HEMATURIA

Dr. Shreedhar PaudelApril, 2009

HEMATURIA• Microscopic hematuria – more than three erythrocytes per high-power field

• HEME-POSITIVE --Hemoglobin --Myoglobin

HEMATURIA……..• Artificial food coloring – Beets – Berries – Chloroquine – Furazolidone – Hydroxychloroquine – Nitrofurantoin – Phenazopyridine – Phenolphthalein – Rifampin

HEMATURIA….

• CAUSES OF HEMATURIA:-– A. RENAL• GLOMERULAR• RENOVASCULAR

– B. HEMATOLOGICAL– C. URETERIC– D. PKCD, UTI, TUMOR

HEMATURIA…..• CAUSES OF HEMATURIA:-– Severe dehydration--- Renal vein thrombosis – Myocardial infarction-- Renal artery embolus or

thrombus – Atrial fibrillation--- Renal artery embolus or

thrombus – Hypertension Glomerulosclerosis-- with or

without proteinuria

HEMATURIA……..• EVALUATION OF PATIENT WITH HEMATURIA:-– H/O passage of clots → extraglomerular cause of

hematuria

– H/O recent trauma to the abdomen → hydronephrosis

– H/O early-morning periorbital puffiness, weight gain, oliguria, the presence of dark-colored urine, and the presence of edema or hypertension suggests a glomerular cause.

HEMATURIA……..• EVALUATION OF PATIENT WITH HEMATURIA….– Painless hematuria due to glomerular causes

– H/O recent throat or skin infection → post infectious glomerulonephritis

– H/O joint pains, skin rashes, and prolonged fever in adolescents → collagen vascular disorder

HEMATURIA……..

• EVALUATION OF PATIENT WITH HEMATURIA….– The presence of anemia cannot be accounted for

by hematuria alone → in a patient with hematuria and pallor, other conditions such as systemic lupus erythematosus and bleeding diathesis should be considered

– H/O fever, abdominal pain, dysuria, frequency, and recent enuresis in older children → UTI as the cause of hematuria

HEMATURIA……..

• EVALUATION OF PATIENT WITH HEMATURIA….

– Skin rashes and arthritis → HSP and SLE

– Information regarding exercise, menstruation, recent bladder catheterization, intake of certain drugs or toxic substances, or passage of a calculus may also assist in the differential diagnoses.

HEMATURIA……..

• EVALUATION OF PATIENT WITH HEMATURIA….– familial, Alport syndrome, collagen vascular

diseases, urolithiasis, or PCKD

– PHYSICAL EXAMINATION

– INVESTIGATION

HEMATURIA……..Indications of kidney biopsy in patients with

hematuria:-• Significant proteinuria • Abnormal renal function • Recurrent persistent hematuria. • Serologic abnormalities (abnormal

complement, ANA, or dsDNA levels). • Recurrent gross hematuria. • A family history of end-stage renal disease

ACUTE GLOMERULNEPHRITIS (AGN)• CONDITIONS PRESENTING AS AGN– POST INFECTIOUS—streptococci, hepatitis B and C,

bacterial endocarditis

– SYSTEMIC VASCULITIS – HSP, SLE, Polyarteritis nodosa

– MEMBRANOPROLIFERATIVE GN

– IGA NEPHROPATHY

– ALPORT SYNDROME

Acute Poststreptococcal Glomerulonephritis

• Sudden onset of – Gross hematuria

– Edema–Hypertension– renal insufficiency

• most common glomerular causes of gross hematuria in children

Acute Poststreptococcal Glomerulonephritis………

• Etiology:-– throat or skin infection by certain “nephritogenic”

strains of group A β-hemolytic streptococci.↓

streptococcal pharyngitis (serotype 12)

streptococcal skin infections or pyoderma (serotype 49)

Acute Poststreptococcal Glomerulonephritis………

• Pathology:-– kidneys → symmetrically enlarged– light microscopy → enlarged glomeruli– Immunofluorescence → granular deposits

of IgG–electron microscopy• Lumpy deposits on the subepithelial side

of the capillary basement membrane

Acute Poststreptococcal Glomerulonephritis………

• Clinical Manifestations:-– 5–12 yr and uncommon before the age of 3 yr. – acute nephritic syndrome 1–2 wk after an

antecedent streptococcal pharyngitis or 3–6 wk after a streptococcal pyoderma.

