Haematuria & Renal Failure

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Haematuria & Renal Failure

  1. 1. Paediatric Nephrology (I) HEAMTOURIA & RENAL FAILURE Jameela Kari, FRCP (UK), CABP, MD, CCST, FRCPCH King AdulAziz University Hospital, Jeddah, Saudi Arabia
  2. 2. RENAL SYSTEM <ul><li>Investigation of renal system </li></ul><ul><li>Haematuria/ PSGN </li></ul><ul><li>ARF/CRF </li></ul><ul><li>Proteinuria/ Nephrotic syndrome </li></ul><ul><li>UTI </li></ul><ul><li>Congenital Anomalies </li></ul>
  3. 3. Investigation of the renal system <ul><li>Urine analysis </li></ul><ul><li>Urine electrolytes : fraction excretion of sodium (pre-renal <1%, renal >1-2%) </li></ul><ul><li>24 hours urine for protein, Ca etc </li></ul><ul><li>Cultures : older children: midstream </li></ul><ul><ul><ul><ul><ul><li>Younger children:SPA, Catheter, Bag </li></ul></ul></ul></ul></ul><ul><li>Urea & creatinine </li></ul><ul><li>GFR (creatinine clearance= ml/1.73m 2 /minute) </li></ul><ul><li>Imaging : US, KUB, MCUG, CT scan, isotope scan (DMSA, DTPA), IVP </li></ul><ul><li>Renal biopsy </li></ul>
  4. 4. HAEMATURIA <ul><li>Macroscopic = frank = gross </li></ul><ul><li>Microscopic > 5 RBCs per high powered field </li></ul><ul><li>Red urine : </li></ul><ul><ul><li>Blood (RBCs= haematuria, haemoglobin= haemoglobinuria) </li></ul></ul><ul><ul><li>Myoglobin </li></ul></ul><ul><ul><li>Food: blackberries </li></ul></ul><ul><ul><li>Aniline dyes used for coloring candy </li></ul></ul><ul><ul><li>Drugs: Rifampicin, phenolphthalein </li></ul></ul><ul><ul><li>Urate </li></ul></ul><ul><ul><li>Porphyrins </li></ul></ul>
  5. 5. Haematuria
  6. 6. Causes <ul><li>Glomerular : brownish or cola-coloured and may contain RBCs cast, proteinuria </li></ul><ul><li>Lower urinary tract : red to pink color urine and may contain clots </li></ul>
  7. 7. PATHOPHYSIOLOGY <ul><li>Haematological : thrombocytopaenia, DIC, coagulopathies, renal vein thrombosis, SCD </li></ul><ul><li>Glomerular : brownish or cola-coloured and may contain RBCs cast, proteinuria </li></ul><ul><li>Stones and hypercalciuria </li></ul><ul><li>Infection : bacterial, TB, viral </li></ul><ul><li>Lower urinary tract : red to pink color urine and may contain clots </li></ul><ul><li>Anatomic abnormalities : congenital, trauma, polycystic kidneys, tumors, vascular abnormalities </li></ul><ul><li>Exercise and drugs </li></ul>
  8. 8. Glomerular Diseases <ul><li>7 years old boy </li></ul><ul><li>Frank haematuria (smokey or tea colored) </li></ul><ul><li>H/O throat infection 2 weeks ago </li></ul><ul><li>O/E peri-orbital edema, BP 140/90 (hypertension) </li></ul><ul><ul><li>What is the most likely diagnosis </li></ul></ul><ul><ul><li>What investigations </li></ul></ul>
  9. 9. Post-streptococcal glomerulonephritis : <ul><li>Rare before the age of 3 years </li></ul><ul><li>Nephritic picture: Gross haematuria, edema , hypertension, renal insufficiency (normal RF-ARF) </li></ul><ul><li>Complications of hypertension: encephalopathy, congestive heart failure </li></ul><ul><li>Rarely: nephritic- nephrotic picture. </li></ul>
  10. 10. Diagnosis: <ul><li>Urine analysis: RBCs, RBCs cast , proteinuria </li></ul><ul><li>Low complement C3 </li></ul><ul><li>Evidence of streptococcal infection: throat culture, ASO titer and DNase B antigen and streptozyme test </li></ul><ul><li>Mild normochromic anaemia </li></ul><ul><li>Renal function </li></ul>
