DOI 10.1515/cclm-2013-0785      Clin Chem Lab Med 2014; 52(6): 845–852

Giovanni B. Fogazzi*, Sandra Secchiero, Giuseppe Garigali and Mario Plebani

Evaluation of clinical cases in External Quality Assessment Scheme (EQAS) for the urinary sediment Abstract

Introduction

Background: The few available External Quality Assessment (EQA) programs on urinary sediment rarely include an evaluation of clinical cases. The present paper provides a descriptive analysis of clinical cases included in the Italian EQA program on urinary sediment. Methods: Ten cases were presented over a 5-year period (2007–2011). Each clinical case included a brief clinical history, some key laboratory data and four key urinary sediment particles obtained by phase contrast microscopy. The clinical diagnoses indicated by participants, chosen among four or five proposed, were evaluated only for those who had been able to correctly identify all four urinary sediment particles. The results of each survey were then evaluated, scored and commented on. Results: The numbers of participants for the 10 surveys ranged from 268 to 325. Throughout surveys, only 63.9% ± 17.0% (range 39.6%–88.7%) of participants achieved access to clinical diagnosis. Of these, 90.2% ± 8.5% (range 73.7%–98.1%) were able to indicate the correct diagnosis. Conclusions: Our findings demonstrate that once the correct identification of urinary sediment particles is obtained, most participants are able to associate urinary findings with the respective clinical conditions, thus establishing the correct diagnosis.

Urinary sediment examination, an integral part of urinalysis, requires an appropriate approach based on correct methodology, equipment, training, knowledge and updating. In addition to conventional Internal Quality Control (IQC) programs, External Quality Assessment Schemes (EQAS) represent mandatory requirements in accreditation programs [1–5]. The aim of this paper is to provide a detailed description of the clinical cases presented throughout a 5-year period (2007–2011) in an Italian EQA program, which was organized and managed by the Centre of Biomedical Research (CRB), an EQA scheme organization with many programs in different fields of laboratory medicine. The Italian EQA scheme for the microscopic analysis of urine, started in 2001 and still active today, is described in detail elsewhere [6]. Briefly, from 2001 to 2006 only images of urine particles were shown, for which the participants were asked to supply identification and one clinical association. Over the years, 50 particles were presented, some of which were shown more than two or three times. Then, from 2007 on two clinical cases each year were included in the program. This was done because laboratory medicine is today conceived as a clinical support service and guidelines and standards emphasize the importance of adding appropriate comments and interpretation to laboratory results [7–13].

Keywords: clinical cases; external quality assessment programs; urinalysis; urinary sediment. *Corresponding author: Giovanni B. Fogazzi, Clinical and Research Laboratory on Urinary Sediment, Unità Operativa di Nefrologia, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Via Commenda 15, 20122 Milan, Italy, Phone: +39 02 55036331, Fax: +39 02 55034550, E-mail: [email protected] Sandra Secchiero and Mario Plebani: Centre of Biomedical Research, Department of Laboratory Medicine, Hospital-University, Padua, Italy Giuseppe Garigali: Clinical and Research Laboratory on Urinary Sediment, Unità Operativa di Nefrologia, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

Materials and methods Ten cases were presented to participants over a 5-year period (from 2007 to 2011) by means of a dedicated website (http://www.urinalysis.net) (Table 1). These cases were chosen by the responsible for the program at that time, a nephrologist with expertise in urinalysis and urine microscopy [14–17], who also is the corresponding author of the present paper. Each case had really occurred and consisted in a brief clinical history, which also included some key laboratory data, and four phase contrast microscopy images showing the particles found in the urinary sediment as well as their number/microscopic field (Figure 1).

Brought to you by | University of California - San Francisco Authenticated Download Date | 12/12/14 12:21 PM

A 23-year-old woman with acute left   lumbar pain without fever and symptoms at micturition. Echography of urinary tract: left hydronephrosis with normal right kidney and bladder.

A 28-year-old woman with urinalysis persistently positive for leukocyte esterase.

