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Approach to a child with
     Hematuria :



             Sunil Agrawal
             1st year
             MD Pediatrics, IOM
Contents:
•   Introduction
•   Pathophysiology
•   Causes
•   History
•   Examination
•   Investigations
•   Management
Introduction
Hematuria means blood in urine.
It may be Gross or macroscopic and microscopic
   hematuria
Gross hematuria is seen by naked eyes while
   microscopic hematuria needs microscope.
   Hematuria is defined as the presence of at
   least 5 red blood cells per HPF of centrifuged
   urine and/or 5 RBC per microliter in
   uncentrifuged specimen
• 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 Hematuria:
A) Glomerular hematuria

   Isolated renal disease                 Multisystem disease

-Postinfectious GN (Post streptococcal)   -HSP nephritis
- IgA nephropathy( Berger ds)             -SLE nephritis
- Alport syndrome( hereditary )           -HUS
- Thin Glomerular Basement membrane       -Wegener granulomatosis
     disease                              -Polyarteritis nodosa
- Membranoproliferative GN
                                          -Goodpasture syndrome
- Membranous nephropathy
                                          -HIV nephropathy
 - Focal segmental glomerulosclerosis
 - Antiglomerular basement membrane       -Sickle cell glomerulopathy
     ds
B) Extraglomerular hematuria
Upper Urinary tract
Tubulointerstitial
   Pyelonephritis
   Interstitial nephritis
   ATN
   Papillary necrosis
   Nephrocalcinosis
Anatomic
   Hydronephrosis
   Polycystic kidney disease
   Tumor (Wilms,
   Rhabdomyosarcoma,
   Angiomyolipoma)
   Trauma
Vascular:
•     Arterial/venous thrombosis
•     Malformation (aneurysms, hemangioma)
•     Nutcracker syndrome
•     Hemoglobinopathy (Sickle cell trait/disease)
Crystalluria: Calcium, Oxalate, Uric acid
Medications: NSAIDs, anticoagulants
Lower urinary tract
  Inflammation- infectious and
  non infectious
       Cystitis
       Urethritis
  Urolithiasis
  Trauma
  Coagulopathy
  Heavy exercise
   Bladder tumor
  Factitious syndrome / by proxy
Common causes of gross hematuria:

