1. Heamaturia & protienuria
Dr.Badi AlEnazi
Consultant pediatric endocrinologest and diabetologist

2. Haematuria may occur as an isolated symptom or as part of a systemic disorder.
It may be visible to the naked eye (frank or macroscopic haematuria) or be detected only on microscopic analysis of the urine.

3. The source of the blood may be anywhere from glomerulus to urethra
most cases in childhood are due to UTI or primary glomerular disease.

4. DDx Urinary tract infection (UTI).
Glomerulonephritis (post-streptococcal, Henoch-Schonlein purpura, ).
IgA nephropathy.
Acute haemorrhagic cystitis. Viral (adenovirus).
drugs (cyclophosphamide).
Calculus.
Trauma.
Exercise-induced. Usually after severe exercise and
resolves within 48 hours.
Tumours. Wilms’ tumour (uncommon presentation),

5. DDX Coagulopathies. Sickle cell disease.
Renal vein thrombosis. Gross haematuria and palpable renal mass in a newborn infant.
Factitious haematuria. As part of the Munchausen by proxy spectrum

6. Post strep Glomerulonephritis
Strep pharyngitis, or strep skin infection, followed 10 to 14 days by microscopic hematuria, nephritis, or nephrosis
Diagnosis: positive ASO
low C3 which normalize in 8 weeks
Management: supportive
Prognosis: Excellellent

7. Pt came with abdominal pain and palpable rash and hematuria

8. This is a boy who presented with abdominal mass and hematuria

9. RBCs

10. RBCs Cast

11. WBCs Cast

12. This patient had history of loin pain and hematuria

13. This urine sample of patient presented with hamaturiamhypertension after 3 week of URTI

14. This is a peripheral smear for patent who presented with hematuria

15. Clinical Features
The urine is usually pink or brown in colour because of the presence of the oxidized haem pigment..

16. Clinical Features
If the urine is bright red with or without clots then a lower urinary tract source should be suspected.
Haematuria may be an isolated finding or be associated with symptoms of a systemic disorder, e.g. Henoch-Schbnlein purpura (rash, joint pains).

17. Clinical Features Hypertension and oliguria are features of acute GMN.
Frequency and dysuria suggest a UTI which may be accompanied by microscopic haematuria
Loin pain or renal colic suggests the presence of a calculus.

18. Hematuria: Historicall Clues
Recent vigorous exercise or trauma. History of new onset of incontinence, dysuria, frequency, or urgency. History of unilateral flank pain that may radiate to the groin. flank pain without radiation but with fever, dysuria, and frequency and/or urgency.

19. Hematuria: Historicall Clues
The timing of hematuria during micturition, especially terminal hematuria. The color of urine may distinguish glomerular bleeding from extraglomerular bleeding.

20. Hematuria: Historicall Clues
A history of predisposing clinical conditions such as sickle cell disease or trait or coagulopathy such as severe hemophilia. Children who have papillary necrosis usually have sickle cell disease, or trait, and the gross hematuria generally is associated with pain , typically abdominal or flank pain. Exposure to medications that can cause hemorrhagic cystitis.

21. Hematuria: Historicall Clues
A history of pharyngitis or impetigo (two or three weeks prior to onset of hematuria). Nephritic syndromes, whether immune or non-immune, usually present with a classical triad of hypertension, azotemia, reduced urine output, edema,

22. Hematuria: Historicall Clues
Patients who have lupus nephritis may develop either microscopic or gross hematuria but they often have associated symptoms (e.g, rashes, arthritis, anorexia )

23. This girl came with haematureia

24. Hematuria: Historicall Clues
Patients who have immunoglobulin A nephropathy typically develop recurrent episodes of gross hematuria

25. Hematuria: Historicall Clues
Patients who have hemorrhaagic cystitis typically have bright red blood in the urine (terminal gross hematuria) and dysuria, abdominal pain, frequency, urgency.