A 60-year-old man with marked edema of   legs. Cardiopathy, liver disease, and venous insufficiency of the lower limbs ruled out at previous workup.

An 82-year-old woman with malaise,   inappetence and weight loss of about 3 kg within a few days. Renal function severely impaired, although normal one month before (Screat: 0.8 mg/dL); diuresis/24 h: 600 mL/24 h. Echography of urinary tract normal.

A 25-year-old asymptomatic woman with persistent “traces of blood” in the urine and without episodes of gross hematuria. Echography of urinary tract normal.

2  

3  

4  

5  

6  

Brought to you by | University of California - San Francisco Authenticated Download Date | 12/12/14 12:21 PM  





A 45-year-old man with rapidly progressive renal failure associated with arterial hypertension and urinary changes; urine output and echography of urinary tract normal.

1  



Clinical history

n  

Table 1 Clinical cases presented.





Screat: 0.7 mg/dL; BUN: 13.1 mg/dL.   Urinalysis: pH: 5.8; SG: 1.020; hemoglobin: +/++; albumin, leukocyte esterase and nitrites: absent. Urinary sediment: 5–8 RBC/HPF (400 × ); 1 cast every 8–10/LPF (160 × ) ( = 1+).

Screat: 7.7 mg/dL; BUN: 107.5 mg/dL;   S-uric acid: 28.0 mg/dL. Proteinuria: absent. Bone marrow biopsy: B cell acute lymphoblastic leukemia.

Screat: 1.2 mg/dL; BUN: 22.4 mg/dL;   S-total proteins: 5.5 g/dL; S-albumin: 2.5 g/dL; S-cholesterol: 355 mg/dL. Urinalysis: albumin: ++++; hemoglobin: +; glucose, leukocyte esterase and nitrites: absent.

Screat: 0.7 mg/dL; BUN: 13.1 mg/dL.   Urinalysis: leukocyte esterase: +++; nitrites: positive; hemoglobin, albumin, glucose: absent.

Screat: 0.8 mg/dL; BUN: 14.0 mg/dL.   Urinalysis: hemoglobin: +++; leukocyte esterase: +/++; nitrites and albumin absent.

Screat: 2.5 mg/dL; BUN: 44.4 mg/dL; Proteinuria: 1.5 g/24 h.

Laboratory data  





Dysmorphic RBCs   Acanthocytes Hyaline-granular cast Erythrocytic cast

RTECs   Cast containing RTECs Granular cast Uric acid crystals

Fatty droplets Oval fat body Fatty cast Cholesterol crystal

Bacteria   Squamous epithelial cells WBCs Candida

Isomorphic RBCs   WBCs Deep transitional cells Superficial transitional cells

Dysmorphic RBCs RTECs Erythrocytic cast Waxy cast

Images



A. AKI with ATN due to dehydration B. AKI due to uric acid urolithiasis C. Acute pyelonephritis D. Acute interstitial nephritis E. AKI with ATN from urate nephropathy

A. Bladder cancer   B. Urolithiasis C. Contamination of urine from menstruation D. Microscopic isolated hematuria of glomerular origin



A. Acute nephritic syndrome B. AKI C. Nephrotic syndrome D. Chronic renal failure due to hypertensive nephrosclerosis E. Polycystic kidney disease



A. Acute pyelonephritis B. Nephrotic syndrome C. Ureteric stone D. Acute nephritic syndrome E. Cystitis





A. Acute nephritic syndrome B. Nephrotic syndrome C. Hypovolemic (pre-renal) AKI D. Acute pyelonephritis E. Ureteric lithiasis

A. Acute pyelonephritis B. Acute pyelitis C. Urinary tract infection D. Urine contamination from genital secretions E. Asymptomatic bacteriuria



Possibile diagnoses

D Microscopic isolated hematuria of glomerular origin

E AKI with ATN from urate nephropathy

C Nephrotic syndrome

D Urine contamination from genital secretions

C Ureteric stone

A Acute nephritic syndrome

Correct diagnosis

846      Fogazzi et al.: Study of clinical cases in an EQA program on urinary sediment

A 30-year-old man with history of prolonged   cocaine use found at home unconscious and recumbent on floor on right side of body. At Emergency Department a marked and painful edema of upper and lower right limbs and severe AKI with preserved diuresis are found. Echography of kidneys normal.

