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Urine Uric Acid

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221. Management of Chronic Kidney Disease

THE PROGRESSION 11 OF CHRONIC KIDNEY DISEASE 4.1 Treatment of Hypertension and Proteinuria for 11 Renoprotection 4.2 Glycaemic Control for Renoprotection 16 4.3 Protein Restriction for Renoprotection 17 4.4 Lipid Lowering for Renoprotection 17 4.5 Uric Acid Reduction for Renoprotection 18 4.6 Miscellaneous Agents for Renoprotection 18 4.7 Special Precautions Management of Chronic Kidney Disease in Adults (Second Edition) TABLE OF CONTENTS No. Title Page 5. INTERVENTIONS IN REDUCING THE RISK OF 20 (...) in one year or >10 ml/ min/1.73 m 2 within five years] ? eGFR 0.3 mg/mol) (exclude other causes e.g. urinary tract infection (UTI), congestive cardiac failure (CCF), others) Overt nephropathy Screen for microalbuminuria on early morning spot urine POSITIVE NEGATIVE Yearly test for microalbuminuria and renal function Retest twice in 3 - 6 months (exclude other causes e.g. UTI, CCF, others) • If 2 of 3 tests are positive, diagnosis of diabetic kidney disease is established • Quantify microalbuminuria

2018 Ministry of Health, Malaysia

222. Urolithiasis

tomography of the kidneys, ureters and bladder for urolithiasis. J Med Imaging Radiat Oncol, 2017. 61: 582. 52. Poletti, P.A., et al. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol, 2007. 188: 927. 53. Zheng, X., et al. Dual-energy computed tomography for characterizing urinary calcified calculi and uric acid calculi: A meta-analysis. Eur J Radiol, 2016. 85: 1843. 54. Niemann, T., et al. Diagnostic performance of low-dose CT (...) of percutaneous chemolysis in the management of urolithiasis: review and results. Urolithiasis, 2013. 41: 323. 127. Bernardo, N.O., et al. Chemolysis of urinary calculi. Urol Clin North Am, 2000. 27: 355. 128. Tiselius, H.G., et al. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis. Scand J Urol Nephrol, 1999. 33: 286. 129. Rodman, J.S., et al. Dissolution of uric acid calculi. J Urol, 1984. 131: 1039. 130. Becker, G. Uric acid stones. Nephrology, 2007. 12

2018 European Association of Urology

223. Paediatric Urology

in diagnosing urinary tract infections in small children. Pediatr Nephrol, 2011. 26: 1923. 329. Whiting, P., et al. Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection (UTI) in children under five years: a systematic review. BMC Pediatr, 2005. 5: 4. 330. Koch, V.H., et al. [Urinary tract infection: a search for evidence]. J Pediatr (Rio J), 2003. 79 Suppl 1: S97. 331. Ma, J.F., et al. Urinary tract infection in children: etiology and epidemiology. Urol Clin North Am, 2004 (...) . 31: 517. 332. Ramage, I.J., et al. Accuracy of clean-catch urine collection in infancy. J Pediatr, 1999. 135: 765. 333. Roberts, K.B., et al. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 2011. 128: 595. 334. Tosif, S., et al. Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. J

2018 European Association of Urology

224. Treatment for Bipolar Disorder in Adults: A Systematic Review

(placebo) Paliperidone Placebo Paliperidone Olanzapine Perphenazine plus Mood Stabilizers Mood Stabilizers alone (placebo) Quetiapine Placebo Quetiapine Lithium Quetiapine plus Mood Stabilizers Mood Stabilizers alone (placebo) Quetiapine and Personalize Treatment Lithium and Personalized Treatment Risperidone Placebo Risperidone Olanzapine Risperidone Long Acting Injectable and Treatment as Usual Placebo and Treatment as Usual ES-7 Category Drug Comparator Valproic Acid plus Aripiprazole Lithium plus