– asymptomatic microscopic hematuria with normal renal function to acute renal failure

Acute Poststreptococcal Glomerulonephritis………

• Clinical Manifestations:- – Edema (puffiness around eyes and pedal edema)– Hypertension– Oliguria (cola colored urine)– encephalopathy and/or heart failure owing to

hypertension or hypervolemia– malaise, lethargy, abdominal or flank pain, and fever are

common

Acute Poststreptococcal Glomerulonephritis………

• Clinical Manifestations:- – The acute phase generally resolves within 6–8 wk

– urinary protein excretion and hypertension usually normalize by 4–6 wk after onset

– persistent microscopic hematuria may persist for 1–2 yr after the initial presentation

Acute Poststreptococcal Glomerulonephritis………

• Diagnosis:-– Urinalysis → • red blood cells (RBCs)• RBC casts• proteinuria(1+ to 2+)• polymorphonuclear leukocytes (indicative of

glomerular inflammation)

– mild normocytic anemia (due to hemodilution)

Acute Poststreptococcal Glomerulonephritis………

• Diagnosis:-– ↓ed serum C3 level

– ↑ed antistreptolysin O (ASO)

– ↑ ed serum urea and creatinine (reflecting degree of renal impairment)

Acute Poststreptococcal Glomerulonephritis………

Complications:- – Hypertension – Acute renal dysfunction– Hypertensive encephalopathy – Heart failure– Hyperkalemia– Hyperphosphatemia– Hypocalcemia– Acidosis– Seizures– Uremia

Acute Poststreptococcal Glomerulonephritis………

• Treatment:-

– Patient with mild oliguria and normal BP → can be managed at home

– Close monitoring of Blood pressure and dietary intake

– 10-day course of systemic antibiotic therapy with penicillin (once AGN occurred penicillin treatment has no effect on course of disease----may be given if active pharyngitis or pyoderma present)

Acute Poststreptococcal Glomerulonephritis………

• Treatment:-

– DIET

• Protein, sodium and potassium restricted till serum urea reduce to normal and urinary output increases

• Fluid intake restricted to amount equal to insensible loss + urinary loss

• Overhydration-- ↑es HTN and precipitates LVF

Acute Poststreptococcal Glomerulonephritis………

• Treatment:-

– WEIGHT• Weighed daily• Should lose about 0.5 % BW/ Day – due to endogenous

catabolism• Gain in weight requires– fluid restriction

– DIURETICS• Not indicated (since edema is rarely massive and

comes to normal with return of renal function)• Used in presence of pulmonary edema (iv frusemide)

Acute Poststreptococcal Glomerulonephritis………

• Treatment:-

– HTN• Mild—controlled by salt and water restriction• Malignant HTN – prompt treatment ( iv nitroprusside)

– LVF• Control HTN• iv frusemide

• Prognosis:-– Complete recovery occurs in 95% of cases

Henoch-Schönlein Purpura• Small vessel vasculitis • Mild renal involvement– microscopic

hematuria, mild proteinuria• Clinical features:-– purpuric rash ( extensor surface)– Arthritis– abdominal pain– Rarely presents with nephritic or nephrotic

syndrome, HTN, azotemia

Henoch-Schönlein Purpura…

Henoch-Schönlein Purpura…

Henoch-Schönlein Purpura….

• TREATMENT:-– Most patients recover without any specific

treatment– Long-term observation– to detect insidious renal

damage– Combination of steroids and azathioprine

recommended – But long-term outcome may not be satisfactory