Common presenting symptoms

in renal system

Assistant Professor Medicine

Dr. Shumaila Rafi
 LEARNING OBJECTIVES
• At the end of session final year students will
be able to:
• Define hematuria and proteinuria
• Discuss all the causes of hematuria and
proteinuria
• Lists the clinical features of hematuria and
proteinuria
• Describe all the investigations of hematuria
and proteinuria
 HEMATURIA

DEFINITION
Hematuria is usually defined as more than 5
red blood cells per high-power field in the
urinary sediment, although the definition is
variable.
Types
• Microscopic
• Macroscopic
 ETIOLOGY
Renal causes of hematuria
Vasculitis
• Henoch-Schönlein purpura,
• Periarteritis nodosa,
• Wegener granulomatosis
Glomerular diseases
• Poststreptococcal glomerulonephritis
• Immunoglobulin A nephropathy
• Lupus nephritis
• Alport syndrome
 Contd.
Tubulointerstitial disease
• Polycystic kidney disease
• Nephrolithiasis
• Analgesic nephropathy
• Reflux nephropathy
• Tumors (primary renal cell, metastatic)
 Contd.
• Urinary tract diseases
• Infection or cancer of the
ureter,bladder,prostate,urethra
• Nephrolithiasis
• Systemic causes of hematuria
• Bleeding diathesis
• Sickle cell disease
 History
• When during urination does the blood appear?
• Hematuria at the start of urination suggests a
problem in the urethra distal to the urogenital
diaphragm,
• Hematuria throughout urination suggests upper
urinary tract or upper bladder disease,
• Hematuria at the end of urination suggests a
problem in the bladder neck or the prostatic
urethra
 Contd.
• History of mensturation in females
• Do you have to urinate often? Does it hurt?
• Increased frequency and dysuria ---UTI or
uroepithelial malignancy
• Colicky pain suggests a stone
• Painless hematuria in the absence of signs and
symptoms of renal disease or urinary tract
infection should prompt an investigation for
genitourinary malignancy
 CONTD.
• Weight loss,
• Extrarenal manifestations (rash), arthritis,
arthralgia, or pulmonary symptoms suggest a
variety of systemic illnesses, including
vasculitic syndromes, malignancy, and
tuberculosis.
• A recent sore throat or skin infection is
consistent with poststreptococcal
glomerulonephritis.
 CONTD.
• Do you take any medications?
• Family history, travel history
PHYSICAL EXAMINATION
• Hypertension, especially if new, may be a sign
of renal disease.
• Petechiae, arthritis, mononeuritis multiplex,
and rash suggest coagulopathy, immunologic
disease, or vasculitis.
 CONTD.
• Hearing should be evaluated if Alport
syndrome is suspected
• Examination of the prostate and urethral
meatus is part of a complete evaluation
 Interpretation of dipstick-positive haematuria

Dipstick test positive Urine microscopy Suggested cause

Haematuria White blood cells Infection

Abnormal epithelial cells Tumour

Red cell casts

Dysmorphic erythrocytes
Glomerular bleeding
(phase contrast microscopy)

Haemoglobinuria No red cells Intravascular haemolysis

Myoglobinuria (brown No red cells Rhabdomyolysis

urine)
 Cause Urine colour
Food dyes
e.g. Acanthocyanins (beetroot) Red
Drugs
e.g. Phenolphthalein Pink when alkaline
Senna/other anthaquinones Orange
Rifampicin Orange
Levodopa Darkens on standing
Porphyria Darkens on standing
Alkaptonuria
Bilirubinuria
e.g. Obstructive jaundice Dark
Dipstick-positive for bilirubin,
negative for haemoglobin

Dipstick-negative dark urine

 Investigations
• Urine dipstick test for hematuria
• Urine DR
• Platelet count,PT,APTT
• Cystoscopy
• IVU
• Ultrasound KUB
• CT Abdomen
• Renal angiography
 Approach to patient
• Hemtauria on repeated urine dipstick
• Exclude for mensturation,infection,trauma
• Red cell confirmed on urine microscopy and
infection absent on culture
• Renal imaging like ultrasound and IVU
• Cystocopy
• If anatiomical lesion is present
• Then full assessment by urologists.
• If anatomical lesion is absent then
• Is any feature of significant renal disease :
• Hypertension,
• Proteinuria ,
• Abnormal renal function,
• Family history of renal disease,
• History of systemic illness
• NO--- observation for urine test ,BP and
creatinine every 6-24 months
• YES ---Renal biopsy
 MANAGEMENT
• According to the cause
 MECHANISMS OF PROTEINURIA
• Increased glomerular filtration of normal
plasma proteins is due to altered glomerular
permeability.
• Inadequate tubular reabsorption
• Overflow of elevated normal or abnormal
plasma proteins
• Increased secretion of tissue proteins from the
epithelial cells of the loop of Henle occurs in
Tamm-Horsfall proteinuria.
THANKS