2018 Effective Health Care Program (AHRQ)

225. When and how to treat hyponatremia in the ED

- or hypervolemia. Edema, ascites, pulmonary effusion Investigations Urine sodium excretion (<20-30 mmol/L), fractional excretion of uric acid, trial of volume expansion Urine sodium excretion (>20-30 mmol/L), trial of volume expansion Urine sodium excretion (<20-30 mmol/L), Elevated BUN Notes on Treatment Correction of volume deficit, treatment of underlying disease, avoiding over-rapid correction. In case of cerebral salt wasting, do NOT restrict fluids See guidelines for recommended treatment by specific (...) levels, particularly in patients with chronic hyponatremia, can lead to osmotic demyelination syndrome (ODS) , a profoundly debilitating condition. In 2011, a patient successfully sued her physician and nurse for overcorrection of sodium levels, leading to ODS and lifelong disability 6 . In all cases, avoid overcorrection of more than 10 mmol/L in 24 hours. Water diuresis (i.e. high urine output) is often the first sign of impending rapid correction (e.g. primary polydipsia, correction of hypovolemia

2018 CandiEM

226. Kaiser Permanente National Dyslipidemia Clinician Guide

and neuropsychiatric causes, etc.), as well as adverse effects associated with statin therapy. Non-statin Safety Recommendations Niacin ? Order baseline ALT levels, fasting blood glucose or hemoglobin A1C, and uric acid before initiating niacin and again during up-titration to a maintenance dose and periodically thereafter. ? Consider not using niacin if: ? Baseline ALT levels are > 2-3 times upper limit of normal. ? Persistent severe cutaneous symptoms, persistent hyperglycemia, acute gout or unexplained (...) to non-statin cholesterol-lowering drugs shown to reduce ASCVD events in RCTs (i.e., ezetimibe). ? In individuals with clinical ASCVD on maximum tolerated oral lipid-lowering therapy (statin, ezetimibe, +/- bile acid sequestrant) and with persistently elevated lipids (e.g., LDL = 130 mg/dL), consider discussing adding PCSK9 inhibitor with a lipid specialist (i.e., designated lipid specialist, cardiologist, or endocrinologist). Lipid Panel Screening and Risk Assessment ? In adults aged 20-39 years

2017 Kaiser Permanente National Guideline Program

227. Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

in Acute Pancreatitis IV fluid therapy is a mainstay of treatment during an episode of AP. Fluid resuscitation maintains adequate fluid status and urine Abu-El-Haija et al JPGN Volume 66, Number 1, January 2018 162 www.jpgn.org Copyright © ESPGHAN and NASPGHAN. All rights reserved. output, but recently attention has focused on the use of IV fluids to prevent potential complications in AP, such as necrosis and organ failure. The pathogenesis of AP and progression to severe forms is thought (...) to improvements in heart rate, urine output, mean arterial pressure and/or hematocrit (69). The American College of Gastroenterology (ACG) recommends an initial rate of 250 to 500 mL/h, in addition to boluses of fluid if hypotension or tachy- cardia is present, and using BUN to direct therapy (32). Similar recommendations are made in a review by Whitcomb (79). Aggar- wal et al (80) advises 3 to 4 L of fluid in the first 24 hours (not to exceed 4 L) with an initial 1 L bolus and to follow with 3mL kg 1 h 1

2018 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

228. Effects of Dietary Sodium and Potassium Intake on Chronic Disease Outcomes and Risks

sodium intake and CVD outcomes have been carefully reviewed and critiqued. 18 Limitations may include methods used for sodium intake assessment, residual confounding, and possible reverse causality. Assessment of sodium intake in observational studies as well as in older randomized controlled trials has typically relied on the use of food frequency questionnaires or spot urine ES-3 assays of urinary sodium excretion. However, these methods have repeatedly been shown to be highly prone to both random (...) and systematic error. More accurate but still error prone methods include 24- to 72-hour food diaries or recall assessment or 8-hour (overnight) urine assays. The most accurate method of assessing sodium intake in observational studies, particularly decreases in sodium intake, is the repeated 24-hour urinary sodium excretion with validation. 19, 20 In light of the limitations of the existing observational studies, the current state of knowledge needs to be reconsidered. Potassium DRIs The 2005 IOM committee

