HEMATURIA Dr Shreedhar Paudel April 2009 HEMATURIA Microscopic

HEMATURIA Dr. Shreedhar Paudel April, 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……. . ØIndications of kidney biopsy in patients with hematuria: • Significant proteinuria • Abnormal renal function • Recurrent persistent hematuria. • Serologic abnormalities (abnormal complement, ANA, or ds. DNA 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 Ig. G – 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 C 3 level – ↑ed antistreptolysin O (ASO) – ↑ ed serum urea and creatinine (reflecting degree of renal impairment)

Acute Poststreptococcal Glomerulonephritis……… Ø 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