•   Urinary tract infection
•   Meatal stenosis
•   Perineal irritation
•   Trauma
•   Urolithiasis/hypercalciuria
•   Coagulopathy
•   Tumor
Glomerular cause of gross hematuria
  IgA nephropathy
  Alport syndrome
  Thin glomerular basement membrane disease
  Post infectious glomerulonephritis
  HSP nephritis
  SLE nephritis
Causes of Hematuria in the Newborn:
• Renal vein thrombosis (Asphyxia, dehydration,
  shock)
• Renal artery thrombosis
• Autosomal recessive polycystic kidney disease
• Obstructive uropathy
• Urinary tract infection
• Bleeding and clotting disorders
• Trauma, bladder catheterization
• Cortical necrosis (Hypoxic/ischemic perinatal
  insult)
• Nephrocalcinosis (Frusemide in premature)
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:
Colour        Causes
Dark yellow   Normal concentrated urine
Dark brown or Bile pigments
black         Homogentisic acid, melanin,
              tyrosinosis, methemoglobinuria
Cola coloured Glomerular hematuria
Red or pink   Extraglomerular hematuria,
urine         Hemoglobin, Myoglobin,
              Porphyrins, Chloroquine,
              Deferoxamine, Beets, blackberries,
              Rifampin, Red dyes in food, Urates
Characteristics of urine:
• Amount of urine: Reduced in AGN, ARF
• Clots in urine: Extraglomerular
•  Frequency, Dysuria, recent enuresis : UTI
• Frothy urine: Suggests Proteinuria seen in
  Glomerular diseases
• Timing: Initial stream – from urethra (Urethrorrhagia
  – spotting in underwear); Terminal (with suprapubic
  pain, disturbance of micturition) – from bladder
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)
• Abnormal external genitalia e.g. ambiguous genitalia
  in WAGR syndrome (Wilms, aniridia, genital
  anomalies, mental retardation), Wilms tumour –
  hypospadias, cryptorchidism, Genital trauma
• 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)
General Approach to
Investigate the child with
       Hematuria
Investigations:
• Urine dipstick test: Based on the
  peroxidase-like activity of
  hemoglobin
       • It can detect trace amounts
         of hemoglobin and
         myoglobin.
       • Can detect 5-10 intact RBC
         per mm3 of unspun urine
       • False +ve: Urine pH >9, H2O2
       • False –ve: High ascorbic acid,
         formalin
• Also for urine albumin
Investigations:
Urine microscopy: Presence of RBCs and casts (> 5
RBCs per HPF) in centrifuged urine
Glomerular                         Non - glomerular
1. Brown, cola coloured or smoky   1. Bright red, pink
2. RBC casts                       2.Terminal hematuria/
                                      Passage of clots
3. Proteinuria 2+ or more          3. Proteinuria of < 2+
4. Deformed urinary RBCs           4. Normal morphology of RBCs
Study on Evaluation of hematuria using the urinary albumin-
to-total-protein ratio to differentiate glomerular and
nonglomerular bleeding
•N. Ohisa · R. Matsuki · H. Suzuki · H. Miura · Y. Ohisa · K. Yoshida
Department of Clinical Laboratory, Tohoku University Hospital,
Sendai, Japan
•microscopy-based differentiation is not only tedious but the sensitivity and
specificity may vary from one examiner to another. Furthermore, once
the specimen has been frozen, differentiation becomes difficult.
•A total of 143 random urine specimens from patients seen at the Division of
Nephrology, Endocrinology and Vascular Disease and the Urology Department
at Tohoku University Hospital were included in the study. The inclusion criterion
for the study was a diagnosis of glomerular disease based on clinical features
or histopathology with hematuria (5 or more RBCs per high-power fi eld). Of the
104 patients diagnosed with glomerular disease and 39 specimens from
patients with nonglomerular disease, used as controls in the study.
• With respect to the albumin-to-total-protein ratio,
  the mean value in the glomerular disease group was
  0.72 •} 0.10, whereas the mean in the
  nonglomerular disease group was 0.35 •} 0.17 (P <
  0.001). The distribution of the albumin-to-total-
  protein ratio in the glomerular and nonglomerular
  disease groups was clearly differentiated. Sensitivity
  and specificity as a function of the albumin-to-total-
  protein ratio. At a ratio cutoff of 0.59, sensitivity and
  specificity was maximized at 96.2% and 100%,
  respectively.
Distribution of urinary albumin-to-total-protein ratio in glomerular and
nonglomerular hematuria. The mean albumin-to-totalprotein ratio in the
glomerular disease group was signifi cantly higher than that in the nonglomerular
disease group. A cutoff of 0.59 excluded all nonglomerular disease cases, while
detecting all but three glomerular disease cases. Gl, glomerular disease; non-Gl,
nonglomerular disease; vertical axis, albumin-to-total-protein ratio; horizontal axis,
glomerular disease, nonglomerular disease
Urine albumin-to-total-protein ratio sensitivities and specifi ities
in differentiating glomerular and nonglomerular hematuria. At a
ratio of 0.59, sensitivity and specificity were 96.2% and 100%,
respectively.
Cola/ brown urine?
                        Proteinuria(>30mg/dl)?
                               RBC cast?
                       Acute nephritic syndrome?
                 Yes                                    NO
Glomerular hematuria            Extraglomerular hematuria
• CBC                           Step 1
• Electrolytes,Ca               • Urine culture
• BUN/Cr                        Step 2
• Serum protein/albumin         • Urine Ca/Cr
• Cholesterol                   • Renal/ bladder USG
• C3/C4                         Step 3
• ASO/Anti-DNase B              • Urinalysis: siblings, parents
• ANA                           • Serum electrolytes, Cr, Ca
• Antineutrophil antibody       • If crystalluria, urolitiasis or
                                   nephrocalcinosis:
• Throat/ skin culture
                                     24-hr urine for Ca, Cr, Uric acid, oxalate
• 24-hour urine total protein
   creatinine clearance         • If hydronephrosis/pyelocaliectasis:
                                     cystogram, renal scan
Investigations:
• 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 (>4 mg/kg/d), or
   – Spot urine calcium-creatinine ratio >0.21
Investigations:
• Imaging Studies
   – Renal and bladder sonography: Urinary tract anomalies,
     such as hydronephrosis, hydroureter, nephrocalcinosis,
     tumor, and urolithiasis, Renal parenchymal disease
   – X-Ray KUB: calculi
   – Doppler study of renal vessels and IVC: Renal vein
     thrombosis
   – Intravenous urography
   – Spiral CT scan - Urolithiasis, Wilms tumor and polycystic
     kidney disease, Renal trauma
   – Micturating cystourethrograms - Urethral and bladder
     abnormalities (eg, cystitis), in recurrent UTI to r/o VUR,
     anomalies
   – Radionuclide studies – Renal function and perfusion
   – Angiogram
   – Chest X-Ray (Pulmonary oedema, CHF)
Investigations:
• Renal biopsy:
    Relative indications -
    • Significant proteinuria (3+ or more) or nephrotic
      syndrome +
    • Recurrent persistent hematuria (Microscopic
      >2yrs)
    • Abnormal renal function, Persistent HTN
    • Hematuria, Proteinuria, diminished renal function,
      low C3 level persist beyond 2 mo of onset of AGN
    • Absence of evidence of streptococcal infection
    • Serologic abnormalities (abnormal ANA or dsDNA
      levels)
    • A family history of end stage renal disease or
      evidence of Chronic renal disease in patient
Dx        Histology                           Clinical         Lab
IgA       IgA deposition in the               Gross,           No specific
Nephro-   mesangium, glomerular               intermittent,    changes,
pathy     sclerosis, proliferative changes,   painless         although
          crescents in severe cases           hematuria        increased serum
                                                               IgA levels
                                                               observed in some
                                                               patients