2018 Effective Health Care Program (AHRQ)

229. Sodium and Potassium Intake: Effects on Chronic Disease Outcomes and Risks

sodium intake and CVD outcomes have been carefully reviewed and critiqued. 18 Limitations may include methods used for sodium intake assessment, residual confounding, and possible reverse causality. Assessment of sodium intake in observational studies as well as in older randomized controlled trials has typically relied on the use of food frequency questionnaires or spot urine ES-3 assays of urinary sodium excretion. However, these methods have repeatedly been shown to be highly prone to both random (...) and systematic error. More accurate but still error prone methods include 24- to 72-hour food diaries or recall assessment or 8-hour (overnight) urine assays. The most accurate method of assessing sodium intake in observational studies, particularly decreases in sodium intake, is the repeated 24-hour urinary sodium excretion with validation. 19, 20 In light of the limitations of the existing observational studies, the current state of knowledge needs to be reconsidered. Potassium DRIs The 2005 IOM committee

2018 Effective Health Care Program (AHRQ)

230. Venetoclax (Venclyxto) - Chronic, B-Cell Lymphocytic Leukemia

lysis syndrome CYP cytochrome P DNA deoxyribonucleic acid DOR duration of overall response DSC Differential Scanning Calorimetry ECCr estimated creatinine clearance rate using Cockcroft Gault formula ECG electrocardiogram ECOG Eastern Cooperative Oncology Group Ecrf electronic case report form EFS event free survival EORTC European Organization for Research and Treatment of Cancer EQ VAS European Quality of Life -Visual Analogue Scale EQ-5D-5L European Quality of Life 5 Dimensions 5 Levels (...) survival PG pharmacogenetics Ph. Eur. European Pharmacopoeia PK pharmacokinetic(s) PLM Polarised light microscopy PP Polypropylene PR partial remission PT prothrombin time PVC Poly vinyl chloride QbD Quality by design QC Quality Control QLQ C30 Quality of Life Questionnaire Core 30 QLQ CLL16 Quality of Life Questionnaire Chronic Lymphocytic Leukaemia 16 QoL quality of life QWP Quality Working Party RH Relative Humidity RNA ribonucleic acid RPTD the recommended Phase 2 dose RRT Relative retention time

2017 European Medicines Agency - EPARs

231. Management of acute (fulminant) liver failure

and radiographically. Acute Budd-Chiari syndrome Abdominal pain, ascites and hepatomegaly; loss of hepatic venous signal and reverse ?ow in portal vein on ultrasound. Wilson disease Young patient with Coombs (DAT) negative haemolytic anaemia with a high bilirubin to alkaline phosphatase ratio; Kayser- Fleischer ring; low serum uric acid level; markedly increased urinary copper. Mushroom poisoning Severe gastro-intestinal symptoms after ingestion; development of early AKI. Autoimmune Usually subacute presentation (...) –Barr virus (EBV) using nucleic acid testing should be undertaken in all patients where the aetiology of ALF is not clear [86,87]. The development of DILI can also be potentiated by the activation of the herpes and CMV viruses, along with host drug interactions [88].Thepresenceoftheseviralinfectionsmaynotalwaysrepre- sent the aetiology of the ALF but may be a co-factor and consid- erationfortreatment.Inthecontextofimmunosuppression,such viralinfectionsmayalsobeofimportanceasaprimaryaetiology

