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……..  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…. 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