HSP       Same as IgA nephropathy             Purpura, joint   No specific
                                              pains,           laboratory data
                                              abdominal
                                              pain,
                                              hematuria, etc
SLE       Mild glomerulitis, proliferative    Hematuria,       Abnormal C3, C4,
          changes, immune complex             proteinuria,     ANA, dsDNA,
          deposition, crescents,              hypertension,    anemia,
          immunoglobulin deposition           joint pains,     thrombocytopeni
                                              rashes, etc      a, etc
Dx              Histology                     Clinical               Lab
Alport          Some thinning of basement     Sensorineural         No
Syndrome        membranes, "basket weave"     hearing loss, corneal specific
                changes in the glomerular     abnormalities,        changes
                basement                      hematuria, renal
                membrane on electron          failure
                microscopy
Thin            Average glomerular basement   Persistent             No
Basement        membranes thin (reported to   microscopic or gross   specific
Membrane        be 100-200 nm)                hematuria,             changes
disease                                       significant family
                                              history

Mesangio-       Glomerular lobulations,       Hematuria,             C3 levels
proliferative   thickening of the mesangial   proteinuria,           may be
GN              matrix and glomerular         hypertension           low
                basement membranes,
                crescents, etc
Investigations:
• Cystourethroscopy: Terminal hematuria,
  disturbances of micturition, suprapubic pain
  (Only if strong suspicion of bladder ulceration,
  tumours)
• Screening of first degree relatives in persistent
  hematuria
Summary
Approach to a child with hematuria
Approach to a child with hematuria
Approach to a child with hematuria
For Asymptomatic, isolated
      microscopic hematuria:
Isolated microscopic
hematuria

Repeat urinalysis weekly x 2    Negative   F/U Urine R/M with
(No exercise x 48hrs)                      examination
              Persistent hematuria

Test parents for               Positive    Benign Familial
hematuria                                  Hematuria
               No               Yes
 Family h/o calculi                        Urine Ca/Cr ratio

