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Lecture- Hematuria and Acute glomerulonephritis by Dr. Muhammad Rafique
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DR. MUHAMMAD RAFIQUE
ASSISTANT PROF. PAEDITRICS
Hematuria+Acute Nephritis
DefinitionMacroscopic (gross) Hematuria:any discolored urine visible to the human eye/>10 RBCs/HPF
Microscopic Hematuria:>5 RBC under microscope/ HPF in 3 of 3 consecutive centrifuged Specimen of urine at least
1 week apart.
HematuriaHematuria
Transient
Phenomenon of little significance
Transient
Phenomenon of little significance
Persistent
sign of seriousrenal disease
Persistent
sign of seriousrenal disease
Classification of hematuria
Macroscopic - Microscopic
Symptomatic - Symptomless.
Transient - Persistent
SHOULD WE CONSIDER ANYCHANGES IN THE URINE COLOUR , RED BROWN AS ?
Differential diagnosis of dark urine
Haemoglobinuria: dipstick positive but no red cells on microscopy
MyoglobinuriaFood, e.g. beet rootDrugs, e.g. rifampicin, nitrofurantoin,
sennaPorphyria: urine darkens on standingBilirubinuria: obstructive billiary disease
Causes of HematuriaInfection: cystitis, tuberculosis.Tumour: Wilm’s tumourTrauma: renal tract trauma e.g. accidents, catheterInflammation: glomerulonephritis, HSP,
IgA nephropathy, polyarteritis nodosa.Structural: calculi (renal, bladder, ureteric).Haematological: SCD, coagulation disorders.Toxins: sulphonamides, cyclophosphamide, NSAID.Others: genital bleeding, child abuse, menstruation. Factitious: (including Munchausen by proxy).
Sites of origin of hematuria
Renal HematuriaUpper urinary tract
glomeruluscollecting tubules
interstitium
Lower urinary tractcalyxpelvisureterbladderurethra
Glomerular Hematuria
RENAL
IgAnephropathy
Post infectious
MPGN
MULTI-SYSTEM
HSP nephrititisSLE nephritisHUSSickle cell Disease
Extraglomerular Hematuria (RENAL)
UPPER UR TRACT
pyelonephritisATNpapillary necrosis
nephrocalcinosisThrombosis.MalformationTumor
LOWER UR TRACT
cystitisurethritisurolithiasistraumacoagulopathyheavy exercise
EXTRA RENAL
Bleeding disorder.
Mention bleeding disorders presented as haematuria ?
HaemophiliaITP
Isolated Hematuria (microscopic)Isolated Hematuria (microscopic)
No other urinary abnormalities.No renal insufficiency.No evidence for systemic disease.
Incidence ( school-aged children ) 4-6% - single urine examination 0.5-1% - repeated testing over 6-12 months
Isolated hematuriaIsolated hematuriaThe child needs to be monitored for new signs:
Hypertension Proteinuria Changes in the pattern or severity of hematuria No change in the first year, observation at yearly intervals adequate (check for serum creatinine) .BP and urine analysis every 3 mo, until the hematuria resolve.
ISOLATED GROSS RECURRENT HEMATURIA
IG-A NEPHROPATHYALPORT’S SYNDROMEHYPERCALCIURIA
ASYMPTOMATIC PATIENT
SYMPTOMATIC / ASYMPTOMATIC
SYMPTOMATIC• Renal symptoms–UTI–Nephrolithiasis
• Systemic symptoms
–HSP–SLE
ASYMPTOMATIC• Hypercalciuria• Cystic kidney disease
• Vascular -thrombosis
• Obstruction• Trauma • Tumor • Exercise• Coagulation disorder
• Hemoglobinopathy• Benign F. Hematuria
• IgA nephropathy• Acute PSGN
Hematuria……
Patient comes to you, complaining that his/her urine is reddish in color...
What is your first step?
HematuriaIs it really blood?Urine Dipstick
detects - Hb. - Myoglobin - Protein
Evaluation of HematuriaHistory
Evaluation of HematuriaHistory
Detailed review of F/Hx.• Hematuria• Proteinuria• Renal insufficiency• Deafness• Stones
Precipitating factors: infection, exercise Abdominal plain radiograph for:• HSP• Hydronephrosis• Pyelonephritis• Urolithiasis
Evaluation of Hematuria…Physical Examination
Evaluation of Hematuria…Physical Examination
Growth failure.Hypertension.Pallor.Edema.Rash.Abdomen: mass or tenderness.External genitalia:
- Bleeding - Infection -Trauma
Do urine analysis
After confirming hematuria .
? isIs it glomerular or not ?Is it from upper / lower utract?
