Presentation on theme: "PROTEINURIA AND HEMATURIA ASHIK HAYAT M.D.. Proteinuria and Nephrotic Syndrome Occurrence of proteinuria in a single urine is relatively common. Will."— Presentation transcript:
Proteinuria and Nephrotic Syndrome Occurrence of proteinuria in a single urine is relatively common. Will present in 5% to 15% of normal children in a random urine specimen.
-Proteinuria is a marker of renal disease. -The dilemma for the PCP is to differentiate the child with transient or any other benign forms of proteinuria from children with renal disease.
PATOPHYSIOLOGY AND CLASSIFICATION Normal protein excretion normal child <100 mg/m2/day or 150mg/day neonates is higher up to 300 mg/m2 (reduced reabsorption of filtered protein)
The normally low rate of urinary protein excretion is: -Restriction of the filtration -Reabsorption of freely filtered low molecular weight protein
Abnormal protein excretion Urinary protein excretion in excess of 100 mg/m2/day or 4mg/m2/hr Nephrotic range proteinuria is defined as >1000 mg/m2/day or 40mg/m2/hr
Three main mechanism: Glomerular (increase filtration) Tubular (increase excretion- decrease reabsorption) Overflow (marked overproduction of a particular protein)
Measurement of urinary protein Urine dipstick negative trace between 15-30mg/dl 1+ 30-100 mg/dl 2+ 100-300mg/dl 3+ 300-1000mg/dl 4+ >1000mg/dl
Quantitative assessment Measurement of 24-hour protein excretion or total protein/creatinine ratio in a spot urine in the morning normal in children: <0.2mg protein/mg creatinine (+2 years) <0.5mg protein/mg creatinine (6-24-month)
Qualitative assessment May be necessary to differentiate glomerular from tubular protein
Approach to the child with proteinuria Transient or Intermittent Orthostatic Persistent
The mechanisms for edema include: -Transudation of fluid from the intravascular space into the intestitium secondary to decreased albumin and - Increased renal tubular reabsorption of sodium and water
The hyperlipidemia is secondary to: -Increase in lipoprotein synthesis by the liver and -Decrease in lipid catabolism resulting from reduced activity of the enzyme lipoprotein lipase and lecithin cholesterol acetyltransferase.
Complications One true complication of NS is the tendency to developed infections. IgG antibody is lost in the urine, and complement activation is impaired by concomitant loss of factor B.
Marked intravascular depletion causes diminished splachnic blood flow and hypoxia, and a marked tendency to thrombosis cause microinfarction, lowering resistance of the bowel wall to bacteria passage.
Peritonitis is a major contributor to the 1% to 2% mortality in NS The second major contributor is Thromboembolism, however anticoagulant therapy is not justified during remission.
Growth is often impaired in NS There may be losses of IGF-binding protein, which could account for the depressed serum concentration of IGF-I and IGF-II.
Prognosis Mortality in minimal-change NS is approximately 2% Of the remaining 98%, most are steroid- responsive about 2/3 experience1/3 possible single relapsedeveloping protracted series of relapses
Introduction Recognition, definition, differential diagnosis, and orderly evaluation of hematuria in infants and children is often an important issue in pediatric practice
Definition Hematuria is defined by the presence of an abnormal quantity of red blood cells in the urine Macroscopic: grossly visible Microscopic: only upon urinalysis >5-10 RBC’s per high power field
A large number of benign and serious conditions can cause hematuria in children.
Gross hematuria UTI Irritation of the meatus or perineum Trauma Nephrolithiasis Sickle cell disease/trait Post infectious glomerulonephritis IgA nephropathy
Microscopic hematuria Glomerulopathies Hypercalciuria Microlithiasis UTI
Children with hematuria may present in one of three way 1-Onset of gross hematuria 2-Onset of urinary or other symptoms with incidental finding 3-Incidental finding during a health evaluation
Historical clues The color of the urine Glomerulonephritis may be brown and/or frothy urine, while bleeding is suggested by the presence of blood clots, or pink or clearly red urine
The timing of the hematuria Initial (urethral bleeding) Terminal (bladder) Throughout (no localizing value)
Circumstances associated History of trauma, pain, micturating symptoms, systemic signs including fever and skin and nasopharyngeal infection
Age of onset Periodicity Blood on diapers of underwear Exposure to medications Relation with exercise Flank pain (loin pain hematuria syndrome)
Physical examination Should Include Blood Pressure measurement Assessment for edema or weight gain Close skin examination Direct visualization of the genitals Abdominal mass or discomfort
Laboratory evaluation -Urinalysis, urine culture, and urinary excretion studies -Glomerular bleeding evaluation (24-hour urinary protein excretion/creatinine ratio, excretion of casts, protein excretion, blood clots)
Imaging studies USD of the kidney and bladder. Cytoscopy Is rarely indicated. May be useful to determine if the bleeding comes from bladder or one or both ureters.