               No              Normal
 +Hearing test, +USG,                      Yearly Urine R/M,
 +X-Ray KUB                                examination, BP
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)
Management:
– 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:
• Nelson Textbook of Pediatrics, 19th Ed
• Nelson Essentials of Pediatrics, 6th Ed
• O.P. Ghai Essential pediatrics, 7th Ed
• Pediatric Nephrology, Shrivastava, Bagga,
  4th Ed
• Japanese Society of Nephrology 2007
• Indian J Pediatrics 1999; 66 : 207-214
• Various Websites
Approach to a child with hematuria

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Approach to a child with hematuria

  • 1. Approach to a child with Hematuria : Sunil Agrawal 1st year MD Pediatrics, IOM
  • 2. Contents: • Introduction • Pathophysiology • Causes • History • Examination • Investigations • Management
  • 3. Introduction Hematuria means blood in urine. It may be Gross or macroscopic and microscopic hematuria Gross hematuria is seen by naked eyes while microscopic hematuria needs microscope. Hematuria is defined as the presence of at least 5 red blood cells per HPF of centrifuged urine and/or 5 RBC per microliter in uncentrifuged specimen
  • 4. • 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
  • 5. Causes of Hematuria: A) Glomerular hematuria Isolated renal disease Multisystem disease -Postinfectious GN (Post streptococcal) -HSP nephritis - IgA nephropathy( Berger ds) -SLE nephritis - Alport syndrome( hereditary ) -HUS - Thin Glomerular Basement membrane -Wegener granulomatosis disease -Polyarteritis nodosa - Membranoproliferative GN -Goodpasture syndrome - Membranous nephropathy -HIV nephropathy - Focal segmental glomerulosclerosis - Antiglomerular basement membrane -Sickle cell glomerulopathy ds
  • 6. B) Extraglomerular hematuria Upper Urinary tract Tubulointerstitial Pyelonephritis Interstitial nephritis ATN Papillary necrosis Nephrocalcinosis Anatomic Hydronephrosis Polycystic kidney disease Tumor (Wilms, Rhabdomyosarcoma, Angiomyolipoma) Trauma
  • 7. Vascular: • Arterial/venous thrombosis • Malformation (aneurysms, hemangioma) • Nutcracker syndrome • Hemoglobinopathy (Sickle cell trait/disease) Crystalluria: Calcium, Oxalate, Uric acid Medications: NSAIDs, anticoagulants
  • 8. Lower urinary tract Inflammation- infectious and non infectious Cystitis Urethritis Urolithiasis Trauma Coagulopathy Heavy exercise Bladder tumor Factitious syndrome / by proxy
  • 9. Common causes of gross hematuria: • Urinary tract infection • Meatal stenosis • Perineal irritation • Trauma • Urolithiasis/hypercalciuria • Coagulopathy • Tumor
  • 10. Glomerular cause of gross hematuria IgA nephropathy Alport syndrome Thin glomerular basement membrane disease Post infectious glomerulonephritis HSP nephritis SLE nephritis
  • 11. Causes of Hematuria in the Newborn: • Renal vein thrombosis (Asphyxia, dehydration, shock) • Renal artery thrombosis • Autosomal recessive polycystic kidney disease • Obstructive uropathy • Urinary tract infection • Bleeding and clotting disorders • Trauma, bladder catheterization • Cortical necrosis (Hypoxic/ischemic perinatal insult) • Nephrocalcinosis (Frusemide in premature)
  • 12. 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
  • 13. Colour of urine: Colour Causes Dark yellow Normal concentrated urine Dark brown or Bile pigments black Homogentisic acid, melanin, tyrosinosis, methemoglobinuria Cola coloured Glomerular hematuria Red or pink Extraglomerular hematuria, urine Hemoglobin, Myoglobin, Porphyrins, Chloroquine, Deferoxamine, Beets, blackberries, Rifampin, Red dyes in food, Urates
  • 14. Characteristics of urine: • Amount of urine: Reduced in AGN, ARF • Clots in urine: Extraglomerular •  Frequency, Dysuria, recent enuresis : UTI • Frothy urine: Suggests Proteinuria seen in Glomerular diseases • Timing: Initial stream – from urethra (Urethrorrhagia – spotting in underwear); Terminal (with suprapubic pain, disturbance of micturition) – from bladder