26. Hematuria: Historicall Clues
Hx of skin or joint abnormalities Weight gain, swelling, recent URTI Hx of favabeen ingestion Family Hx: hematuria, deafness, CRF

27. Hematuria: Physical Findings
Hypertension, growth impairment Chest: murmurs, . . Abdomen: masses, ascites, tenderness. . . Abnormal urinary stream Edema, skin rashes, joint swelling

28. symptomaticHematuria: Diagnostic Approach
GLOMERULAR HEMATURIA
1-IMMUNE MEDIATED GN NONIMMUNNE GN
POST INFECTIOUS ALPORTS SYNDROME
IgA NEPHROPATHY BENIGN FAMILIAL

29. symptomatic Hematuria: Diagnostic Approach-cont’d
NON GLOMERULAR HEMATURIA: URINARY TRACT CYSTITIS, INFECTION UT CALCULI UT ANOMALIES HYPERCALCIURIA HYPERURICOSURIA SICKLE CELL TRAIT Unrecognized UT Anomalies, Infection , stones.

30. Urinary dipsticks are not very reliable.
They are also positive for myoglobin and
free haemoglobin

31. Urine microscopy should always be performed to confirm
the presence of red cells
The presence of red cell casts indicates an intrarenal cause (either glomerular or tubular)
Glomerular casts indicate a glomerular cause.
Pyuria and bacteriuria point to an infective cause which should be confirmed by culture.

32. Urine culture will confirm a bacterial infection.
CBC and coagulation tests. To
exclude coagulopathies and sickle cell disease.

33. Radiology. An abdominal US scan may identify a renal mass, evidence of obstruction or a renal
tract calculus.

35. Proteinuria Protein is normally found in the urine of healthy children
Since albumin has a relatively small molecular size, it tends to become the dominant constituent in proteinuria.

36. Non Persistent Proteinuria
Fever
Strenuous exercise
Cold exposure
Epinephrine infusion
Orthostatic

37. Proteinuria Glomerular Tubualr absorption Protein overload ATN
Congenital:
-Finish- type
- TORCH infection
Nephritis:
- postinfectious GN
- lupus
- Wegner
- HUS
- Goodpasture
Nephrotic:
- Minimal change
- FSGS
- MPGN
Drugs: captopril
Neoplasia
Renal vein throbosis
ATN
Fanconi Syndrome
Cystic/dysplastic
Interstial nephritis
Pyelonephritis
Hemolysis
Rhabdomyolysis

38. This patient came with high liver enzyme, and protinuriea

39. MECHANISMS OF PROTEIN HANDLING BY KIDNEY
Normal protein excretion affected by interplay of glomerular and tubular mechanisms
Glomerular injury: abnormal losses of intermediate MW proteins like albumin
Tubular damage: increased losses of low MW proteins

40. ABNORMAL PROTEIN EXCRETION
Urinary protein excretion in excess of 100 mg/m2 per day or 4 mg/m2 per hour
Nephrotic range proteinuria (heavy proteinuria) is defined as ≥ 1000 mg/m2 per day or 40 mg/m2 per hour.

41. ABNORMAL PROTEIN EXCRETION
Glomerular proteinuria
Due to increased filtration of macromolecules
May result from glomerular disease (most often minimal change disease) or from nonpathologic conditions such as fever, intensive exercise, and orthostatic (or postural) proteinuria

42. ABNORMAL PROTEIN EXCRETION
Tubular proteinuria
Results from increased excretion of low molecular weight proteins such as beta-2-microglobulin,
Tubulointerstitial diseases, can lead to increased excretion of these smaller proteins

43. ABNORMAL PROTEIN EXCRETION
Overflow Proteinuria
Results from increased excretion of low molecular weight proteins due to marked overproduction of a particular protein to a level that exceeds tubular reabsorptive capacity

44. ASYMPTOMATIC PROTEINURIA
Levels of protein excretion above the upper limits of normal for age
No clinical manifestations such as edema, hematuria, oliguria, and hypertension

45. MEASUREMENT OF URINARY PROTEIN
Use of a urine dipstick to detect proteinuria
  Dipstick proteinuria reflects primarily albuminuria.
 False-positive dipstick tests are seen with gross hematuria, concentrated urine, alkaline urine (pH >8), or contamination with chlorhexidine or certain medications (e.g., phenazopyridine therapy).

