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seminar on Haematuria
Dr. Habibur Rahim
Apr 28, 2021 • 3 likes • 720 views

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seminar on Haematuria

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seminar on Haematuria
1. WELCOME To Seminar Dr Mehadi Hasan Rimon Resident, Year-1(neonatology) Dr. Ishrat Zahan Nigar Resident, Year-2( Pediatric
Neurology) Dr. Zannatul Ferdous Resident, Year-2 (Pediatric Neurology)
2. Case Scenerio Redwan , 6 years old boy, 3rd issue of his non consanguineous parents, got admitted with the complaints of
generalized swelling of body for 7days along with scanty micturition and passage of red colored urine for same duration. O/E, he had
pu!y face with generalized oedema . He was mildly pale, anicteric, BP: 130/80mm of Hg (> 99th centile) & BSUA ++. Genitourinary
system examination revealed abdomen was distended; ascites present. Provisional Diagnosis Acute Glomerulonephritis
3. Approach to a child with Hematuria
4. Definition Presence of red blood cell (RBC) in the urine, >10 RBC per cubic mm of freshly voided, uncentrifuged urine or >5 RBC per
high power field of 10 ml of freshly voided centrifuged urine.
5. Physiological Pathological Gross Microscopic glomerular non glomerular non glomerular glomerular • Heavy proteinuria • Fever
• menstruation Classification painless Painful
6. Classification Painful Hematuria Painless Hematuria UTI Calculi Hypercalciuria IgA nephropathy Renal tumor Renal TB
Coagulation disorder Alport syndrome Post traumatic
7. Classification Gross hematuria Microscopic hematuria UTI Infection related GN Renal calculi IgA nephropathy Hypercalciuria
alport syndrome TBMD Coagulation disorder Thrombocytopenia malignancy Vasculitis membranous nephropathy IgA nephropathy
TBMD alport syndrome idiopathic hypercalciuria renal vesical calculi urinary tract anomalies UTI PKD tuberous sclerosis wilms
tumour sickle cell disease Penicilium lithium recurrent
8. Classification Glomerular Nonglomerular PSGN RPGN IgA nephropathy Vasculitis HSP nephritis Lupus nephritis Alport
syndrome Membranous nephropathy TBMD HUS Hypercalciuria Renal calculi UTI Hemorrhagic cystitis Coagulation disorder
Thrombocytopenia Malignancy Urinary tract anomalies Vascular malformation Trauma Exercise Drugs
9. Conditions mimicking hematuria Drugs: Rifampicin Phenothiazines Nitrofurantoin Desferoxamine Chloroquine Ibuprofen
Levodopa
10. Foods: beet root, fruit containing anthocyanins (eg. black berries, plums, cherries) and food dyes (cake coloring). Pigments:
hemoglobinuria (intravascular hemolysis) myglobinuria (rhabdomyolysis) Bilirubin urate crystal (pink).
11. Approach to a child with Hematuria
12. History + symptom analysis Physical findings Lab investigations
13. History • Age: 5-12 yrs: PSGN 2-8 yrs: HSP <4 yrs: HUS 2-5 yrs: Wilms tumor 2nd decade: IgA nephropathy • Sex: F>>M in >1-2 yrs:
UTI F>>M: SLE nephritis M>F : X-linked form of Alport syndrome • Race: whites: Idiopathic hypercalciuria blacks: Sickle cell disease
14. History contd… • Amount of urine: Reduced in AGN, AKI • Clots in urine: Extraglomerular • Frequency, Dysuria, recent enuresis :
UTI • Frothy urine: Suggests Proteinuria seen in Glomerular diseases • Hematuria in relation to time of micturition: Initial stream –
from urethra (Urethrorrhagia – spotting In underwear) Terminal – from bladder (with suprapubic pain, disturbance of micturition)
Throughout the urinary stream - glomerular
15. Associated Symptoms Fever Infection SLE AGN Facial pu!iness Oedema of legs weight gain Shortness of breath Acute
Glomerulonephritis
16. Abdominal pain Urolithiasis (Loin to groin) Cystitis (lower abdominal) Pyelonephritis (loin pain) Abdominal mass
Hydronephrosis PKD Wilm’s tumour Joint pain Rashes HSP SLE Neurologic (seizures, irritability) SLE HUS
17. Jaundice Hemolysis, Obstructive jaundice APSGN HUS IgA nephropathy HSP nephritis Recent upper respiratory tract, skin
infection, GI infection Bleeding disorders, Hemoptysis in Good Pasture syndrome H/o bleeding from other sites
18. H/o Vision or hearing defects Alport syndrome Family h/o hematuria Hereditary glomerular diseases (Alport syndrome, Thin
glomerular Basement Membrane Disease, IgA Nephropathy), Urolithiasis, Hypercalciuria, Sickle cell disease/trait H/o consanguinity or