Glomerular versus extraglomerular bleeding
Urinary findingUrinary findingGlomerularGlomerularExtraglomerulExtraglomerularar
- Red cell casts- Red cell castsMay be presentMay be presentAbsentAbsent
- Red cell- Red cell
morphologymorphologyDysmorphicDysmorphicUniformUniform
- Proteinuria- ProteinuriaMay be presentMay be presentAbsentAbsent
- Blood Clots- Blood ClotsAbsentAbsentMay be May be presentpresent
- Urine Color- Urine ColorMay be May be red/brown, cola red/brown, cola likelike
May be redMay be red
INVESTIGATIONSGLOMERULAR CBC Electrolyte,
Ca BUN C3 / C4 Cholesterol ASO titer ANA, ANCA Throat
culture Skin culture 24 hr urinary protein
EXTRA GLOMERULARSTEP1 : Urine cultureSTEP 2 : Urine -ca./cr.Hb. Electrophoresis for
SCDUSG - renal/bladderSTEP 3:Serum electrolytes , ca.
cr.If nephrocalcinosis,
urolithiasis -24 hr urine for: ca; cr; uric acid ,
oxalatesIf hydronephrosis: -cystogram, renal scan
When to refer to nephrologist ?
• Patient with nephritis.• Hypertension.• Renal insufficiency.• Urolithiasis ,nephrocalcinosis• F/Hx. of renal disease• Persistent asymptomatic hematuria > year
Nephritis• Nephritis often caused by infections, toxins
and auto-immune diseases. -Autoimmune Diseases - IgA nephropathy
-Hereditary Nephritis –Alport’s Syndrome
-Infection-related Glomerular Disease, bacterial endocarditis -HIV
Nephritis• Most common cause of glomerular injury. • It is a disturbance of the glomerular structure
with inflammatory cell proliferation. This can leads to: reduced glomerular blood flow(GFR) –(oliguria).
retention of waste products-(uremia/azotemia).
leakage of RBCs from damaged glomerulous -(hematuria).
Low renal blood flow activates the renin-angiotensin-aldosterone system leading to (hypertension).
Types of nephritis Glomerulonephritis: inflammation of glomeruli.
Interstitial nephritis: inflammation of the spaces between renal tubules.
pyelonephritis: when UTI has reached the pyelum (pelvis) of the kidney.
Lupus nephritis: a disease of the immune system
A 7 year-old boy presents with coca-colored urine, periorbital edema, and headache.
His blood pressure is 150/100.
Etiology of PSGN Follow1-3 weeks infection by group-A beta
hemolytic streptococci (M and T serotypes).
M types 1, 2, 4, 12, 18, 25, 49, 55, 57, and 60 may have nephritogenic potential. These may be caused by skin or throat infections.
The risk of developing nephritis infection by M type 49 is 5% if it is present in the throat, 25% if infection by the same organism in the skin .
Clinical picture of PSGNlatent period 1-3 weeks between onset of
strep. infection and development of clinical nephritis
Edema is the most frequent symptom.Gross hematuria at onset in 30-50% .
Urine is smoky, cola/tea colored, or rusty. The color is dependent on amount of blood present and the pH of the urine.
Observant parents may note oliguriaHypertension.
Diagnosis of PSGN
Investigations for recent Group-A Strep. Infection.Throat or skin cultureASO titerAnti –DNase B (skin)Streptozyme test
Decreased complement levels -usually C3 complement returns normal in 4-6 weeks
Urine analysis in PSGNUrine output mostly reduced.Hematuria - most consistent
abnormality.Hyaline and/or epithelial cellular castsRBC casts have been found in 60-85%
of hospitalized children with PSGN.
Urine color in PSGN
Urine microscopy
-Erythrocyte cast. Arrows:erythrocytes embedded in the matrix of the cast
-Their presence indicatesglomerular hematuria
RBCs casts formation
HISTOLOGICAL FINDINGS
light microscopy: the glomerular tufts appear enlarged and swollen, often filling Bowman space.
Immunofluorescent microscopy: Granular deposits of immunoglobulin G (IgG) and C3 along the capillary walls.
Electron microscopy: electron-dense deposits (humps) in the subepithelial space.
PSGN
Admission criteria for PSGN?
Hypertension.Increased S. creatinine.Electrolyte disturbance (high K+)
Duration of Hematuria/Proteinuria?
Gross Hematuria: Few weeksMicroscopic Hematuria:18 monthsProteinuria: Decreasing over 18 months
Compilications of PSGNHypertensive encephalopathy
Heart Failure.
K, po4, ca
Acidosis Seizure Renal failure.
Treatment of PSGN
Symptomatic. - Antibiotics - Antihypertensives - DiureticsComplete recovery in 95 %Recurrence is extremely rare.
Question?
14 yr female with hematuria.
More “tired” latelyWhat is your diagnosis?
What labs. will you order?
SLE Nephritis
C3 and C4 will be low.Anti DNAse-B +veSometimes will only manifest as
kidney disease.
When to consider renal biopsy in GN ?
Acute renal failure.Nephrotic SyndromeAbsence of evidence of strep. infectionAbsence of hypocomplementemia. Persistent proteinuria, hematuria
>6mo.Persistently low C3 for>3 months.
Thank you for your attention!