AN APPROACH TO HEMATURIA. Dr Saima Ali

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1 AN APPROACH TO HEMATURIA Dr Saima Ali

2 Definition Microscopic hematuria hematuria is defined as the presence of 5 or more RBCs per high-power field in 3 of 3 consecutive centrifuged specimens obtained at least 1 week apart. > 5 RBCs / HPF ) Gross hematuria > 2500 RBCs / μl

3 causes Depends upon age,sex and race. AGE; preschooler :Wilms tumor School-aged: post infectious GN SEX; F>>M :>1-2 yrs: UTI F>>M: SLE nephritis RACE; sickle cell disease common in blacks.

4 GLOMERULAR HEMATURIA IgA nephropathy (Berger disease) Alport syndrome (hereditary nephritis) Post infectious GN (poststreptococcal GN) Membranous nephropathy Membranoproliferative GN Focal segmental glomerulosclerosis

5 EXTRAGLOMERULAR HEMATURIA Urinary tract infection Urolithiasis Tumor

6 Hematuria With Multisystem Disease Systemic lupus erythematosus nephritis Henoch-Schönlein purpura nephritis Polyarteritis nodosa Goodpasture syndrome Hemolytic-uremic syndrome Sickle cell glomerulopathy HIV nephropathy

7 False Positive Tests for Hematuria HEME POSITIVE Hemoglobin Myoglobin

8 HEME NEGATIVE Drugs Chloroquine Deferoxamine Ibuprofen Iron sorbitol Metronidazole Rifampacin Salicylates Sulfasalazine Dyes Vegetable/Fruit: Food Coloring

9 history cola-colored urine, facial/body edema, hypertension, and oliguria suggest acute nephritic syndrome A history of recent upper respiratory, skin, or gastrointestinal infection suggests acute glomerulonephritis, hemolytic-uremic syndrome, or HSP nephritis Rash and joint complaints suggest HSP nephritis or SLE nephritis

10 history Frequency, dysuria, and unexplained fevers suggest urinary tract infection, renal colic suggests nephrolithiasis. A flank mass may be a sign of hydronephrosis, cystic disease, renal vein thrombosis, or tumor. Patients with a history of trauma Child abuse must always be suspected in the child presenting with unexplained bruising and hematuria

11 Physical exam Hypertension, body edema, hepatosplenomegaly, or signs of heart failure suggest acute glomerulonephritis. Abdominal masses may be caused by posterior urethral valves, ureteropelvic junction obstruction or tumors Several malformation syndromes are associated with renal disease including VATER (vertebral body anomalies, anal atresia, tracheo esophageal fistula, and renal dysplasia) syndrome.

12 Why anemia occur with hematuria intravascular dilution secondary to hypervolemia associated with acute renal failure hemolysis from hemolytic-uremic syndrome or SLE; blood loss from pulmonary hemorrhage as seen in Goodpasture syndrome maleena in patients with Henoch-Schönlein purpura or hemolytic-uremic syndrome

13 Upper v lower urinary tract hematuria Hematuria from within the glomerulus is frequently associated with brown, cola-colored, or burgundy urine, proteinuria >100 mg/dl via dipstick, urinary microscopic findings of RBC casts, deformed urinary RBCs.

14 Upper v lower urinary tract hematuria Lower urinary tract sources of hematuria associated with gross fresh hematuria, blood clots, normal urinary RBC morphology, minimal proteinuria on dipstick (<100 mg/dl).

15 Glomerular Non-glomerular

16 Acute Poststreptococcal Glomerulonephritis acute nephritic syndrome characterized by the sudden onset of gross hematuria, edema, hypertension, and renal insufficiency

17 Etiology PSGN follows infection of the throat or skin by certain nephritogenic strains of group A β- hemolytic streptococci. M protein is the chief virulent factor

18 pathology Exoantigens Streptolysin O Dnase Hyaluronidase Nicotinamide Adenine Dinucleotidase Streptokinase Are produced Patients react to exo-antigens by producing antibodies

19 pathology Two major sites of infection Upper respiratory tract Skin If infections left untreated, it can lead to poststreptococcal sequelae Acute glomerulonephritis Rheumatic fever

20 Clinical features PSGN is most common in children aged 5 12 yr and uncommon before the age of 3 yr Males are more commonly affected than females. The severity of renal involvement varies from asymptomatic microscopic hematuria with normal renal function to acute renal failure The acute phase generally resolves within 6 8 wk microscopic hematuria may persist for 1 2 yr after the initial presentation.

21 Investigations Urine R/E Serum electrolyte Hb and ESR Complement level Evidence of streptococcal infection Renal function tests

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24 TREATMENT 10 days course of oral penicillin recommended to limit the spread of the nephritogenic organisms. Sodium and fluid restriction Avoid fruit juices Avoid protein

25 prevention Family members of patients with acute glomerulonephritis should be cultured for group A β-hemolytic streptococci and treated if culture positive.

26 prognosis 95 % of children recover completely.

27 Henoch-Schönlein Purpura is a small vessel vasculitis characterized by a purpuric rash, arthritis, abdominal pain, and glomerulonephritis. The symptoms and signs of HSP nephritis typically appear 1 3 wks after an upper respiratory tract infection The prognosis in HSP nephritis is generally favorable, although the risk of chronic kidney disease is 2 5%

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30 Nephroblastoma is the most common childhood abdominal malignancy. The median age at diagnosis of Wilms tumor is approximately 3.5 years.

31 Clinical features Asymptomatic abdominal mass (in 80% of children at presentation) Abdominal pain or hematuria (25%) Urinary tract infection Hypertension, gross hematuria, and fever (5-30%) Rarely Respiratory symptoms related to lung metastases (in patients with advanced disease)

32 diagnosis Renal US Abdominal MRI Supportive RFTs Urine R/E

33 Management Nephrectomy followed by chemotherapy

34 Urolithiasis Urolithiasis nephrocalcinosis

35 epidemiology In children, calcium stones are most common. the boy-to-girl ratio (3:2

36 Etiology Supersaturation of stone-forming compounds in urine Presence of chemical or physical stimuli in urine that promote stone formation Inadequate amount of compounds in urine that inhibit stone formation (eg, magnesium, citrate)

37 treatment A high fluid intake leading to increased urine output is safe and generally beneficial for children with all types of stones, The goal is to lower urinary calcium such that no new stones are formed without producing calcium deficiency. Alkalinizing agents Diuretics- hydrochlorthiazide Xanthine oxidase inhibitors- Allopurinol

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