Proteinuria & Hematuria
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  • 1. PROTEINURIA AND HEMATURIA CARMEN PRIET0-JIMENEZ, M.D.
  • 2. Proteinuria and Nephrotic Syndrome
    • Occurrence of proteinuria in a single urine is relatively common.
    • Will present in 5% to 15% of normal children in a random urine specimen.
  • 3.
    • -Proteinuria is a marker of renal disease.
    • -The dilemma for the PCP is to differentiate the child with transient or any other benign forms of proteinuria from children with renal disease.
  • 4.
    • PATOPHYSIOLOGY AND CLASSIFICATION
    • Normal protein excretion
    • normal child <100 mg/m2/day or 150mg/day
    • neonates is higher up to 300 mg/m2
    • (reduced reabsorption of filtered protein)
  • 5.
    • The normally low rate of urinary protein excretion is:
    • -Restriction of the filtration
    • -Reabsorption of freely filtered low molecular weight protein
  • 6.
    • Abnormal protein excretion
    • Urinary protein excretion in excess of 100 mg/m2/day or 4mg/m2/hr
    • Nephrotic range proteinuria is defined as >1000 mg/m2/day or 40mg/m2/hr
  • 7.
    • Three main mechanism:
    • Glomerular (increase filtration)
    • Tubular (increase excretion- decrease reabsorption)
    • Overflow (marked overproduction of a particular protein)
  • 8.
    • Measurement of urinary protein
    • Urine dipstick
    • negative
    • trace between 15-30mg/dl
    • 1+ 30-100 mg/dl
    • 2+ 100-300mg/dl
    • 3+ 300-1000mg/dl
    • 4+ >1000mg/dl
  • 9.
    • Quantitative assessment
    • Measurement of 24-hour protein excretion or total protein/creatinine ratio
    • in a spot urine in the morning
    • normal in children :
    • <0.2mg protein/mg creatinine (+2 years)
    • <0.5mg protein/mg creatinine (6-24-month)
  • 10.
    • Qualitative assessment
    • May be necessary to differentiate glomerular from tubular protein
  • 11.
    • Approach to the child with proteinuria
    • Transient or Intermittent
    • Orthostatic
    • Persistent
  • 12.  
  • 13.
    • History and physical
    • Thorough history and physical
    • change in urine volume or color
    • edema
    • increase BP
    • recent strep infection
    • family history for renal disease and hearing loss (Alport disease)
  • 14.  
  • 15. The Need for Renal Biopsy
    • The key indication for biopsy in any renal disorder are the need to make specific diagnosis for therapeutic reasons or to provide a prognosis.
  • 16. Neprotic Syndrome
    • Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, edema, and hyperlipidemia; the most common presenting symptom is edema.
  • 17. Introduction
    • The annual incidence of Nephrotic syndrome in healthy children is 2 to 7 new case per 100,000 children younger than 18 years of age.
    • The peak age lf onset is at 2 to 3 years.
  • 18. Definition
    • The diagnosis of NS is the presence of urinary protein, with the albumin disproportionately greater than globulin.
  • 19. Clinical Diagnostic Criteria
    • 1- Generalized edema
    • 2- Hypoproteinemia <2 g/dL (disproportionately low albumin in relation to globulin)
  • 20.
    • 3-Urine protein to urine creatinine ratio in excess of 2 (first A.M. void) or a 24- hour urine that exceeds 50mg/Kg body weight
    • 4-Hypercholesterolemia (>200 mg/dL)
  • 21.  
  • 22.  
  • 23.
    • The mechanisms for edema include:
    • -Transudation of fluid from the intravascular space into the intestitium secondary to decreased albumin and
    • - Increased renal tubular reabsorption of sodium and water
  • 24.  
  • 25.
    • The hyperlipidemia is secondary to:
    • -Increase in lipoprotein synthesis by the liver and
    • -Decrease in lipid catabolism resulting from reduced activity of the enzyme lipoprotein lipase and lecithin cholesterol acetyltransferase.
  • 26.
    • INCIDENCE FOR UNDERLYING PATHOLOGY
  • 27.  
  • 28.  
  • 29.  
  • 30.
    • TREATMENT
  • 31.  
  • 32.  
  • 33. Complications
    • One true complication of NS is the tendency to developed infections.
    • IgG antibody is lost in the urine, and complement activation is impaired by concomitant loss of factor B.
  • 34.
    • Marked intravascular depletion causes diminished splachnic blood flow and hypoxia, and a marked tendency to thrombosis cause microinfarction, lowering resistance of the bowel wall to bacteria passage.
  • 35.
    • Peritonitis is a major contributor to the 1% to 2% mortality in NS
    • The second major contributor is Thromboembolism, however anticoagulant therapy is not justified during remission.
  • 36.
    • Growth is often impaired in NS
    • There may be losses of IGF-binding protein, which could account for the depressed serum concentration of IGF-I and IGF-II.
  • 37.  
