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Sumário de Urina

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Aula de Propedêutica ou Clínica Médica

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Sumário de Urina

  1. 1. Sumário de Urina Paulo Novis Rocha ( [email_address] ) Professor Adjunto do Depto de Medicina Faculdade de Medicina da Bahia - 200 anos
  2. 2. Exame da Urina: Exame laboratorial mais antigo!
  3. 3. História <ul><li>Papiros egípcios </li></ul><ul><li>400 AC - Hipócrates </li></ul><ul><li>Século I, Caraka, 10 tipos de urina </li></ul><ul><li>Século II, Galeno, teoria dos humores </li></ul><ul><li>Século X, Isaac Judaeus, uromancia, 20 tipos de urina </li></ul><ul><li>Século XVII, microscópio, sedimento urinário </li></ul><ul><li>Século XIX, Addis </li></ul>Un disco de vidrio de orina con 20 matices de color (1491 DC)
  4. 4. Exame da urina <ul><li>Constitui um dos meios mais simples e seguros para se comprovar a patologia intrínseca do trato urinário. </li></ul><ul><li>Componentes: </li></ul><ul><ul><li>Aspecto </li></ul></ul><ul><ul><li>Fita reagente (Dipstick) </li></ul></ul><ul><ul><li>Análise do sedimento </li></ul></ul>
  5. 5. Fita reagente (dipstick) <ul><li>pH </li></ul><ul><li>Densidade </li></ul><ul><li>Glicose </li></ul><ul><li>Cetonas </li></ul><ul><li>Esterase leucocitária </li></ul><ul><li>Sangue </li></ul><ul><li>Proteína </li></ul><ul><li>Nitrito </li></ul><ul><li>Urobilinogênio </li></ul>
  6. 6. Dipstick : pH <ul><li>Varia normalmente de 4,5 a 7,8 </li></ul><ul><li>Não constitui, isoladamente, índice da capacidade excretora de íons H + </li></ul><ul><li>Utilidades: </li></ul><ul><ul><li>ITU </li></ul></ul><ul><ul><li>Acidose tubular renal distal </li></ul></ul><ul><ul><li>Urolitíase </li></ul></ul><ul><ul><li>Comprovar alcalinização da urina em certas situações </li></ul></ul>
  7. 7. Dipstick : densidade <ul><li>Varia normalmente entre 1.002 e 1.032 </li></ul><ul><li>Substitui grosseiramente a osmolaridade </li></ul><ul><li>Utilidades: </li></ul><ul><ul><li>estado de hidratação </li></ul></ul><ul><ul><li>capacidade de concentração urinária </li></ul></ul><ul><ul><li>interpretação de outros componentes do sumário de urina </li></ul></ul>
  8. 8. Dipstick : glicose <ul><li>Detecção de glicosúria </li></ul><ul><li>Utilidades: </li></ul><ul><ul><li>Diagnóstico e controle do diabetes mellitus </li></ul></ul><ul><ul><li>Determinação de distúrbio tubular proximal </li></ul></ul><ul><ul><ul><li>Glicosúria renal, síndrome de Fanconi </li></ul></ul></ul>
  9. 9. Dipstick : Cetonas <ul><li>Detecção de cetonúria </li></ul><ul><li>Cetose de jejum, cetoacidose diabética </li></ul><ul><li>Sensível ao ácido aceto-acético, porém não acusa o beta-hidroxibutírico </li></ul>
  10. 11. Dipstick : esterase leucocitária <ul><li>Detecção de piúria </li></ul><ul><li>Exame do sedimento, colorações </li></ul><ul><li>Diagnósticos: </li></ul><ul><ul><li>ITU </li></ul></ul><ul><ul><li>Tuberculose renal </li></ul></ul><ul><ul><li>Nefrite intersticial </li></ul></ul><ul><ul><li>Glomerulonefrites </li></ul></ul>
  11. 12. Dipstick : sangue <ul><li>Detecção de hematúria </li></ul><ul><li>Importante confirmar presença de hemácias no sedimento </li></ul><ul><li>Na ausência de hemácias: </li></ul><ul><ul><li>hemoglobinúria </li></ul></ul><ul><ul><li>mioglobinúria </li></ul></ul>
  12. 13. Dipstick : proteinúria <ul><li>Importante para diagnóstico diferencial da etiologia da doença renal </li></ul><ul><li>Só detecta albumina </li></ul><ul><li>Exame da tira reagente é meramente qualitativo </li></ul><ul><li>Quantificação exige urina de 24 horas ou razão proteína/creatinina urinária </li></ul>
  13. 15. Proteinúria: significado clínico <ul><li>“ Funcionais” </li></ul><ul><li>Estados patológicos diversos </li></ul><ul><li>Infecções urinárias </li></ul><ul><li>Doença renal </li></ul><ul><ul><li>glomerular vs não glomerular </li></ul></ul><ul><ul><li>150 mg, 1000 mg, 3500 mg </li></ul></ul>
  14. 16. Análise do Sedimento: A biópsia renal do pobre <ul><li>Hemácias </li></ul><ul><li>Leucócitos </li></ul><ul><li>Bactérias </li></ul><ul><li>Cilindros </li></ul><ul><li>Cristais </li></ul>
  15. 17. Hematúria
  16. 18. Urine dipstick + Repeat Urine dipstick Workup ends Microscopic analysis Myoglobin Hemoglobin Workup ends Cystoscopy Cystoscopy > 50 years old or risk factors for bladder Ca < 50 years old, no risk factors for bladder Ca Isomorphic red cells NON-GLOMERULAR Referral Helical CT Urine cytology - - + + - + - Acantocytes, casts GLOMERULAR Isolated Microhematuria Proteinuria, renal failure Routine checkup Referral