2017 European Association for the Study of the Liver

232. Management of Hypertension (5th Edition)

of hypertension after 55 years or deterioration in BP control in a previously well-controlled patient • resistant hypertension • abdominal bruit; particularly if associated with a unilateral small kidney • flash pulmonary oedema • renal failure of uncertain cause in the presence of normal urine sediment • renal failure induced by ACEIs or ARBs • coexisting diffuse atherosclerotic vascular disease Renal angiography including measurement of the pressure gradient remains the gold standard in the diagnosis (...) Korotkoff V is absent. 238(Level III) Measurement of BP is similar to that of the general population, as stated earlier. 37 8.8.1.1 Proteinuria Significant proteinuria in pregnancy is defined as =300 mg protein in a 24 hour urine sample, or a spot urine protein-creatinine ratio =30 mg/mmol. 238 If the dipstick is the only test available, 1+ (30 mg/dl) is often, but not always, associated with =300 mg/day proteinuria. 238 Significant proteinuria reflects advanced disease and is associated with poorer

2018 Ministry of Health, Malaysia

233. CRACKCast E097 – Renal Failure

, hemoglobinuria Other Diseases and Conditions Severe liver disease Allergic reactions NSAIDs 6) List the RFs for contrast induced ATN According to LITFL Top 3: Pre-existing renal disease (especially Cr >120) Diabetes mellitus Age >75yrs Others: CHF Hypertension Hypovolemia Nephrotoxins (NSAIDs, cyclosporin, aminoglycosides, amphotericin) High dose contrast, intra-arterial worse than IV Cirrhosis/nephrotic syndrome Multiple myeloma PVD High uric acid and hypercholesterolemia 7) List the causes of postrenal (...) renal failure Box 87.3 Intrarenal and Ureteral Causes Kidney stone Sloughed papilla Malignancy Retroperitoneal fibrosis Uric acid, oxalic acid, or phosphate crystal precipitation Sulfonamide, methotrexate, acyclovir, or indinavir precipitation Bladder Kidney stone Blood clot Prostatic hypertrophy Bladder carcinoma Neurogenic bladder Urethra Phimosis Stricture 8) List the causes of pigment induced AKI Box 87.5 Rhabdomyolysis and myoglobinuria Crush injury Compartment syndrome Electrical injury

2017 CandiEM

234. CRACKCast E099 – Urological Disorders

(Magnesium, ammonium, phosphate) – 15% Occur exclusively in patients with UTIs because they require bacteria to split urea into precipitates Uric acid stones – 10% Occur in people with gout 20% of patients with urolithiasis have NO microscopic hematuria Imaging with CT KUB vs. U/S is recommended only if: First presentation of disease Do not improve with initial treatment Have a urinalysis suspicious for infection Have a solitary/transplanted kidney Diagnostic uncertainty Complete ureteric obstruction (...) ; prepubescent—supportive only [6] What are the causes of different urine colour pigmentation? Straight from Life in the fast lane Green Drugs: Cimetidine, Promethazine, Amitriptyline, Flutamide, Indomethacin, Methocarbamol, Methylene blue, Mitoxantrone, Propofol, Phenylbutazone, Triamterene Condition: Hartnup Disease, Indicanemia, Indicanuria Infection: Pseudomonas Infection Dyes: Carbolic Acid, Flavine derivatives, Indigo Blue, Methylene Blue, Resorcinol Other: Clorets, Listerine, Magnesium Salicylate

2017 CandiEM

235. BSR guideline on the management of gout Full Text available with Trip Pro

fractional clearance of uric acid in > 90% of patients with gout [ ]. Age, male gender, menopausal status in females, impairment of renal function, hypertension and the co-morbidities that comprise the metabolic syndrome are all risk factors for incident gout associated with decreased excretion of uric acid, as are the use of diuretic and many anti-hypertensive drugs, ciclosporin, low-dose aspirin, alcohol consumption and lead exposure. Tophi and chronic arthritis [ ], alcohol consumption [ ] and recent (...) [ , ] and secondary care [ , ] do not achieve reductions of serum uric acid (sUA) levels to the target level recommended in the BSR/BHPR (300 µmol/l) or EULAR (360 µmol/l) guidelines. Finally, as evidence has accumulated that the provision of information to patients with gout is suboptimal [ ] and qualitative studies have begun to define a range of patient and provider barriers to effective care [ ], preliminary data are emerging that demonstrate that these barriers can be overcome, and outcomes improved

