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Introduction to Renal System and Hematuria
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Introduction to Renal System and Hematuria

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  • 1. Introduction to Renal System and Hematuria Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  • 2. Contents• Clinical anatomy of the renal system.• Hematuria – causes, evaluation and treatment.
  • 3. Causes of Kidney Disease Inflammatory and degenerative disease  Acute glomerulonephritis  Nephrotic syndrome  Chronic renal failure Damage from other diseases  Hypertension, diabetes mellitus Infection and obstruction
  • 4. Causes of Kidney Disease Damage from other agents  Environmental agents  Malnutrition Genetic defects
  • 5. Renal Anatomy• Paired retroperitoneal-• 12 thoracic & 3rd lumbar vertebra• Covered by perinephric fat extending to hilum• Weight- 150gm, 11 cm in length, 6 cm in width, and 3 cm thick
  • 6. Kidney Anatomy• Hilum -anteromedial side of kidney (VAP- anterior to posterior)
  • 7. Anatomy of kidney• Newborn – length - 6cm, wt- 24 gms• Cortex- glomeruli , PCT,DCT,CD• Medulla- straight portion of tubules, loops of Henle, vasa recta terminal collecting ducts
  • 8. Nephrone Structural and functional unit of kidney 1 million in each KidneyA. GlomerulusB. Renal tubules-Bowman’s capsule PCT Loop of Henle DCT CT Tubules
  • 9. • Glomerulus –Cluster of branching capillaries –Cup-shaped membrane at the head of each nephrone forms the Bowman’s capsule –Filters waste products from blood
  • 10. Glomerulus• Tuft of capillaries invaginated in the Bowman’s capsule
  • 11. Juxtaglomerular apparatus• specialised muscle cells in wall of afferent arteriole + lacis cells + macula densa – secretion of renin
  • 12. Function of Kidney
  • 13. Functions– Filtration of materials in blood– Filtrate includes – water, ions, urea, glucose, amino acids,minerals, vitamins, drugs– Reabsorption of substances - 99% of the filtrate components are reabsorbed actively or passively by tubular cells– Secretion of hydrogen ions to maintain acid-base balance
  • 14. Functions– Water & Electrolyte balance– Excretes waste products-Urea, Uric acid, Creatinine– Secretes erythropoietin-erythropoiesis– Renin secretion (for body water balance)– Regulates blood pressure– Excretion of drugs, various toxic substances– Vitamin D activation
  • 15. Definition Hematuria :Presence of an abnormal quantity of red blood cells in the urine
  • 16. HematuriaClassification:A) Based on No of RBCs in urine:1. Macroscopic Hematuria -Gross Hematuria visible to naked eye. Here RBC >106 (10 lakh) per ml of urine2.Microscopic - >5RBCs/HPF in a sediment from 10ml of centrifuged freshly voided Urine
  • 17. Microscopic hematuria without other symptoms - 2% of children• More commonly found in girlsB) Based on site of bleeding: 1. Glomerular 2. Non glomerular
  • 18. Urinary Hues• Dark yellow – Conc urine, Bile pigment• Red- Hb, beets, blackberries, chloroquine, rifampicin, red food coloring• Dark brown /Black- Homogentisic acid, melanin
  • 19. Causes of Hematuria1. Infection (UTI)- Bacterial , Viral Schistosomiasis, Tuberculosis2. Glomerular diseases a) Recurrent gross hematuria IgA Nephropathy Benign familial idiopathic H (thin basement membrane disease)
  • 20. Causes of hematuria• Alport Syndromb) APGNc) Membranous GNd) Secondary causes of GN – lupus Nehpritis ,Henoch schonlein purpura, HUSe) Menbranoproloferative GNf) Rapid progressive GNg) Good Pasture DS
  • 21. Causes of Hematuria3. Trauma4. Anatomical anomalies- PUJ obstruction, Polycystic Kidneys, Hydronephrosis5. Vascular- Arteritis, Infarction, thrombosis6. Idiopathic hypercalciuria
  • 22. Causes of Hematuria7. Hematological- Coagulopathies, sickle cell Ds, Renal Vein thrombosis8. Drugs- Cyclophosphamide - Haemorrhagic cystitis9. Acute interstitial nephritis
  • 23. Glomerular vs extraglomerular hematuria:Urinary finding Glomerular ExtraglomerularColor Red/brown Usually red Cola/teaRBC cast Present AbsentClots Absent May be +Proteinuria >2 (+) AbsentRed cell morphology Dysmorphic Eumorphic
  • 24. Casts in urine:1 Physiological casts: Hyaline cast, granular cast2. Pathological casts: Lipid cast – Nephrotic syndrome RBC cast – Acute glomerulonephritis WBC cast – Pyelonephritis Crystal cast – Hypercalcemia Broad waxy cast – Chronic renal failure
