics © 2015 National Kidney Foundation,
    [Show full text]
  • Urine Anion Gap to Predict Urine Ammonium and Related Outcomes in Kidney Disease
    Article Urine Anion Gap to Predict Urine Ammonium and Related Outcomes in Kidney Disease Kalani L. Raphael,1,2 Sarah Gilligan,1 and Joachim H. Ix3,4,5 Abstract Background and objectives Low urine ammonium excretion is associated with ESRD in CKD. Few laboratories measure urine ammonium, limiting clinical application. We determined correlations between urine 1 fi Division of Nephrology, ammonium, the standard urine anion gap, and a modi ed urine anion gap that includes sulfate and Department of Internal phosphate and compared risks of ESRD or death between these ammonium estimates and directly measured Medicine, University of ammonium. Utah Health, Salt Lake City, Utah; 2 Design, setting, participants, & measurements We measured ammonium, sodium, potassium, chloride, Nephrology Section, Veterans Affairs Salt phosphate, and sulfate from baseline 24-hour urine collections in 1044 African-American Study of Kidney Lake City Health Care Disease and Hypertension participants. We evaluated the cross-sectional correlations between urine System, Salt Lake City, ammonium, the standard urine anion gap (sodium + potassium 2 chloride), and a modified urine anion gap Utah; 3Division of that includes urine phosphate and sulfate in the calculation. Multivariable-adjusted Cox models determined Nephrology- fi Hypertension, the associations of the standard urine anion gap and the modi ed urine anion gap with the composite end Department of point of death or ESRD; these results were compared with results using urine ammonium as the predictor of Medicine and interest. 5Division of Preventive Medicine, Department Results The standard urine anion gap had a weak and direct correlation with urine ammonium (r=0.18), whereas of Family Medicine and fi r 2 Public Health, the modi ed urine anion gap had a modest inverse relationship with urine ammonium ( = 0.58).
    [Show full text]
  • Correlation of Urinary Foam with Proteinuria in Patients with Chronic
    Research Article iMedPub Journals Translational Biomedicine 2017 http://www.imedpub.comhttp://www.imedpub.com ISSN 2172-0479 Vol. 8 No. 2: 110 DOI: 10.21767/2172-0479.100110 Correlation of Urinary Foam with Pisharam JK, Daiwajna R, Proteinuria in Patients with Chronic Chong VH, Khalil MAM, Liew A, Ching FE and Kidney Disease Jackson Tan Raja Isteri Pengiran Anak Saleha Hospital Bandar Seri Begawan, Brunei-Muara, Brunei Abstract Darussalam, Brunei Background: Foamy urine is often reported to be associated with proteinuria and kidney diseases. There is no objective measure on the nature and correlation of this relationship. Literature reviews revealed very few studies that can confirm or Corresponding author: Pisharam JK refute this relationship. This study hypothesized that the severity and persistence of urinary foam were associated with the degree of proteinuria (as determined by [email protected] urine protein-creatinine ratio and dipstick). Methods: We analyzed urine samples of patients from our chronic kidney disease Raja Isteri Pengiran Anak Saleha Hospital (CKD) clinics for urine protein and foam. The urine samples were shaken in a Bandar Seri Begawan, Brunei-Muara, Brunei standardized way and heights of resting foam (in millimeters) were measured Darussalam, Brunei. after a pre-determined resting time. The foam heights were correlated with clinical variables including proteinuria, stages of CKD, gender, age, co-morbidities Tel: 006738178123 and urine specific gravity. Results: A total of 160 urine samples were analyzed. Greater foam height was significantly associated with advanced CKD stages (p=0.015), urine dipstick protein Citation: Pisharam JK, Daiwajna R, Chong (p<0.001), urine PCR (p=0.005) and diabetes mellitus (p=0.013).
    [Show full text]
  • Proteinuria Tests As Useful Tools in Clinical Practice
    SPOTLIGHT Proteinuria tests as useful tools in Complete this course and earn clinical practice 1 CME POINT Dr. HO Chung Ping Ms. AU Yim Fong MBBS (HK), MRCP, FRCP (Glas, Edin), Manager, Integrated Dialysis Facilities FHKCP, FHKAM (medicine), Specialist in Nephrology The kidneys are amongst the most obscure organs in the medical attention, (‘the screening test of the common folks’). body. Unlike the lungs, the heart and the intestines, they do The commonest urine test performed in the clinics is not generate any sound. Unlike the liver and the spleen, they the common urine dipstick (Figure 3). It detects mainly are so deeply seated that palpation is not possible unless they albumin in the urine. The test is positive when the urine are grossly enlarged. It is said (arguably) that kidneys are like albumin is >150 mg/L. It is simple and specific. the nephrologists looking after them – they work long hours Another time-honoured test is the sulphosalicylic acid quietly and diligently in the background. The easiest way to test. Protein can be detected by adding one part urine examine the kidneys is to check the substance they produce, the urine. Indeed, as a medical student, the author was taught that ‘urine examination is part of a complete physical examination’. Tests for proteinuria It is a common belief amongst patients that frothy urine means proteinuria. While it is true that heavy proteinuria causes frothy urine, in many instances the urine froth noted by the patient is only mild and transient. It is usually due to causes other than proteinuria.
    [Show full text]
  • Original Research
    ORIGINAL RESEARCH William A. Alto, MD, MPH Maine-Dartmouth Family No need for routine Practice Residency, Fairfield, Maine glycosuria/proteinuria screen in pregnant women Practice recommendations investigating glycosuria as a predictor for I Screening for gestational diabetes gestational diabetes mellitus, or proteinuria using urine dipsticks for glycosuria is as a predictor for preeclampsia (1 exam- ineffective with low sensitivities. False- ined both). Because every study used positive tests outnumber true positives different dipstick methods of determining 11:1. A 50-g oral glucose challenge is a results, or definitions of abnormal, each better test. Tests for glycosuria after this was evaluated separately. blood test are not useful (B). Results Glycosuria is found at some point in about 50% of pregnant women; I Proteinuria determined by dipstick in it is believed to be due to an increased pregnancy is common and a poor pre- glomerular filtration rate.3 The renal dictor for preeclampsia with a positive threshold for glucose is highly variable predictive value between 2% and 11%. and may lead to a positive test result for If the blood pressure is elevated, a glycosuria despite normal blood sugar. more sensitive test should be used (B). High intake of ascorbic acid or high I After urinalysis at the first prenatal visit, urinary ketone levels may result in false- routine urine dipstick screening should positive results. Four published studies be stopped in low-risk women (B). assessed the value of glycosuria as a screen for gestational diabetes.4–7 All used Abstract urine dipsticks. Three of the 4 most likely Objective More than 22 million prenatal overestimate the sensitivity of glycosuria visits occur in the US each year.1 Each for predicting gestational diabetes.
    [Show full text]