By Brent Lee Lechner, DO MAJ, MC, USA Blood in Urine By Brent Lee Lechner, DO MAJ, MC, USA

Outline Case Presentation Input on Labs and Rads Work-up Audience Work-up Proteinuria Discussion Trivia: Military Movies

Case Presentation 16 year old white male Upper Respiratory Infection X 10 days Pediatrician diagnosis: sinusitis Amoxicillin Started Rash after two days: Red, ? Hives Changed antibiotics to Z-pack Trip to Mexico Two weeks later: periorbital edema and ankle swelling Returns to Pediatrician with dark urine

Case Presentation No SOB, No trouble breathing No abdominal pain No n/v/d, No f/u/d Occasional headache: 1/ month Relieved by Motrin No blurred vision No Joint pain, No arthritic pain

Case Presentation Past Medical History Past Surgical History Exercise Induced Asthma Past Surgical History None Medications Albuterol MDI with Spacer Motrin 400 mg for Pain Allergies: NKDA Amoxicillin: ? Rash Imm: UTD Family History Father: Obese, HTN, Gout Mother: None Paternal GF: Bladder Cancer Maternal GF: Death – MI SSHx Smoke: No! ETOH: 1-2 times per month after football games Drugs: No! No Sexual activity Middle Linebacker in Football Goal: US Army Helicopter Pilot

Bonus Question What “state” was the bar in which Maverick and Goose frequently sang “Great Balls of Fire” in Fighter Town, USA, named after? Movie: TOP GUN

Questions as part of H&P Fluid po intake? 4: 6 oz Glasses/ Day (usually iced tea with sugar) Frequency of voids? 2-3 times per day Weight Gain? 7 lbs Recent colds or strep throat or impetigo? No colds, URI, recent illness or rash

Other Questions as part of H&P Flank pain or CVA tenderness? None Gross Hematuria? Color: Sam Adams Trauma? Denies Self-manipulation? Yes, as all adolescents Sexual history? No, never been lucky

Other Questions as part of H&P Circumsized or Hygiene ? No but good hygiene and no signs of trauma Medication History? Motrin: 1 time per week No Nutritional or steroid supplements Family history of hematuria or hearing loss? None: No ESRD, No Dialysis, No Renal Disease Family history of stones? Father: lithotrisomy

Physical Examination VSS T: 99. 1 BP: 143/89 Physical Examination VSS T: 99.1 BP: 143/89 P:87 R:13 PO2:100% HGT: 5’8” WGT: 58 kg Head: NC, 0 lesions Eyes: PERRLA, EOMI, Normal Fundo B, B periorbital Edema 2+/4 Ears: B clear TM Nose: Non-swollen turb. Throat: non-red, 0 exudates Neck: 0 LA, 0 mass, Supple Genitalia: B Testes down, no trauma, no meatus tear Chest: RRR,S1,S2, 0 m Lungs: Decreased BS at bases Abdomen: NT, Soft, BS(+), 0 HSM, Slightly Distended Ext: 0 c/c, FROM, Cap Refill <2s, LE Edema 2+/4 at ankles Pulses: 2+/2 all extremities Back: Straight, 0 hair patch, 0 dimple

Bonus Question In the movie “A scent of a woman,” how did the infantry colonel played by Al Pacino lose his sight?

Urine Tests Urinanalysis pH: 5.0 SG: 1.030 Ketones: (-) Glucose: (-) Protein: 3+ Blood: Large Nitrites: (-) LE: (-)

Micro Exam of Urine Microscopy urine RBCs/hpf: 50+ WBCs/hpf: 0 Casts/hpf: 15+ Dysmorphic RBCs/hpf: 60%

Laboratory studies WBC: 7.1/mm3 X 1000 HBG: 13.2(g%) HCT: 37.5% Platelets: 378 (103)/mm3 MCV: 73 fl

Laboratory Studies Na+: 129 mEq/L K+: 4.9 mEq/L Cl-: 108 mEq/L HCO3-: 18.3 mEq/L BUN: 26.0 mg/dl Creatinine: 1.5 mg/dl Ca 2+: 7.4 mEq/L PO4 2-: 5.4 mg/dl Mg 2+: 2.0 mEq/L

Bonus Question In the movie “An officer and gentleman,” what does Mayo’s (Richard Gere) friend (the guy from Oklahoma) tell his “girlfriend” (the girl faking the pregnancy) job is waiting at home?

Work-up of Hematuria Must do urine microscopy after positive dipstick for blood Urine Examination RBCs: RBCs/hpf > 5 significant Eumorphic versus Dysmorphic RBCs Lower Tract versus Upper Tract No RBCs: Think Pigmented Nephropathy Myoglobinuria or Hemoglobulinuria Usually Granular Casts!!

Evaluation of Dark Urine Dipstick for Occult Blood Negative Positive Pigments No RBC RBC Present Bilirubin Hemoglobin Dyes Hemolysis Drugs Myoglobin Factitious Muscle Injury Seizures Eumorphic Dysmorphic (No RBC Casts) (RBC Casts) T.I.C.S Nephritis Acute Chronic

Causes of Hematuria I C S T Tumor, TB,Trauma Infection and Inflammation (Nephritis) C Calcuria, Cystic Disease, congenital anomaly S Sickle Cell Disease, Stones, Somewhere

Nephritis Differential Diagnosis Nephritic Syndrome Hypertension Hematuria with active sediment Azotemia

Nephritis Differential Diagnosis Glomerulonephritis Alport’s Syndrome Membranoproliferative GN Post Infectious GN SLE Hemolytic Uremic Syndrome HSP

Bonus Question What is the occupation and home state of Tom Hanks character in the movie “Saving Private Ryan,” prior to him entering the U.S. Army?

Laboratory Work-Up Urine culture Spot urine Ca++/creatinine ratio If ratio > 0.2, then 24h urine Ca++ and creatinine If 24 hour urine Ca++ greater than 4 mg/kg/d, then hypercalcuria If protein on urine dipstick, then spot protein/creatinine urine ratio If ratio > 0.2, then 24 hour protein in urine Greater than 1000mg/day, significant proteinuria Nephrotic Range (3.5 g/d or greater than 40 mg/kg/d )

Laboratory Work-up Blood tests: Chem 10 to check renal function Serologies: C3, C4, ANA, Anti-Strep Dnase B, ASO C3 and C4: low Stay low SLE C3: low Stay low MPGN C3: low Returns to normal (6-8 wks) PIGN Consider HIV and Hepatitis B screen

Radiology Work-up Renal Ultrasound CT scan: gold standard for stones Hydronephrosis in stones vs. anatomical process Renal Mass (Wilm’s Tumor) Cystic Disease Unlikely but AVM CT scan: gold standard for stones

Other tests Alport’s Syndrome: hearing and opthlmo exam Rising creatinine, persistent low C3 or significant proteinuria, then consider biopsy.

Bonus Question At the end of basic training in the movie “Full Metal Jacket,” what job in the U.S. Marine Corps does “Joker” obtain?

Our Patient C3: 12 (90 – 120) C4: 19 (12 – 26) ANA (-) ASO (-) Anti-Dnase B (-) Urine Ca/creatinine ratio: 0.06 Urine Protein /creatinine ratio: 3.2 24 hour urine Protein: 3.6 g/d Creatinine: 1.6 g/d Repeat C3: 16 in 6 weeks with gradual increase in creatinine to 1.7 mg/dl

What does the Renal Biopsy Show?