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Proteinuria, Hematuria, UTI
| Question | Answer |
|---|---|
| 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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