0071643192.pdf

RENAL AND GENITOURINARY

EMERGENCIES

TABLE 18.2. Clinical Clues That Suggest a Particular Diagnosis in Patients With Hematuria

CLINICALFINDINGS DISEASE

Dysuria, frequency UTI

Hearing loss Alport syndrome

Hemoptysis Goodpasture syndrome

Recent URI Glomerulonphritis or IgA nephropathy

Proteinuria, RBC casts Glomerulonephritis

Petechiae/purpura, schistocytes Hemolytic uremic syndrome (children) or

on smear thrombotic thrombocytopenic purpura [TTP] (adults)

Nephrotic syndrome, flank pain Renal vein thrombosis

Third World country Shistosomiasis

If a urine dipstick is positive

for heme but no RBCs are

seen on microscopic

urinalysis, consider

rhabdomyolysis.

■ The character of hematuria may help localize the source.
■ Blood clots indicate a nonglomerular source.
■ Brown-colored urine indicates a renal source.
■ Occurring with initiation of voiding or between voids suggests urethral
source.
■ Occurring at the end of voiding suggests a source in the bladder neck
or prostatic urethra.
■ Occurring throughout the urinary stream suggests a source proximal to
the urethra.
■ Table 18.2 lists clues from the clinical presentation that suggest a particu-
lar diagnosis in patients with hematuria.

DIAGNOSIS

■ Obtain UA, BUN/Cr, CBC in all.
■ Gross hematuria will be dipstick positive for protein.
■ Other studies as indicated based on clinical suspicion and severity of
bleeding, including coagulation studies, urine culture, renal imaging (CT,
USN), cystoscopy.

DIFFERENTIAL

■ Pseudohematuria: Can be due to ingestion of beets, berries, medications
(rifampin, pyridium), porphyrias
■ Rhabdomyolysis: Presence of myoglobin in urine →urine dipstick positive
for heme, but negative for RBCs.

TREATMENT

■ Depends on underlying cause.
■ Patients with bladder outlet obstruction from clot formation require three-
way foley catheter placement and bladder irrigation.

ACUTE RENAL FAILURE

Acute renal failure (ARF) describes a sudden decline in kidney function
marked by the accumulation of nitrogenous waste products, disturbances of
fluid balance, and a wide range of other metabolic disturbances. It is classi-
fied according to underlying pathophysiology into three groups: Prerenal,
intrinsic,andpostrenal(see Table 18.3 and Table 18.4).