HEMATURIA Hardi Hussein Qader KUCOM

OBJECTIVES :1. to know the definition and types of

hematuria.2. to identify the causes of hematuria.3. How to investigate patient .4. How to treat the patient.

DEFINITION

Generally, hematuria is defined as the presence of 5 or more red blood cells (RBCs) per high-power field in 3 of 3 consecutive centrifuged specimens obtained at least 1 week apart.

Hematuria can be either gross (ie, overtly bloody, smoky, or tea-colored urine) or microscopic(detected by dipstick).

It may also be either symptomatic or asymptomatic. either transient or persistent, and either isolated or associated with proteinuria and other

urinary abnormalities

PATHOPHYSIOLOGY: Structural disruption in the integrity

of glomerular basement membrane caused by inflammatory or immunologic processes

Toxic disruptions of the renal tubules Mechanical erosion of mucosal

surfaces in the genitourinary tract

CAUSES OF RED URINE

APPROACH TO PATIENT WITH HEMATURIA 1. History :

Age: 2-5yrs: Wilms tumor 5-12yrs: PSGN• Sex: F>>M in >1-2yrs: UTI F>>M: SLE nephritis M>F : X-linked form of Alport syndrome• Race: whites: Idiopathic hypercalciuria blacks:

Sickle cell disease

Colour of urine

causes Colour

Normal concentrated urine Dark yellow

Bile pigmentMelaninTyrosinosisMethemoglobinemia

Dark brown or black

Glomerular hematuria Cola coloured

Extra glomerular hematuriaHemoglobin MyoglobinChloroquine , refampin.Beet , black berries , red dye in food.

Red or pink urine

ASSOCIATED SYMPTOMS: Fever: Infections, SLE, AGN. Facial puffiness, Oedema of legs, weight gain,

Shortness of breath: Acute Glomerulonephritis. Hypertension : (Headache, visual changes, epistaxis,

seizures): AGN, ARF Abdominal pain: Urolithiasis (Loin to groin), UTI, clots,

Nutcracker syndrome Painless: Glomerular Abdominal mass: Hydronephrosis, PKD, Wilm’s

tumour Joint pain : (HSP, SLE) Rashes :(HSP, SLE, PAN) Neurologic : – SLE, HUS (seizures, irritability) Jaundice: Hemolysis, Obstructive jaundice

H/o exercise, menstruation, recent bladder catheterization or passage of a calculus

Recent upper respiratory (1-2wks back), skin infection (3-6 wks): PSGN

GI infection: HUS, HSP nephritis Gross hematuria precipitated by URI: Alport

syndrome, IgA Nephropathy H/o bleeding from other sites: Bleeding disorders,

Hemoptysis in Good Pasture syndrome H/o Trauma, abdominal surgery, Child abuse (Social

factors - Munchausen), crush injury H/o ingestion of drugs (ATT – Rifampicin, Ibuprofen,

Chloroquine, Metronidazole, Iron), i.v. contrast agents (Toxic nephropathy, RVT)

H/o Vision or hearing defects: Alport syndrome

Family h/o: Hereditary glomerular diseases (Alport syndrome, Thin glomerular Basement Membrane Disease, IgA Nephropathy), Urolithiasis, Hypercalciuria, Sickle cell disease/trait

H/o consanguinity or affected siblings in ARPKD, Metabolic disorders

EXAMINATION: Vitals: – BP: in AGN, PKD – Temperature Oedema: in AGN Pallor: Bleeding disorders, HUS, SLE, CRF JVP: Raised in CHF Per abdomen: Mass – Kidney: Hydronephrosis (Urinary tract obstruction), Wilms tumour; B/L in ARPKD, hydronephrosis - Bladder palpable: Distal obstruction Tenderness: HSP

Skin lesions : - Purpura(HSP) - Butterfly rash (SLE) - Bruises (Trauma, Child abuse) Signs of Congestive cardiac failure, HTNsive

encephalopathy: AGN Joint swelling, tenderness: HSP, SLE Ophthalmologic: Alport syndrome (Anterior

lenticonus, macular flecks, recurrent corneal erosions), Aniridia (Wilms)

Hearing assessment: Alport (B/L SNHL)

Urine C/S RFT: Blood urea nitrogen/serum creatinine, Na/K

(↓Na in AGN, ↑K in ARF) Complete blood counts (CBC): Hb - ↓ in

bleeding, HUS, SLE, CRF; Abnormal TC, DC in infections, HUS, ↓ in SLE;

Platelet counts and Coagulation studies: (history suggestive of bleeding disorder, HUS), Sickle cell (Hemoglobin electrophoresis)

PBS: Microangiopathic hemolytic anemia ESR, CRP – Infections 24 hr urinary protein, Spot urinary protein:

Creatinine ratio, Serum albumin and cholesterol if associated proteinuria (Nephrotic syndrome)

Urine calcium: - Hypercalciuria is a relatively common finding in children.

– 24-hour urinary calcium (>4mg/kg/d), or – Spot urine calcium-creatinine ratio >0.21

IMAGING STUDIES 1. Renal and bladder sonography: Urinary tract

anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, Renal parenchymal disease

2. X-Ray KUB: calculi 3. Doppler study of renal vessels and IVC: Renal

vein thrombosis 4. Intravenous urography 5. Spiral CT scan - Urolithiasis, Wilms tumor and

polycystic kidney disease, Renal trauma 6. Micturating cystourethrograms - Urethral and

bladder abnormalities (eg, cystitis), in recurrent UTI to r/o VUR, anomalies

7. Radionuclide studies 8. Renal function and perfusion – Angiogram 9. Chest X-Ray (Pulmonary oedema, CHF)

RENAL BIOPSYRelative indications : 1. Significant proteinuria (3+ or more) or nephrotic

syndrome + 2. Recurrent persistent hematuria (Microscopic

>2yrs) 3. Abnormal renal function, Persistent HTN 4. Hematuria, Proteinuria, diminished renal function,

low C3 level persist beyond 2 mo of onset of AGN 5. Absence of evidence of streptococcal infection 6. Serologic abnormalities (abnormal ANA or dsDNA

levels) 7. A family history of end stage renal disease or

evidence of Chronic renal disease in patient

MANAGEMENT

According to cause Reassurance and F/U Treat cystitis, pyelonephritis, AGN: Antibiotics Supportive treatment: Diuretics, Fluid and salt

restriction, Antihypertensives Monitoring – BP, I/O, weight, Urine R/M Treat Hyperkalemia, ARF, CHF, acidosis, fluid

overload, HTN and its complications ACE inhibitors useful in proteinuria Immunosuppressive therapy: Depending on cause

(Steroids, cyclophosphamide)

Idiopathic Hypercalciuria: Hydrochlorothiazide , Potassium citrate, Sodium restriction

Calculi: Plenty of water ESRD: Dialysis, Renal transplantation Correct thrombocytopenia, anemia,

coagulation factor deficiency Renal vein thrombosis: Anticoagulant

therapy or thrombectomy may be needed Surgical correction: Calculi, PUJ

obstruction, Posterior urethral valves, Wilms tumour

REFERENCES:

1. Nelson Textbook of Pediatrics, 19th Ed2. Nelson Essentials of Pediatrics, 6th Ed3. Pediatric board study guide

THANK YOU