  17. 19. Hematúria Phase contrast microscopy
  18. 20. Hematúria Scanning microscopy
  19. 21. Urine from a 34-year-old man with biopsy-proven IgA nephropathy
  20. 22. Cilindros <ul><li>Formações alongadas e de contorno regular </li></ul><ul><li>Originam-se ao nível dos túbulos distais ou ductos coletores </li></ul><ul><li>Todos se organizam às expensas da mucoproteína de Tamm-Horsfall </li></ul>
  21. 23. NTA, nefrite intersticial Células tubulares Pielonefrite, nefrite intersticial Leucocitário Glomerulonefrite Hemáticos Urina concentrada, estados febris, exercício, diuréticos (não é = doença renal) Hialinos NTA; não-específico Granulares Doença renal crônica Céreos largos Significado Tipo de Cilindro
  22. 25. “ Futuro Cilindro Hemático” na Biópsia Renal
  23. 26. Cilindros Hemáticos
  24. 27. Panel A shows red-cell cast (arrow) Panel B shows dysmorphic red cells (arrows)
  25. 28. In Panel A (x 440), urinary sediment shows a red-cell cast and red cells In Panel B (x 440), urinary sediment shows normal red cells (arrow) and crenated red-cell forms with spicules (arrowhead). Crenated red cells form in concentrated urine and are not diagnostically relevant. In Panel C (x 440), a more specific finding of glomerular bleeding is shown. Acanthocytes are doughnut like cells with membrane blebs attached .
  26. 29. IgA Nephropathy PANEL A PANEL B Moderate mesangial matrix expansion, mild hypercellularity Mesangial IgA deposition
  27. 31. Urine dipstick + Repeat Urine dipstick Workup ends Microscopic analysis Myoglobin Hemoglobin Workup ends Cystoscopy Cystoscopy > 50 years old or risk factors for bladder Ca < 50 years old, no risk factors for bladder Ca Isomorphic red cells NON-GLOMERULAR Referral Helical CT Urine cytology - - + + - + - Acantocytes, casts GLOMERULAR Isolated Microhematuria Proteinuria, renal failure Routine checkup Referral
  28. 32. Cilindro eritrocitário Cilindro hemoglobina hemácias
  29. 33. Poststreptococcal GN Marked, diffuse hypercellularity, with infiltration of PMNs Large, nodular, subepithelial deposits referred to as &quot;humps&quot; PANEL A PANEL B
  30. 34. Anti-GBM Disease PANEL A PANEL B Large crescent and compressed glomerular capillary tufts Linear deposition of IgG along the GBM
  31. 35. Urine dipstick + Repeat Urine dipstick Workup ends Microscopic analysis Myoglobin Hemoglobin Workup ends Cystoscopy Cystoscopy > 50 years old or risk factors for bladder Ca < 50 years old, no risk factors for bladder Ca Isomorphic red cells NON-GLOMERULAR Referral Helical CT Urine cytology - - + + - + - Acantocytes, casts GLOMERULAR Isolated Microhematuria Proteinuria, renal failure Routine checkup Referral
  32. 38. Cilindro leucocitário Bactérias
  33. 39. Cilindros Leucocitários
  34. 40. Lipóide birrefringente Cilindro hialino Corpo graxo ovalado Cilindro epitelial Cilindro céreo Cilindro graxo
  35. 41. Cilindros Graxo Polarized light microscopy
  36. 43. Cilindros Granulares na NTA Klahr et al., NEJM 1998, 338 (10):671-675
  37. 44. Cilindros Granulares
  38. 45. <ul><li>A 26-year-old man had sudden fever and chills with severe muscle pain and weakness in his legs and pectoral muscles while mountaineering in the Andes. </li></ul><ul><li>He was brought to a local hospital, where he received hemodialysis three times because of anuria and a rapid rise in the serum creatinine level before being transferred to our unit. </li></ul>
  39. 46. <ul><li>The following laboratory values were recorded on admission to our unit: </li></ul><ul><li>Urine dipstick analysis was positive (+++) for protein and blood. </li></ul>Myoglobin 283 µg/dl Phos 6.19 mg/dl Ca++ 8.16 mg/dl CK 1990 U/l BUN 85 mg/dl Cr 10.5 mg/dl
  40. 47. Myoglobinuria Sedimento urinário Biópsia renal
  41. 48. <ul><li>Possible causes of the rhabdomyolysis were physical strain at high altitude and the consumption of coca leaves and coca tea to prevent mountain sickness. No infectious cause could be identified. </li></ul><ul><li>The patient had anuria or oliguria for 10 days. He received a total of seven sessions of hemodiafiltration, until urine flow returned and the serum creatinine levels began to fall. At the time of discharge, he had a serum creatinine level of 1.0 mg per deciliter. </li></ul>