2017 British Society for Rheumatology

236. CRACKCast E127 – Rhabdomyolysis

is intracellular Necrosis of 100g of muscle can lead to serum potassium increase of 1 mmol/L Metabolic acidosis Dehydration, myoglobin induced kidney dysfunction Metabolic acidosis is also induced by the release of organic acids (eg, lactic acid, uric acid, sulfur-containing proteins). Hyperphosphatemia From muscle cell destruction Early hypocalcemia (calcium phosphate crystal deposition in the muscle cells) → late hypercalcemia (as the cytoplasm of necrotic muscle cells gets extruded into the circulation (...) kidney injury are: myoglobin cast formation in the distal convoluted tubules (in an acidic environment, myoglobin precipitates with uric acid to form obstructive casts) Direct cytotoxic action of myoglobin on the epithelial cells of the proximal convoluted tubules Myoglobin itself has been shown to exhibit peroxidase-like enzyme activity. Ferrihemate causes direct nephrotoxic effects along with the resultant increased oxidative stress within the tubular epithelial cell, leading to acute tubular

2017 CandiEM

237. Hypertension management and renin-angiotensin-aldosterone system blockade in patients with diabetes, nephropathy and/or chronic kidney disease

have some of the benefits of dihydropyridine calcium channel blockers in the management of diabetic nephropathy. 67 Through their ability to reduce intraglomerular pressure, blood pressure and uric acid levels, sodium glucose cotransporter-2 (SGLT-2) inhibitors may offer the possibility of renal protection. One study suggests that SGLT-2 inhibitors can offer a reduction in glomerular hyperfiltration. 68 Recent analysis of the Empagliflozin, Cardiovascular Outcomes and Mortality in Type 2 Diabetes (...) than 90 mmol per day (less than 2 g per day of sodium – equivalent to 5 g of sodium chloride) (Grade 1C). 2 In patients with type 2 diabetes, CKD and urine albumin excretion rate (AER) of less than 30 mg per 24 hours (albumin:creatinine ratio (ACR) less than 3 mg/mmol), we recommend that their target upright blood pressure should be less than 140/90 mmHg, using antihypertensive therapy in the maximum tolerated doses (Grade 1D). 3 In patients with type 2 diabetes, CKD and urine AER of greater than

2017 Association of British Clinical Diabetologists

238. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

and/or urine albumin:creatinine ≥300 mg/g). Table 5. CVD Risk Factors Common in Patients With Hypertension Modifiable Risk Factors Relatively Fixed Risk Factors Current cigarette smoking, secondhand smoking CKD Family history Diabetes mellitus Increased age Dyslipidemia/hypercholesterolemia Low socioeconomic/educational status Overweight/obesity Male sex Physical inactivity/low fitness Obstructive sleep apnea Unhealthy diet Psychosocial stress * Factors that can be changed and, if changed, may reduce CVD

2017 American Heart Association

239. Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

and Gout Prevalence and Pathogenesis Hyperuricemia is nearly universal in patients with cya- notic CHD, but clinical gout is relatively uncommon. Arthralgias, however, may be common. Hyperuricemia occurs as a result of increased production of uric acid and decreased renal clearance. Diuretics increase serum uric acid levels through hemoconcentration, decreased uric acid secretion, and increased reabsorption. Low frac- tional uric acid excretion is the primary mechanism of hyperuricemia in patients (...) with cyanotic CHD. 212,213 Hy- peruricemia is a marker of disease severity in cyanotic patients and is negatively correlated with cardiac index. Those with the highest uric acid levels had worse survival in a cohort of 94 patients with Eisenmenger syndrome. 214 Management Hyperuricemia is diagnosed by testing serum uric acid, which should be done annually in cyanotic CHD. 2 Di- agnosis of gout is difficult because patients with Eisen- menger syndrome often have pain resulting from hy- pertrophic

2017 American Heart Association

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