a!ected siblings ARPKD, Metabolic disorders
19. Others • H/o exercise, trauma, menstruation, recent bladder catheterization or passage of a calculus • H/o ingestion of drugs (ATT
– Rifampicin, Ibuprofen, Chloroquine, Metronidazole, Iron), i.v. contrast agents (Toxic nephropathy, RVT)
20. Examination HTN AGN PKD Raised temp. Infection SLE AGN Oedema AGN Pallor HUS SLE CKD Bleeding disorders Raised JVP
CHF
21. Palpable flank mass Hydronephrosis (Urinary tract obstruction) Wilms tumour ARPKD, hydronephrosis (B/L) Bladder palpable
Skin lesions Abnormal external genitalia, hypospadias, cryptorchidism, Genital trauma Distal obstruction Palpable Purpura(HSP)
Butterfly rash (SLE) Bruises (Trauma, Child abuse) WAGR syndrome Wilms tumour
22. Signs of Congestive cardiac failure, Hypertensive encephalopathy Joint swelling, tenderness Ophthalmologic (Anterior
lenticonus, macular flecks, recurrent corneal erosions) AGN HSP, SLE Alport syndrome Hearing assessment (B/L SNHL) Alport
syndrome
23. NEXT
25. Glomerular VS Non glomerular Features Glomerular hematuria Non-glomerular hematuria Pattern of hematuria: Hematuria
throughout urinary stream. Initial, terminal. Urinary symptoms: Painless. Dysuria, urgency, frequency Associated feature: Sore throat,
hypertension, edema. Fever, colicky pain. Family history: Deafness, renal failure. Renal stone, urinary infection. Clinical HTN, edema:
Usually present Less common
26. Features Glomerular hematuria Non-glomerular hematuria color Tea colored. Bright red, blood clots. Proteinuria 2+ or more on
dipstick; protein creatinine ratio>1. Trace to 1+; protein creatinine ratio<1. Dysmorphic RBC >20%. <15%, eumorphic. Cellular cast RBC
cast, leukocyte or tubular cast may be present Absent Crystal absent May be present Glomerular VS Non glomerular Urinalysis
27. No No How to investigate a case of Hematuria Physiological cause like viral illness, exercise, trauma, menstruation Take History &
do physical examination Do Urine R/E including phase contrast microscopy Do a dipstick test & exclude ABCDE ( ABCDE are Dipstick –
ve) A=Alkaptonuria B=billirubinuria C=Carotinemia D=Drugs E= Endocrine/Metabolic-Porphyria+
28. Role of Urine examination A. Urinanalysis 1. Urine dipstick test Based on the peroxidase- like activity of hemoglobin. • Positive in
presence of- Hb, Myoglobin & RBC • False +ve: Urine pH >9, H2O2 • False –ve: High ascorbic acid, formalin 2. Urine R/M/E RBC, protein,
RBC cast Pus cells, WBC cast Crystalluria Eosinophil Glomerular disease UTI Urolithiasis, Nephrocalcinosis Interstitial nephritis 3.
Urine C/S Number & type of bacteria UTI RBC: False negative in case of low specific gravity or alkaline pH as it causes hemolysis. Phase
Contrast microscopy >90-95% isomorphic >20% dysmorphic
29. No RBC Hemoglobinuria/ Myoglobinuria RBC/+- Hb Hb only, no RBC Search other cause of red urine Nonglomerular Glomerular
Check RBC Morphology
30. Urea, Creatinine, Electrolyte, ABG, ASO, C3, Spot urinary PCR, S Albumin, Cholesterol , Glomerular Hematuria No Consistent with
PSGN HTN, Azotemia Supportive Treatment USG, ANA, anti ds DNA, Family history of blurring & visual examination, Renal biopsy
31. Positive Renal US +/- VCUG Non glomerular Hematuria Negative Pyelonephritis, Cystitis Hydronephrosis, PUJ, PUV, MCKD, Tumor,
PKD,VUR, Lithiasis, RVT Abnormal Urine Culture Urinary Ca/Cr Normal Hypercalciuria Check 24-h Urine Bleeding disorder Meatitis
Idiopathic Abnormal Normal
32. Isolated microscopic hematuria Follow up Urine R/E with examination For asymptomatic, isolated microscopic hematuria
Repeat urinalysisis weekly × 2 No exercise × 48 hr F/H/O calculi Test parents for hematuria Benign familial hematuria ± hematuria, ±
USG, ± X ray KUB region Urinary Ca/Cr ratio Urine R/E, examination, BP
34. Role of Imaging 1. Structure: USG of KUB X-Ray KUB Doppler study of renal vessels and IVC Intravenous urography Spiral CT scan
Micturating cystourethrograms Renal cystic disease Hydronephrosis, Hydroureter, nephrocalcinosis, tumor, urolithiasis, Renal
parenchymal disease calculi Renal vein thrombosis Nutcracker syndrome Urolithiasis, Wilms tumor and polycystic kidney disease,
Renal trauma Urethral and bladder abnormalities (eg, cystitis), in recurrent UTI to r/o VUR, anomalies 2. Function DTPA DMSA
Functional excretory function. To see renal scar.