  42. 50. Waxy casts have a smooth consistency but are more refractile and therefore easier to see compared to hyaline casts. They commonly have squared off ends, as if brittle and easily broken Waxy casts indicate tubular injury of a more chronic nature than granular or cellular casts and are always of pathologic significance
  43. 51. Cilindros Céreos
  44. 52. Unresponsive at 18 <ul><li>The patient is a 18 year old male presenting to the ED by paramedics after found at home unresponsive, face down in bed. According to friends, the patient had consumed several beers and wine earlier that day following a period of depression. The patient was orally intubated in the field by paramedics after no response to D50 and naloxone administration . </li></ul>
  45. 53. <ul><li>Physical Exam: </li></ul><ul><li>General: Patient responsive only to deep painful stimuli </li></ul><ul><li>Vitals: BP 150/70, HR=92, RR=24, T=95.4F </li></ul><ul><li>Lungs: CTA, BS Equal, (Intubated) </li></ul><ul><li>CV: RRR, no murmur </li></ul><ul><li>Abd: Soft, Non-Tender, No Trauma, No Masses </li></ul><ul><li>Rectal: Normal Tone, Heme- </li></ul><ul><li>Neuro: DTR's Hyporeflexive, Withdraws to Painful Stimuli </li></ul>
  46. 54. <ul><li>Diagnostic Studies </li></ul><ul><li>CBC: WBC 29K HCT=45 </li></ul><ul><li>ABG: 6.97 PO2=321 PCO2=15 </li></ul><ul><li>Lytes: Na=145 Cl=105 K=5.2 HCO3=5 </li></ul><ul><li>BUN/Cr: 28/1.8 Glucose 180 </li></ul><ul><li>Osm: 370 (Measured) </li></ul><ul><li>Calcium 7.0 </li></ul><ul><li>Toxicology Screen: Pending </li></ul><ul><li>CXR: ET tube above carina, no infiltrates, no edema </li></ul><ul><li>ECG: NSR, No ischemic changes </li></ul>
  47. 55. Cristais
  48. 56. Ethylene Glycol Poisoning <ul><li>Clinical Course: </li></ul><ul><li>With a strong clinical suspicion for toxic alcohol ingestion, an ethanol drip is ordered, but due to pharmacy delay, the patient is orally loaded with whiskey obtained from another patient in the ER waiting room. </li></ul><ul><li>Sodium Bicarbonate is administered for the profound acidosis and dialysis is initiated by the renal service . </li></ul><ul><li>Ethylene glycol level of 310 mg/dl returns 12 hours later. The patient recovers with mild renal insufficiency, and is subsequently followed-up by the psychiatric service for his depression. </li></ul>
  49. 57. <ul><li>A 33-year-old man with hemophilia and the AIDS had a six-hour history of severe right-sided flank pain and right-lower-quadrant pain accompanied by nausea, vomiting, and anorexia. </li></ul><ul><li>The patient was afebrile and euvolemic. </li></ul><ul><li>His medications included zidovudine, lamivudine, and indinavir. </li></ul><ul><li>Urinalysis showed a specific gravity of 1.010, a pH of 5.0, and more than 50 red cells per high-power field. </li></ul>
  50. 58. A 33-year-old man with hemophilia and the AIDS had a six-hour history of severe right-sided flank pain and right-lower-quadrant pain accompanied by nausea, vomiting, and anorexia. His medications included zidovudine, lamivudine, and indinavir. KUB x-ray following CT with IV contrast Urine under polarized microscopy
  51. 59. A CT scan with IV contrast, obtained to assess the possibility of appendicitis and retroperitoneal bleeding, revealed a mildly dilated right renal collecting system. KUB x-ray following CT Polarized microscopy
  52. 60. <ul><li>To reduce the risk that the patient's strains of human immunodeficiency virus would become resistant if indinavir were withdrawn from the treatment regimen, the patient was instructed to continue taking the drug and to increase his fluid intake. </li></ul><ul><li>Although his pain decreased initially, crystalluria persisted, and several weeks later, he returned with flank pain and hematuria. Ultrasonography at this time confirmed the development of several renal calculi. </li></ul><ul><li>Treatment with indinavir was discontinued, and nelfinavir was added to his regimen of zidovudine and lamivudine. The renal calculi and crystalluria resolved spontaneously, and the patient was well at the time of the most recent follow-up visit. </li></ul>
  53. 61. Resumo <ul><li>Exame laboratorial mais antigo </li></ul><ul><li>Permanece essencial: </li></ul><ul><ul><li>IRA </li></ul></ul><ul><ul><li>IRC </li></ul></ul><ul><ul><li>Infecção urinária </li></ul></ul><ul><ul><li>Litíase </li></ul></ul><ul><ul><li>DHEAB </li></ul></ul>

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