  11. 11. Complications: <ul><li>ARF  volume overload, hypertension, fits, hyperkalemia, hyperphosphatemia, hypocalcaemia and acidosis </li></ul><ul><li>Treatment </li></ul><ul><li>Antibiotics </li></ul><ul><li>Management of ARF </li></ul>
  12. 12. Prognosis <ul><li>Complete recovery 95% </li></ul><ul><li>Infrequently: severe acute phase leading to chronic renal insufficiency </li></ul><ul><li>Recurrence are extremely rare </li></ul>
  13. 13. <ul><li>What is this? </li></ul>
  14. 14. <ul><li>RBCs cast </li></ul><ul><li>Glomerulonephritis or vasculitis </li></ul><ul><li>Exclude extra-renal disorders </li></ul>
  15. 15. Glomerular Diseases <ul><li>MPGN </li></ul><ul><li>Rapidly progressive glomerulonephritits </li></ul><ul><li>SLE </li></ul><ul><li>Shunt nephritis </li></ul><ul><li>Goodpasture disease </li></ul><ul><li>Membranous </li></ul><ul><li>Anaphlactoid purpura </li></ul><ul><li>IgA nephropathy </li></ul><ul><li>Idiopathic (benign familial) </li></ul><ul><li>Alport syndrome </li></ul>
  16. 16. EVALUATION OF A CHILD WITH HAEMATURIA <ul><li>History </li></ul><ul><li>Examination </li></ul><ul><li>Investigation: </li></ul><ul><ul><li>Studies performed in all patients : </li></ul></ul><ul><ul><ul><li>urine microscopy and culture </li></ul></ul></ul><ul><ul><ul><li>CBC </li></ul></ul></ul><ul><ul><ul><li>serum creatinine </li></ul></ul></ul><ul><ul><ul><li>serum C3 level </li></ul></ul></ul><ul><ul><ul><li>US kidneys </li></ul></ul></ul><ul><ul><ul><li>urine protein = urine albumin/creatinine ratio </li></ul></ul></ul><ul><ul><ul><li>calcium = urine calcium/creatinine ratio </li></ul></ul></ul>
  17. 17. <ul><ul><li>Studies performed in selected patients: </li></ul></ul><ul><ul><ul><li>Dnase B titer or streptozyme < 6 months duration </li></ul></ul></ul><ul><ul><ul><li>Skin or throat culture </li></ul></ul></ul><ul><ul><ul><li>ANA titer </li></ul></ul></ul><ul><ul><ul><li>Urine analysis looking for cast </li></ul></ul></ul><ul><ul><ul><li>Coagulation study/ platelet count </li></ul></ul></ul><ul><ul><ul><li>Sickle cell screen in black patients </li></ul></ul></ul><ul><ul><ul><li>Audiogram </li></ul></ul></ul><ul><ul><li>Renal biopsy </li></ul></ul><ul><ul><ul><li>Microscopic haematuria plus any of the following: </li></ul></ul></ul><ul><ul><ul><ul><li>Diminished renal function </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Proteinuria </li></ul></ul></ul></ul><ul><ul><ul><li>Persistant microscopic haematuria (>1 year) </li></ul></ul></ul><ul><ul><ul><li>Second episode of gross haematuria </li></ul></ul></ul><ul><ul><li>Cystoscopy </li></ul></ul><ul><ul><ul><li>Pink o microscopic haematuria, dysuria and sterile urine culture </li></ul></ul></ul>
  18. 18. Case History: <ul><li>5 years old boy </li></ul><ul><li>Generalized malaise, abdominal pain, joints pain, peri orbital oedoma </li></ul>
  19. 21. Henoch-Schönlein Purpura or (Anaphylactoid Purpura) <ul><li>Renal involvement occurs in 25–50% of children during the acute phase </li></ul><ul><li>Haematuria with or without casts or proteinuria during the first few weeks of illness </li></ul><ul><li>The nephrotic syndrome, moderate azotemia, hypertension, oliguria, and hypertensive encephalopathy may occasionally occur. </li></ul><ul><li>Most children with renal involvement recover </li></ul>
  20. 22. Recurrent Gross Haematuria or Persistent Microscopic Haematuria <ul><li>IgA nephropathy (Berger) </li></ul><ul><li>Alport syndrome </li></ul><ul><li>Familial idiopathic haematuria </li></ul><ul><li>Idiopathic hypercalciuria. </li></ul>