  • 15. 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
  • 16. • 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)
  • 17. • 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
  • 18. 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
  • 19. • Skin lesions Purpura(HSP) Butterfly rash (SLE) Bruises (Trauma, Child abuse) • Abnormal external genitalia e.g. ambiguous genitalia in WAGR syndrome (Wilms, aniridia, genital anomalies, mental retardation), Wilms tumour – hypospadias, cryptorchidism, Genital trauma • 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)
  • 20. General Approach to Investigate the child with Hematuria
  • 21. Investigations: • Urine dipstick test: Based on the peroxidase-like activity of hemoglobin • It can detect trace amounts of hemoglobin and myoglobin. • Can detect 5-10 intact RBC per mm3 of unspun urine • False +ve: Urine pH >9, H2O2 • False –ve: High ascorbic acid, formalin • Also for urine albumin
  • 22. Investigations: Urine microscopy: Presence of RBCs and casts (> 5 RBCs per HPF) in centrifuged urine Glomerular Non - glomerular 1. Brown, cola coloured or smoky 1. Bright red, pink 2. RBC casts 2.Terminal hematuria/ Passage of clots 3. Proteinuria 2+ or more 3. Proteinuria of < 2+ 4. Deformed urinary RBCs 4. Normal morphology of RBCs
  • 23. Study on Evaluation of hematuria using the urinary albumin- to-total-protein ratio to differentiate glomerular and nonglomerular bleeding •N. Ohisa · R. Matsuki · H. Suzuki · H. Miura · Y. Ohisa · K. Yoshida Department of Clinical Laboratory, Tohoku University Hospital, Sendai, Japan •microscopy-based differentiation is not only tedious but the sensitivity and specificity may vary from one examiner to another. Furthermore, once the specimen has been frozen, differentiation becomes difficult. •A total of 143 random urine specimens from patients seen at the Division of Nephrology, Endocrinology and Vascular Disease and the Urology Department at Tohoku University Hospital were included in the study. The inclusion criterion for the study was a diagnosis of glomerular disease based on clinical features or histopathology with hematuria (5 or more RBCs per high-power fi eld). Of the 104 patients diagnosed with glomerular disease and 39 specimens from patients with nonglomerular disease, used as controls in the study.
  • 24. • With respect to the albumin-to-total-protein ratio, the mean value in the glomerular disease group was 0.72 •} 0.10, whereas the mean in the nonglomerular disease group was 0.35 •} 0.17 (P < 0.001). The distribution of the albumin-to-total- protein ratio in the glomerular and nonglomerular disease groups was clearly differentiated. Sensitivity and specificity as a function of the albumin-to-total- protein ratio. At a ratio cutoff of 0.59, sensitivity and specificity was maximized at 96.2% and 100%, respectively.
  • 25. Distribution of urinary albumin-to-total-protein ratio in glomerular and nonglomerular hematuria. The mean albumin-to-totalprotein ratio in the glomerular disease group was signifi cantly higher than that in the nonglomerular disease group. A cutoff of 0.59 excluded all nonglomerular disease cases, while detecting all but three glomerular disease cases. Gl, glomerular disease; non-Gl, nonglomerular disease; vertical axis, albumin-to-total-protein ratio; horizontal axis, glomerular disease, nonglomerular disease
  • 26. Urine albumin-to-total-protein ratio sensitivities and specifi ities in differentiating glomerular and nonglomerular hematuria. At a ratio of 0.59, sensitivity and specificity were 96.2% and 100%, respectively.