  • 38. Prognosis
    • Mortality in minimal-change NS is approximately 2%
    • Of the remaining 98%, most are steroid-responsive
    • about 2/3 experience 1/3 possible
    • single relapse developing protracted series of relapses
  • 39. Hematuria and Glomerulonephitis
  • 40. Introduction
    • Recognition, definition, differential diagnosis, and orderly evaluation of hematuria in infants and children is often an important issue in pediatric practice
  • 41. Definition
    • Hematuria is defined by the presence of an abnormal quantity of red blood cells in the urine
    • Macroscopic: grossly visible
    • Microscopic: only upon urinalysis
    • >5-10 RBC’s per high power field
  • 42.
    • A large number of benign and serious conditions can cause hematuria in children.
  • 43.
    • Gross hematuria
    • UTI
    • Irritation of the meatus or perineum
    • Trauma
    • Nephrolithiasis
    • Sickle cell disease/trait
    • Post infectious glomerulonephritis
    • IgA nephropathy
  • 44.
    • Microscopic hematuria
    • Glomerulopathies
    • Hypercalciuria
    • Microlithiasis
    • UTI
  • 45.
    • Children with hematuria may present in one of three way
    • 1-Onset of gross hematuria
    • 2-Onset of urinary or other symptoms with incidental finding
    • 3-Incidental finding during a health evaluation
  • 46.
    • Historical clues
    • The color of the urine
    • Glomerulonephritis may be brown and/or frothy urine,
    • while bleeding is suggested by the presence of blood clots, or pink or clearly red urine
  • 47.
    • The timing of the hematuria
    • Initial (urethral bleeding)
    • Terminal (bladder)
    • Throughout (no localizing value)
  • 48.
    • Circumstances associated
    • History of trauma, pain, micturating symptoms, systemic signs including fever and skin and nasopharyngeal infection
  • 49.
    • Age of onset
    • Periodicity
    • Blood on diapers of underwear
    • Exposure to medications
    • Relation with exercise
    • Flank pain (loin pain hematuria syndrome)
  • 50. Physical examination
    • Should Include
    • Blood Pressure measurement
    • Assessment for edema or weight gain
    • Close skin examination
    • Direct visualization of the genitals
    • Abdominal mass or discomfort
  • 51. Laboratory evaluation
    • -Urinalysis, urine culture, and urinary excretion studies
    • -Glomerular bleeding evaluation
    • (24-hour urinary protein excretion/creatinine ratio, excretion of casts, protein excretion, blood clots)
  • 52.
    • Imaging studies
    • USD of the kidney and bladder.
    • Cytoscopy
    • Is rarely indicated. May be useful to determine if the bleeding comes from bladder or one or both ureters.
  • 53.  
  • 54. Etiology
    • The causes of gross and microscopic hematuria are extensive.
  • 55.
    • A natomical abnormalities
    • B ladder and kidney infection
    • C oagulation/hematology
    • D rugs
    • E xercise
    • F amilial hematuria
    • G lomerulonephritis
    • H ypercalciuria-hyperuricosuria-urolithiasis
    • I nterstitial nephritis
    • T rauma and tumors
  • 56.
    • Extrarrenal causes
    • Usually gross hematuria, no proteinuria, and RBC’s that are suggestive of nonglomerular origin.
  • 57.
    • -Neprholithiasis
    • -UTI
    • -Adenovirus
    • -Kidney tumor
    • -Polycystic kidney
    • -Urethral irritation
  • 58.
    • -Obstructive uropathy
    • -Post-traumatic kidney
    • -Onset of menarche
    • -Exposure to cyclophosphamide
    • -Thrombogenic condition
    • -Sickle cell trait
  • 59.
    • -Vascular bleeding
    • -”Nutcracker syndrome”
    • -Left renal vein entrapment
    • (Also orthostatic proteinuria)
    • -Loin pain hematuria syndrome
    • -Urethrovesical bleeding
  • 60.
    • Renal Causes ( Glomerular causes)
    • Most patients also have proteinuria, red cell casts, and/or renal insufficiency. The clinical context is also suggestive.
  • 61.
    • -Postinfectious glomerulonephritis
    • -Henoch-Schonlein purpura
    • (tetrad: rash, arthralgias, abdominal pain and renal disease)
    • -IgA nephropathy persistent
    • -Alport Syndrome hematuria
    • -Thin base membrane disease
    • (heterozygote carrier)
  • 62.
    • -Systemic diseases
    • Lupus
    • Shunt nephritis
    • Hemolitic-uremic syndrome
  • 63.
    • Unexplained hematuria
    • - Factitious hematuria
  • 64.  
  • 65.  
  • 66.  
  • 67.
    • Poststreptococcal glomerulonephritis
    • The most common type in children results through immunologic process, from A Beta-hemolytic streptococcus.
  • 68.  
  • 69.
    • Immunoglobulin A nephropathy
    • The most common variety of primary glomerulonephritis. Usually negative family history.
    • Mesangial IgA deposition is the most prominent finding on renal biopsy.
  • 70.
    • Alport Syndrome
    • Its classically X-linked form, suggested by hematuria in a male.
    • Positive family history of hematuria, deafness, and renal failure.
    • Abnormal collagen IV composition.
  • 71.
    • Thin base membrane disease
    • Also called benign familial hematuria , transmitted in a dominant fashion but, in most cases a heterozygous form of autosomal recessive Alport syndrome.
  • 72. Treatment
    • General management
    • Salt and water restriction.
    • Specific treatment
    • Depends of the etiology or severity of the disorder.
  • 73.