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- 1.Pete A. Gutierrez MD, MMS, PA-C Miami Dade College Physician Assistant ProgramMarch 2009
- Urine Analysis:
- Dip stick testing:
- Urine Ph may change with time
- Contamination may cause bacteria to multiply and convert nitrate to nitrite causing a false positive.
- At low specific gravity (Less than 1.010), cells lyse and casts from less readily.
- Cast also dissolve in alkaline Urine.
- Midstream Urine Collection
- Contamination more common in women than in men.
- Suprapubic aspiration is the more secure method of getting an Uncontaminated Urine
- Urine Casts.Are formed from Tamm-Horsfall glycoprotein which is synthesized and secreted in the ascending limb of the loop of Henle and distal convoluted tubules.
- Physiologic CastsHyaline are transparent and cylindrical and are seen in urine of normal subjects.
- Both can be increased by fever, exercise and volume depletion
- Pathologic casts: this may contain cellular material (erythrocytes, leukocytes, tubular cells, bacteria, or fungi) , fibrin, lipids, bile, and crystals.
- The most important is the erythrocytes, because it indicates glomerular bleeding.
- Those composed of polymorphonuclear leukocytes usually indicate renal parenchyma infection.
- Leukocytes in the urine means infection
- Renal tubular cells are found in the urine in acute tubular necrosis and acute interstitial nephritis
- Crystals of calcium oxalate and uric acid may be seen in normal urine however large bizarre crystals of any type including calcium oxalate and uric acid indicate calculus disease.
- IGA nephropathy:
- The most common form of primary glomerular disease in the world.
- It is particular prevalent in Asia, and Australia, and rare in African Americans.
- It originally thought to be benign.
- Now understood it will progress to renal failure in 20 to 40% of patients affected.
- Primary gross hematuria,
- No therapeutic regimen has been shown to clearly affect the outcome in IgA disease.
- However warfarin and dipyridamole with or without cyclophosphamide have been suggested as worthy of further investigation
- Also omega 3 fatty acids, ACE, and long term steroids are also on trial.
- Membranous nephropathy:
- Two thirds of patients with this disorder either have a spontaneous remission or have stable or very slow progressive renal insufficiency.
- Those with heavy proteinuria greater than 10 gram per day, hypertension, diminished GFR, male gender, dont do well.
- Gram Negative
- Klesbsiella Pneumoniae
- Gram Positive
- Staphylococcus saprophyticus
- Staphylococcus aureus
- Staphylococcus not aureus
- Other bacteria mixed
- Symptomatic UTIs:
- Obstruction to urine flow.
- Congenital anomalies
- Renal Calculi
- Ureteral occlusion (partial or total).
- Vesicoureteral reflux
- Residual urine in bladder
- Neurogenic bladder
- Urethral stricture
- Prostatic hypertrophy
- Instrumentation of urinary tract;
- Indwelling urinary catheter
- Urethral dilation
- Acute Urethral syndrome:
- Vaginitis approximately 20% of women in the United States have an episode of dysuria each year.(Candida is the most common cause).
- Urethritis most commonly cause by Chlamydia trachomatis
- Prostatitis The most common addiction in men causes dysuria and urinary frequency. (E. Coli).
- Pregnancy and the increases risk of UTI:
- 20-40% of which develop pyelonephritis.
- Either short acting sulfonamides or amoxicillin for 7 days usually suffices.
- Avoid Tetracycline, trimethropin and fluoroquinolones.
- Hypertensive disorders of pregnancy:
- Preeclampsia is characterized by, 1. Hypertension, proteinuria, edema, and at time coagulation and liver abnormalities usually occurring at about the (20) weeks of pregnancy. Primarily in nulliparas. Pressure of 140/90.
- Patient will go into convulsions and diet condition called eclampsia.
- Kidney function and morphology in preeclampsia:
- Both GFR and RPF decrease in preeclampsia.
- Uric acid increases in blood.
- Increased proteinuria.
- Calcium develop hypocalciuria
- Lesion at the glomerular capillary endotheliosis.
- Management of preeclampsia:
- Hospitalization rest and if signs of impeding eclampsia(hyperreflexia, headache, epigastric pain) develop termination of pregnancy should be considered.
- The drug of choice for impeding convulsion is parenteral magnesium sulfate.
- Regulation of blood pressure:
- Hydralazine administered intravenously is the drug of choice. (5mg as a bolus follow by 5-10mg every 20-30 minutes.
- Labetalol intravenously 20mg and repeat the dose every 20 minutes, up to 200 mg.
- Refrain from using nitroprusside.
- Use of Radiologic Techniques:
- Intravenous pyelography (IVP) Stone, obstruction.(allergic reactions).
- Ct evaluation of renal disease
- Renal angiography provides definitive diagnosis of renal arterial pathology
- Algorithm for treatment of hypertension:
- First line of therapy should be diuretic (thiazide).
- In patients with type I diabetes and proteinuria (Diabetic nephropathy) the treatment is with an ACE inhibitor.
- In patients with heart failure (Systolic dysfunction), ACE inhibitor or diuretic is indicated
- Beta blockers or Ca Channels blocker can them be use.
- Causes of resistant Hypertension:
- White coat
- Pseudohypertension in elderly persons
- Use of improper size blood pressure cuff.
- Patient non compliant
- Failure due to cost, side effects, or ignorance
- Dietary noncompliance
- Excess salts.
- Causes of resistant Hypertension:
- Excess ethanol intake
- Volume overload