A 45-year-old woman with renal allograft under immunosuppressive treatment and known vesico-ureteral reflux is hospitalized for fever (39.5 °C) associated with shivering and pain at transplanted kidney. Thorax radiography normal.

A 57-year-old woman with AKI and normal   urine output associated with generalized cutaneous rash and fever (38.5 °C), without signs of dehydration. Seven days before intake of oral amoxycillin (1 g twice/day for 3 consecutive days) for “acute bronchitis”. At ultrasonography, slight increase in kidney size, with normal parenchyma and without dilatations of the excretory system.

8  

9  

10  

Brought to you by | University of California - San Francisco Authenticated Download Date | 12/12/14 12:21 PM







Screat: 4.5 mg/dL; peripheral blood WBC: 7.800/µL; peripheral blood eosinophils: 1.100/µL. Urinalysis: pH: 7.0; SG: 1.015; hemoglobin: ++; leucocyte esterase: +++; nitrites and albumin: absent. Urine culture: negative.



Screat: 2.5 mg/dL; peripheral blood   WBC: 21.500/µL; peripheral blood neutrophils: 85%; CRP: 20.7 mg/dL. Urinalysis: pH: 7.0; SG: 1.010; hemoglobin: ++; leukocyte esterase: +++; nitrites: positive; albumin: absent.

Screat: 8.8 mg/dL; S-CK: 15.000 U/L. Urinalysis: pH: 7.0; SG: 1.005; hemoglobin: ++; leukocyte esterase, nitrites and albumin: absent.

Screat: 0.8 mg/dL. Urinalysis: pH: 5.5; SG: 1.015; leukocyte esterase: ++; albumin, hemoglobin and nitrites: absent.

Laboratory data





WBCs Isomorphic RBCs Leukocytic cast Granular cast.



WBCs ± bacteria   Leukocytic cast Superficial transitional cells Isomorphic RBCs

Granular cast RTECs Myoglobinic cast RTEC cast

Bacteria   WBCs Squamous epithelial cells Trichomonas vaginalis

Images

D Acute pyelonephritis

B Drug-induced acute interstitial nephritis

A. Acute post-infectious   glomerulonephritis B. Abdominal colic due to urolithiasis C. ATN D. Acute pyelonephritis A. Acute pyelonephritis B. Drug-induced acute interstitial nephritis C. ATN D. Acute post-infectious glomerulonephritis



B AKI from acute rhabdomyolysis

A. Chronic renal failure from prolonged  cocaine use B. AKI from acute rhabdomyolysis C. Acute glomerulonephritis D. Acute pyelonephritis

Correct diagnosis C Protozoan contamination of the urine



A. Contamination of urine with yeasts   from vaginal secretions B. Bacterial urinary tract infection C. Protozoan contamination of urine D. Urinary tract infection due to Schistosoma haematobium

Possibile diagnoses

AKI, acute kidney injury; ATN, acute tubular necrosis; BUN, blood urea nitrogen; HPF, high power field; LPF, low power field; RBCs, red blood cells (erythrocytes); RTECs, renal tubular epithelial cells; Screat, serum creatinine; SG, specific gravity; WBCs, white blood cells (leukocytes). Reference rangesa: Screat: 0.5–1.0 mg/dL (44.2–88.4 μmol/L); BUN: 7.0–21.0 mg/dL (2.48–7.45 mmol/L); proteinuria:  

Evaluation of clinical cases in External Quality Assessment Scheme (EQAS) for the urinary sediment.

The few available External Quality Assessment (EQA) programs on urinary sediment rarely include an evaluation of clinical cases. The present paper pro...
699KB Sizes 0 Downloads 0 Views