  21. 23. IgA Nephropathy (Berger) <ul><li>Glomerulonephritis with IgA as the predominant immunoglobulin in mesangial deposits, in the absence of any systemic disease </li></ul><ul><li>Haematuria + minimal proteinuria </li></ul><ul><li>Normal C3 + usually normal RF </li></ul><ul><li>Diagnosis: renal biopsy </li></ul>
  22. 24. IgA Nephropathy (Berger) <ul><li>Treatment: supportive </li></ul><ul><li>Prognosis: mainly good, only 30% has progressive disease:hypertension, diminished renal function, or proteinuria exceeding 1 g/24 hr between episodes of gross hematuria </li></ul>
  23. 25. ALPORT Syndrome . <ul><li>Hereditary nephritis. </li></ul><ul><li>Haematuria + proeinuria + sensorineural hearing loss (minority) + eye abnormalitie (10%). </li></ul><ul><li>Diagnosis: renal biopsy. </li></ul><ul><li>Males with Alport syndrome commonly develop end-stage renal failure in the 2nd or 3rd decade of life, occasionally in association with hearing loss. Females usually have a normal life span and only subclinical hearing loss. </li></ul>
  24. 26. Idiopathic Familial Benign Haematuria <ul><li>No proteinuria </li></ul><ul><li>All investigations normal </li></ul><ul><li>Urine test of the parents and siblings </li></ul><ul><li>An excellent prognosis, but long-term follow-up is required to exclude Alport syndrome </li></ul>
  25. 27. Idiopathic Hypercalciuria <ul><li>RGH, persistent microscopic hematuria, or dysuria in the absence of stone formation </li></ul><ul><li>Hypercalciuria (without hypercalcemia) </li></ul><ul><li>Diagnosis: 24-hr urinary calcium excretion exceeding 4 mg/kg, urine calcium to creatinine ratio (mg/mg) </li></ul><ul><li>Hypercalciuria may lead to nephrolithiasis </li></ul><ul><li>RX: Oral thiazide </li></ul>
  26. 28. Membranous Glomerulopathy <ul><li>Uncommon in childhood and a rare cause of haematuria. </li></ul><ul><li>The most common cause of nephrotic syndrome in adults. </li></ul><ul><li>Associated with systemic lupus erythematosus, cancer, gold or penicillamine therapy, and syphilis and hepatitis B virus infections. </li></ul>
  27. 29. MEMBRANOPROLIFERATIVE (MESANGIOCAPILLARY) GLOMERULONEPHRITIS <ul><li>Chronic glomerulonephritis that frequently leads to glomerular destruction and end-stage renal failure. </li></ul><ul><li>Most common in the second decade of life. </li></ul><ul><li>Presentation: nephrotic syndrome, gross hematuria or asymptomatic microscopic hematuria, proteinuria and hypertension . renal function may be normal to depressed. Low C3 complement level. </li></ul><ul><li>Diagnosis by renal biopsy. </li></ul>
  28. 30. RAPIDLY PROGRESSIVE (CRESCENTIC) GLOMERULONEPHRITIS <ul><li>Nephritis with rapid progression to end-stage renal failure </li></ul><ul><li>Causes : poststreptococcal, lupus, membranoproliferative, and the glomerulonephritides of Goodpasture disease, anaphylactoid purpura, and other forms of vasculitis </li></ul><ul><li>Acute renal failure, often after an acute nephritic or nephrotic episode </li></ul><ul><li>Diagnosis: Renal biopsy </li></ul><ul><li>Paediatric Nephrology Emergency </li></ul>
  29. 31. Acute Renal Failure <ul><li>Develops when renal function is diminished to the point at which body fluid homeostasis can no longer be maintained. </li></ul><ul><li>Oliguria (daily urine volume less than 400 ml/m2) is common, the urine volume may approximate normal. </li></ul><ul><li>Nonoliguric renal failure : in certain types of acute renal failure (aminoglycoside nephrotoxicity). </li></ul>