  • 25. • History• Physical examination• Lab tests
  • 26. Presentation:May present in one of three ways 1 Onset as gross hematuria 2 Onset with urinary or other symptoms 3. Incidental finding during a health evaluation
  • 27. Approach:• Age: Preschool age- Wilm’s tumor School age – PIGN• Sex: Females- lupus nephritis Males – Alport syndrome• Race: Blacks- Sickle cell disease Caucasians- Hypercalciuria
  • 28. History:• H/O passage of clots- extraglomerular cause• Fever, dysuria, abdominal pain, recent enuresis, frquency- UTI• Recent trauma to abdomen- hydronephrosis• Early morning periorbital puffiness, weight gain, oliguria, dark-coloured urine, edema and hypertension- glomerular cause
  • 29. History:• Painless hematuria- glomerular• Recent h/o skin or sore throat infection- PSGN• Prolonged fever, joint pain, skin rashes- connective tissue disease• Anemia – SLE or bleeding disorder• Skin rash and arthritis- HSP, SLE• Similar family history- SLE, Alport syndrome, urolithiasis, Polycystic kidney disease
  • 30. History:• Timing of the hematuria Initial (urethral bleeding) Terminal (bladder) Throughout (no localizing value)• Also important- h/o passage of calculi per urethra, exercise, ingestion of drugs or toxic agents, menstruation, recent bladder catheterisation
  • 31. Physical examination:• Edema- periorbital and pedal• Blood pressure, weight• Skin- purpura• Abdomen- palpable kidneys (Wilm’s tumor, hydronephrosis)• Genitalia
  • 32. Lab TestsStep 1- Must be done in all Patients• CBC• Urine R/E, Urine C/S• S. Creatinine, B. Urea• C3 Level• USG Or IVP
  • 33. Confirmation of Hematuria:Urinalysis:• Uncentrifuged (fresh) urine specimen- >5 RBCs/ cu.mm• Centrifuged sample -> 5 RBCs/HPF RBC casts- glomerulotubular origin WBC/ WBC casts- UTI
  • 34. Red cell morphology: Look for presence of “dysmorphic RBCs” in fresh urine specimen by light or phase contrast microscopy- > 60-80% dysmorphic RBCs  indicates glomerular cause- Eumorphic RBCs indicate origin in renal pelvis or lower urinary tract
  • 35. Phase-contrast microscopy: Non-glomerular /Eumorphic RBCs
  • 36. Confirmation of hematuria-Dipstick test :Test is negative when “red urine” is due to beeturia and drugs (rifampicin, phenazopyridine) Pseudoperoxidase activity of Haemoglobin or myoglobin catalyzes a reaction between hydrogen peroxide and tetramethyl benzidine - to produce an oxidized chromogen having green-blue colour- Detects 5-10 intact RBCs per cu.mm (~ 2-5 RBCs per HPF)
  • 37. Step 2• ASO titre / anti-DNAse B Titre• Throat C/S• ANA, ds-DN• Urine Electrolytes• Coagulation studies• MCU
  • 38. Step 2 Hb electrophoresis (HbS) Urinary calcium excretion (> 4 mg/kg/day or urinary calcium to creatinine ratio > 0.21) Urine Calcium Excretion (normal <4 mg/kg/day) Urine Calcium to Creatinine ratio (normal <0.2- 0.25) Urinalysis of a Family Member
  • 39. Step 2 - Imaging tests:• USG (KUB region)• Spiral CT scan- Urolithiasis, Wilm’s tumor, polycystic kidney disease• Voiding cystourethrogram• Radionuclide studies- calculi• IVP
  • 40. Step 3Renal Biopsy• Persistent High grade microscopic hematuria• Microscopic Hematuria + decre R.function• ,, ,, +Protenuria +++• ,, ,, + Hypertension• Second episode of gross hematuriaCystocopy
  • 41. Referral Criteria• Concurrent systemic signs – Hypertension, edema, Arthritis• Abnormal RFT , ↓C3• Significant Proteinuria• Episodes of Gross Hematuria• Persistant hematuria > 1yr• Hypercalciuria• Parental anxiety
  • 42. Referral Criteria• Evidence of nephrolithiasis• F/H/O hereditary nephritis• RBC cast on microscopic urine examination
  • 43. Spectrum of Anomalies• Renal disorders• Horseshoe Kidney• Renal Agenesis and Dysplasia• Polycystic Kidneys• Prune Belly
  • 44. • Urinary Tract Obstructions• Antenatal Renal Pelvi-caliceal Dilatation• VUR• PUJO, VUJO• Posterior Urethral Valves• Ureterocoeles, Megaureter• Calculi
  • 45. VUR
  • 46. PUJO, VUJO
  • 47. Posterior Urethral Valves
  • 48. Ureterocoeles
  • 49. • Abnormalities of Genitalia• Phimosis, Paraphimosis, Circumcision• Labial Fusion• Abnormalities of Bladder• Voiding dysfunction and Wetting• Neurogenic• Sacral Agenesis and Neural Tube Defects
  • 50. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]