35. • Significant proteinuria (>1g/1.73m2/day) except Post- infectious GN. • Recurrent persistent hematuria (Microscopic >2yrs) •
Recurrent gross hematuria • Abnormal renal function, Persistent HTN • Hematuria, Proteinuria, diminished renal function, low C3 level
persist beyond 2 mo of onset of AGN • Serologic abnormalities (abnormal ANA or dsDNA levels) • A family history of end stage renal
disease. Indication of Renal biopsy
36. • Urinanalysis of siblings & parents: Thin glomerular basement membrane disease • Urine Ca/Creatinine ratio: > 0.2 in Idiopathic
hypercalciuria. • 24hrs urine for Calcium, uric acid, oxalate: Urolithiasis & Nephrocalcinosis • Cystogram & renal scan. • Slit lamp
examination of eye & audiometry.-Alport How to screen families in a case of Hematuria Hereditary causes of hematuria: •Benign
familial Hematuria(Thin basement membrane disease) •Alport Syndrome(Hereditary Nephritis) •Idiopathic hypercalciuria •Polycystic
kidney disease •Fabry’s disease •Nail patella syndrome •Sickle cell trait/disease
37. Management
38. • Hematuria is a clinical (or laboratory) sign, not a diagnosis. • Treatment is according to cause. • Reassurance and F/U: isolated
microscopic hematuria, familial microscopic haematuria. • Antibiotics : To treat cystitis, pyelonephritis • Supportive treatment: Proper
nutrition Diuretics Fluid and salt restriction Antihypertensives General Management
39. • Treatment of complication: Electrolyte abnormality, AKI, HF, acidosis, fluid overload, HTN. • Monitoring: Vitals, I/O, weight, urine
RME.
40. Management of some specific diseases
41. • Adequate fluid intake • Appropriate antibiotic • Prophylactic antibiotic when indicated. UTI
42. • Salt, fruit & fluid restriction • Diuretics • Antihypertensive • Antibiotics • Treatment of complication Prognosis • 98% complete
recovery within 1-2 weeks • 1% immediate mortality • 1% may proceed to chronic GN/CKD • 0.7-7% recurrence PSGN
43. • Prednisolone • MMF, cyclosporine, azathioprim • IV methylprednisolone, IV/oral cyclophosphamide • Immunosuppressive in
di!erent combination Prognosis • Not good • 50% turn into CKD within 10 years • 90% turn into CKD within 20 years Rx: RRT
Membranoproliferative Glomerulonephritis
44. • Treatment according to staging • Immunosuppressive therapy Prednisolone Cyclophosphamide MMF Prognosis • Relapse: 33% •
Childhood onset: worse prognosis SLE Nephritis
45. • Mild disease: no specific therapy • Persistent proteinuria: ACEi, corticosteroid • Severe nephritis/ Nephrotic syndrome:
corticosteroids & cytotoxic drugs. • Crescentic glomerulonephritis: IV corticosteroids, cyclophosphamide, plasma exchange in
nonresponsive cases. Prognosis • 15-40% at least 1 recurrence • <1% ESRD HSP Nephritis
46. • ACE inhibitor • Immune suppressive: prednisolone, azathioprime • Omega 3 fatty acid, fish oil Prognosis • Good in children •
RPGN: bad prognosis • ESRD: 30-40% cases in 3rd to 4th decade Ig A nephropathy
47. • ACE inhibitor • Renal replacement Prognosis • 60% ESRD by 60 years • 40% ESRD by 40 years Alport Syndrome
48. • Avoid dehydration • High liquid intake • Moderate salt restriction • Avoidance of high protein(animal protein) diet • Avoid excess
dietary calcium • Citrate supplementation • Thiazide diuretics Idiopathic hypercalciuria
49. • Usually benign. • Episodic gross hematuria in association with acute infection. • Prognosis: favorable. • Follow up: annually for
proteinuria & hypertension. Thin Basement Membrane Disease
50. • Increased fluid intake • Appropriate antibiotics Renal Stone • Increased fluid intake • Urological consultation Pyelonephritis
51. • Every case of hematuria should be properly evaluated. • Isolated asymptomatic microscopic hematuria can be an incidental
finding. Most of the cases it possess no threat to health, only reassurance & F/U is needed. • Gross & microscopic hematuria with family
history/additional findings are usually pathological. Proper evaluation & family screening can elicit a diagnosis. • With early diagnosis
and proper treatment of most of the disease related to hematuria can be well managed. Take home message

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