  30. 32. Etiology <ul><li>Prerenal causes </li></ul><ul><ul><li>Hypovolemia, hypotension, hypoxia </li></ul></ul><ul><li>Renal causes </li></ul><ul><ul><li>Acute tubular necrosis </li></ul></ul><ul><ul><li>Acute interstitial nephritis </li></ul></ul><ul><ul><li>Glomerulonephritis </li></ul></ul><ul><ul><li>Localized intravascular coagulation </li></ul></ul><ul><ul><li>Tumors </li></ul></ul><ul><ul><li>Developmental abnormalities </li></ul></ul><ul><ul><li>Hereditary nephritis </li></ul></ul><ul><li>Postrenal causes </li></ul><ul><ul><li>Obstructive uropathy, stone, blood clot </li></ul></ul>
  31. 33. CLINICAL MANIFESTATIONS <ul><li>Diminished urine output </li></ul><ul><li>Oedema (salt and water overload) </li></ul><ul><li>Hypertension, vomiting, and lethargy (uremic encephalopathy). </li></ul><ul><li>Complications of acute renal failure: volume overload with congestive heart failure and pulmonary edema, arrhythmias, gastrointestinal bleeding due to stress ulcers or gastritis, seizures, coma, and behavioral change </li></ul><ul><ul><li>Life threatening: GIT bleed, pericarditis and encephalopathy </li></ul></ul>
  32. 34. Diagnosis <ul><li>Careful history </li></ul><ul><li>Examination </li></ul><ul><li>Investigation: CBC, urea and electrolytes, PO4, Ca, blood gases, C3, US kidneys, urine electrolytes ( Na and creatinine), fractional excretion of Na (less than 1% in hypovalaemia) </li></ul>
  33. 35. Urine Analysis <ul><li>Prerenal. </li></ul><ul><li>Urine osmolality exceeds 500 mOsm/kg [mmol/l] H2O. </li></ul><ul><li>Sodium content is usually less than 20 mEq/l (mmol/l). </li></ul><ul><li>The fractional excretion of sodium (urine/plasma sodium concentration divided by the urine/plasma creatinine concentration X 100) is usually less than 1%. </li></ul><ul><li>Renal </li></ul><ul><li>osmolality less than 350 mOsm/kg [mmol/l] H2O </li></ul><ul><li>Usually exceeds 40 mEq/l (mmol/l) </li></ul><ul><li>Usually exceeds 1% </li></ul>
  34. 36. Treatment <ul><li>Pre-renal=Hypovolemia : volume replacement may be critical </li></ul><ul><li>Renal : </li></ul><ul><ul><li>Fluid restriction: input= output + 400 ml/m2/24 hr (insensible losses) </li></ul></ul><ul><ul><li>Hyperkalemia: no potassium-containing fluid, foods, or medications until adequate renal function is re-established </li></ul></ul><ul><ul><ul><li>> 7 mEq/L (mmol/L): Nebulised salbutamul, IV Calcium gluconate, sodium bicarbonate, ca resonium, glucose and insulin </li></ul></ul></ul><ul><ul><li>Moderate acidosis is common in renal failure: Na bicarbonate </li></ul></ul>
  35. 37. Treatment <ul><li>Hypocalcemia and hyperphosphataemia: Ca binders (Ca carbonate). </li></ul><ul><li>Hypertension: </li></ul><ul><ul><li>The primary disease process (nifedipine, diazoxide, sodium nitroprusside or labetalol as a continuous intravenous infusion is indicated for hypertensive crises). </li></ul></ul><ul><ul><li>Expansion of the extracellular fluid volume (salt and water restriction is critical). </li></ul></ul><ul><li>Indications for dialysis: fluid overload, and congestive heart failure, electrolyte abnormalities (especially hyperkalemia), central nervous system disturbances, hypertension. </li></ul>
