AN APPROACH TO HEMATURIA

Dr Saima Ali

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

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.

GLOMERULAR HEMATURIA

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

EXTRAGLOMERULAR HEMATURIA

¨  Urinary tract infection ¨  Urolithiasis ¨  Tumor

Hematuria With Multisystem Disease

¨  Systemic lupus erythematosus nephritis ¨  Henoch-Schönlein purpura nephritis ¨  Polyarteritis nodosa ¨  Goodpasture syndrome ¨  Hemolytic-uremic syndrome ¨  Sickle cell glomerulopathy ¨  HIV nephropathy

False Positive Tests for Hematuria

HEME POSITIVE ¨  Hemoglobin ¨  Myoglobin

HEME NEGATIVE

Drugs ¨  Chloroquine ¨  Deferoxamine ¨  Ibuprofen ¨  Iron sorbitol ¨  Metronidazole ¨  Rifampacin ¨  Salicylates ¨  Sulfasalazine

¨  Dyes ¨  Vegetable/Fruit: ¨  Food Coloring

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

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

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.

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

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.

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).

Glomerular Non-glomerular

Acute Poststreptococcal Glomerulonephritis

acute nephritic syndrome characterized by the sudden onset of gross hematuria,

edema,

hypertension, and renal insufficiency

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

pathology

¨  Exoantigens ¤  Streptolysin O ¤ Dnase ¤ Hyaluronidase ¤ Nicotinamide Adenine Dinucleotidase ¤  Streptokinase Are produced

¨  Patients react to exo-antigens by producing antibodies

pathology

¨  Two major sites of infection ¤ Upper respiratory tract ¤ Skin

¨  If infections left untreated, it can lead to post-streptococcal sequelae ¤ Acute glomerulonephritis ¤ Rheumatic fever

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.

Investigations

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

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

prevention

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

prognosis

¨  95 % of children recover completely.

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%

Nephroblastoma

¨  is the most common childhood abdominal malignancy.

¨  The median age at diagnosis of Wilms tumor  is approximately 3.5 years.

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)

diagnosis

¨  Renal US ¨  Abdominal MRI Supportive RFTs Urine R/E

Management

¨  Nephrectomy followed by chemotherapy

Urolithiasis

¨  Urolithiasis ¨  nephrocalcinosis

epidemiology

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

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)

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