46. MEASUREMENT OF URINARY PROTEIN
Urine dipstick
Measures albumin concentration
Negative
Trace — between 15 and 30 mg/dL
1+ — between 30 and 100 mg/dL
2+ — between 100 and 300 mg/dL
3+ — between 300 and 1000 mg/dL
4+ — >1000 mg/dL

47. MEASUREMENT OF URINARY PROTEIN
Sulfosalicylic acid test
Detects all proteins in the urine including the low molecular weight proteins that are not detected by the dipstick

48. ORTHOSTATIC PROTEINURIA
Increase in protein excretion in the erect position compared with levels measured during recumbency
Mechanism postulated to involve an increased permeability of the glomerular capillary wall and a decrease in renal plasma flow
Long-term studies have documented the benign nature of this condition, with recorded normal renal function up to 50 years later

49. PERSISTENT PROTEINURIA
Present for long periods after initial detection
Absence of both orthostatic proteinuria and clinical evidence of renal disease
Clinical course may be benign
May be secondary to parenchymal disease

50. DIFFERENTIAL DIAGNOSES OF PERSISTENT PROTEINURIA
Benign proteinuria
Acute Glomerulonephritis
Chronic Glomerular Disease that can lead to nephrotic syndrome
Chronic nonspecific glomerulonephritis
Chronic interstitial nephritis
Congenital and acquired structural abnormalities of urinary tract

51. HISTORY Recent infection Weight changes Presence of edema
Symptoms of hypertension
Gross hematuria
Changes in urine output
Dysuria
Skin lesions

52. HISTORY Swollen joints Abdominal pain Previous abnormal urinalysis
Growth history
Medications
Family history
Renal disease, hypertension, deafness, visual disorders

53. PHYSICAL EXAMINATION Vital signs
Inspect for presence of edema, pallor, skin lesions, skeletal deformities
Screening for hearing and visual abnormalities
Abdominal exam
Lung exam
Cardiac exam

54. TRANSIENT PROTEINURIA
Follow-up routinely
Patient should have a repeat urinalysis on a first morning void in one year

55. ORTHOSTATIC PROTEINURIA
Perform Orthostatic Test
CBC
BUN
Creatinine
Electrolytes
24-hr urine excretion
< 1.5g/day  repeat UA and blood work in 1 year
> 1.5g/day  refer to Pediatric Nephrologist

56. FURTHER EVALUATION OF PERSISTENT PROTEINURIA
Examination or urine sediment
CBC
Renal function tests (blood urea nitrogen and creatinine)
Serum electrolytes
Cholesterol
Albumin and total protein

57. OTHER TESTS Renal ultrasound Serum complement levels (C3 and C4) ANA
Streptozyme testing,
Hepatitis B and C serology
HIV testing

58. PERSISTENT PROTEINURIA
If further work-up normal, urine dipstick should be repeated on at least two additional specimens. If these subsequent tests are negative for protein, the diagnosis is transient proteinuria.
If the proteinuria persists or if any of the studies are abnormal, the patient should be evaluated more extensively

59. Nephrotic Syndrome
Nephrotic syndrome is a clinical state characterized by:
Massive proteinuria (>40 mg/m2/hr)
Hypoalbuminemia (albumin <2.5 g/dL)
Edema
Hypercholesterolemia .

60. Nephrotic Syndrome Minimal change disease
Focal segmental glomerulosclerosis
Membranoproliferative
Membranous GN
Infection: HIV, hepatits, syphilis
Lupus, Ig A, HSP, post strep

61. Initial therapy Supportive: albumin 25% and lasix prn Salt restriction
Fluid restriction while nephrotic
Prednisone 60 mg/m2/day for 6 weeks
followed by 40 mg/m2/day for 6 weeks
then wean..

64. This is infant with protinuria since age of 2 month

65. Please remember : Edema Nephrotic range proteinuria Low albumin
Nephritis
Nephrosis
Hematuria
Hypertension
Oliguria
Increased Cr
Edema
Nephrotic range proteinuria
Low albumin
Hypercholestrolemia

66. Thank you