  • 27. Cola/ brown urine? Proteinuria(>30mg/dl)? RBC cast? Acute nephritic syndrome? Yes NO Glomerular hematuria Extraglomerular hematuria • CBC Step 1 • Electrolytes,Ca • Urine culture • BUN/Cr Step 2 • Serum protein/albumin • Urine Ca/Cr • Cholesterol • Renal/ bladder USG • C3/C4 Step 3 • ASO/Anti-DNase B • Urinalysis: siblings, parents • ANA • Serum electrolytes, Cr, Ca • Antineutrophil antibody • If crystalluria, urolitiasis or nephrocalcinosis: • Throat/ skin culture 24-hr urine for Ca, Cr, Uric acid, oxalate • 24-hour urine total protein creatinine clearance • If hydronephrosis/pyelocaliectasis: cystogram, renal scan
  • 28. Investigations: • 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 (>4 mg/kg/d), or – Spot urine calcium-creatinine ratio >0.21
  • 29. Investigations: • Imaging Studies – Renal and bladder sonography: Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, Renal parenchymal disease – X-Ray KUB: calculi – Doppler study of renal vessels and IVC: Renal vein thrombosis – Intravenous urography – Spiral CT scan - Urolithiasis, Wilms tumor and polycystic kidney disease, Renal trauma – Micturating cystourethrograms - Urethral and bladder abnormalities (eg, cystitis), in recurrent UTI to r/o VUR, anomalies – Radionuclide studies – Renal function and perfusion – Angiogram – Chest X-Ray (Pulmonary oedema, CHF)
  • 30. Investigations: • Renal biopsy: Relative indications - • Significant proteinuria (3+ or more) or nephrotic syndrome + • Recurrent persistent hematuria (Microscopic >2yrs) • Abnormal renal function, Persistent HTN • Hematuria, Proteinuria, diminished renal function, low C3 level persist beyond 2 mo of onset of AGN • Absence of evidence of streptococcal infection • Serologic abnormalities (abnormal ANA or dsDNA levels) • A family history of end stage renal disease or evidence of Chronic renal disease in patient
  • 31. Dx Histology Clinical Lab IgA IgA deposition in the Gross, No specific Nephro- mesangium, glomerular intermittent, changes, pathy sclerosis, proliferative changes, painless although crescents in severe cases hematuria increased serum IgA levels observed in some patients HSP Same as IgA nephropathy Purpura, joint No specific pains, laboratory data abdominal pain, hematuria, etc SLE Mild glomerulitis, proliferative Hematuria, Abnormal C3, C4, changes, immune complex proteinuria, ANA, dsDNA, deposition, crescents, hypertension, anemia, immunoglobulin deposition joint pains, thrombocytopeni rashes, etc a, etc
  • 32. Dx Histology Clinical Lab Alport Some thinning of basement Sensorineural No Syndrome membranes, "basket weave" hearing loss, corneal specific changes in the glomerular abnormalities, changes basement hematuria, renal membrane on electron failure microscopy Thin Average glomerular basement Persistent No Basement membranes thin (reported to microscopic or gross specific Membrane be 100-200 nm) hematuria, changes disease significant family history Mesangio- Glomerular lobulations, Hematuria, C3 levels proliferative thickening of the mesangial proteinuria, may be GN matrix and glomerular hypertension low basement membranes, crescents, etc
  • 33. Investigations: • Cystourethroscopy: Terminal hematuria, disturbances of micturition, suprapubic pain (Only if strong suspicion of bladder ulceration, tumours) • Screening of first degree relatives in persistent hematuria
  • 38. For Asymptomatic, isolated microscopic hematuria: Isolated microscopic hematuria Repeat urinalysis weekly x 2 Negative F/U Urine R/M with (No exercise x 48hrs) examination Persistent hematuria Test parents for Positive Benign Familial hematuria Hematuria No Yes Family h/o calculi Urine Ca/Cr ratio No Normal +Hearing test, +USG, Yearly Urine R/M, +X-Ray KUB examination, BP
  • 39. 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)
  • 40. Management: – 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
  • 41. References: • Nelson Textbook of Pediatrics, 19th Ed • Nelson Essentials of Pediatrics, 6th Ed • O.P. Ghai Essential pediatrics, 7th Ed • Pediatric Nephrology, Shrivastava, Bagga, 4th Ed • Japanese Society of Nephrology 2007 • Indian J Pediatrics 1999; 66 : 207-214 • Various Websites