  36. 38. Prognosis <ul><li>In general, recovery of function is likely following renal failure resulting from prerenal causes, the hemolytic-uremic syndrome, acute tubular necrosis, acute interstitial nephritis, or uric acid nephropathy. </li></ul><ul><li>On the other hand, recovery of renal function is unusual when renal failure results from most types of rapidly progressive glomerulonephritis, bilateral renal vein thrombosis, or bilateral cortical necrosis. </li></ul>
  37. 39. Chronic Renal Failure <ul><li>In children under 5 yr of age is commonly the result of anatomic abnormalities (hypoplasia, dysplasia, obstruction, malformations) </li></ul><ul><li>After 5 yr of age acquired glomerular diseases (glomerulonephritis, hemolytic-uremic syndrome) or hereditary disorders (Alport syndrome, cystic disease) predominate </li></ul><ul><li>UT malformation + Glomerulonephritis + Pyelonephritis…..  > 50% of causes </li></ul>
  38. 40. Clinical Manifestations <ul><li>Nonspecific symptoms (headache, fatigue, lethargy, anorexia, vomiting, polydipsia, polyuria, growth failure). </li></ul><ul><li>Physical examination: pallor and weakness, hypertension, growth retardation and signs of renal osteodystrophy. </li></ul>
  39. 41. Investigations <ul><ul><li>CBC: anaemia. </li></ul></ul><ul><ul><li>Electrolytes: hyponatremia, hyperkalemia, acidosis. </li></ul></ul><ul><ul><li>BUN and creatinine (nitrogen accumulation and level of renal function). </li></ul></ul><ul><ul><li>hypocalcemia, hyperphosphatemia, osteodystrophy. </li></ul></ul><ul><ul><li>High of intact parathyroid hormone levels. </li></ul></ul>
  40. 42. MANAGAMENT depends upon the degree of renal insufficiency (CRD) STAGE of CKD GFR ML/MINUTE/1.73M 2 FEATURES 1 : chronic changes with normal GFR 90-120 None 2 :Impaired RF (mild) 60-89 None 3 : Moderate 30-59 None, short stature,  PTH 4 : Severe (pre-terminal) 15-29 Acidosis, anaemia,  BP, lethargy, etc 5 :ESRF < 15% Dialysis or RX
  41. 43. Management <ul><li>Diet in chronic renal failure. </li></ul><ul><li>Water and electrolyte management in chronic renal failure (fluid, K, Na). </li></ul><ul><li>Acidosis in chronic renal failure. </li></ul><ul><li>Renal Osteodystrophy. </li></ul><ul><li>Anemia in chronic renal failure. </li></ul><ul><li>Hypertension in chronic renal failure. </li></ul><ul><li>Drug dosage in chronic renal failure. </li></ul>
  42. 44. End-stage Renal Failure <ul><li>Dialysis is generally initiated when the patient's GFR < 15 ml/1.73m2/minute </li></ul><ul><ul><li>Continuous ambulatory peritoneal dialysis (CAPD) </li></ul></ul><ul><ul><li>Continuous cyclic peritoneal dialysis (CCPD) </li></ul></ul><ul><ul><li>Haemodialysis </li></ul></ul><ul><ul><li>Haemofiltration </li></ul></ul><ul><li>Renal transplantation </li></ul>
  43. 45. PD <ul><li>Peritoneal cavity- has a semipermeable membrane that surrounds intestine and other organs in abdominal cavity. </li></ul>
  44. 46. PD <ul><li>CAPD : dialysate flows in, dwells, then drain; this process is repeated 4-5 times </li></ul><ul><li>While it dwells, osmosis and diffusion occurs </li></ul><ul><li>No machine used </li></ul><ul><li>Fill volume: up to 50mls/kg = 1100ml/m 2 </li></ul>
  45. 47. Peritoneal Dialysis=CAPD
  46. 48. APD=CCPD
  47. 49. Haemodialysis
  48. 50. Haemodialysis
  49. 51. Haemodialysis
  50. 52. Haemodialysis
  51. 53. اللهم فك اسر اقصانا السليب وطهر قبلتنا الأولي ومسري نبيينا الحبيب اللهم نصرك القريب ... اللهم نصرك القريب

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