Introduction to Renal System and Hematuria


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Introduction to Renal System and Hematuria

  1. 1. Introduction to Renal System and Hematuria Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ ]
  2. 2. Contents• Clinical anatomy of the renal system.• Hematuria – causes, evaluation and treatment.
  3. 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. 4. Causes of Kidney Disease Damage from other agents  Environmental agents  Malnutrition Genetic defects
  5. 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. 6. Kidney Anatomy• Hilum -anteromedial side of kidney (VAP- anterior to posterior)
  7. 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. 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. 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. 10. Glomerulus• Tuft of capillaries invaginated in the Bowman’s capsule
  11. 11. Juxtaglomerular apparatus• specialised muscle cells in wall of afferent arteriole + lacis cells + macula densa – secretion of renin
  12. 12. Function of Kidney
  13. 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. 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. 15. Definition Hematuria :Presence of an abnormal quantity of red blood cells in the urine
  16. 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. 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. 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. 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. 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. 21. Causes of Hematuria3. Trauma4. Anatomical anomalies- PUJ obstruction, Polycystic Kidneys, Hydronephrosis5. Vascular- Arteritis, Infarction, thrombosis6. Idiopathic hypercalciuria
  22. 22. Causes of Hematuria7. Hematological- Coagulopathies, sickle cell Ds, Renal Vein thrombosis8. Drugs- Cyclophosphamide - Haemorrhagic cystitis9. Acute interstitial nephritis
  23. 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. 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. 25. • History• Physical examination• Lab tests
  26. 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. 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. 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. 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. 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. 31. Physical examination:• Edema- periorbital and pedal• Blood pressure, weight• Skin- purpura• Abdomen- palpable kidneys (Wilm’s tumor, hydronephrosis)• Genitalia
  32. 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. 33. Confirmation of Hematuria:Urinalysis:• Uncentrifuged (fresh) urine specimen- >5 RBCs/• Centrifuged sample -> 5 RBCs/HPF RBC casts- glomerulotubular origin WBC/ WBC casts- UTI
  34. 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. 35. Phase-contrast microscopy: Non-glomerular /Eumorphic RBCs
  36. 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 (~ 2-5 RBCs per HPF)
  37. 37. Step 2• ASO titre / anti-DNAse B Titre• Throat C/S• ANA, ds-DN• Urine Electrolytes• Coagulation studies• MCU
  38. 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. 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. 40. Step 3Renal Biopsy• Persistent High grade microscopic hematuria• Microscopic Hematuria + decre R.function• ,, ,, +Protenuria +++• ,, ,, + Hypertension• Second episode of gross hematuriaCystocopy
  41. 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. 42. Referral Criteria• Evidence of nephrolithiasis• F/H/O hereditary nephritis• RBC cast on microscopic urine examination
  43. 43. Spectrum of Anomalies• Renal disorders• Horseshoe Kidney• Renal Agenesis and Dysplasia• Polycystic Kidneys• Prune Belly
  44. 44. • Urinary Tract Obstructions• Antenatal Renal Pelvi-caliceal Dilatation• VUR• PUJO, VUJO• Posterior Urethral Valves• Ureterocoeles, Megaureter• Calculi
  45. 45. VUR
  46. 46. PUJO, VUJO
  47. 47. Posterior Urethral Valves
  48. 48. Ureterocoeles
  49. 49. • Abnormalities of Genitalia• Phimosis, Paraphimosis, Circumcision• Labial Fusion• Abnormalities of Bladder• Voiding dysfunction and Wetting• Neurogenic• Sacral Agenesis and Neural Tube Defects
  50. 50. Thank youDownload more documents and slide shows on The Medical Post [ ]