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Understanding Hematuria in Children: Causes, Symptoms, and Management

Learn about hematuria in children, its causes including inborn errors of metabolism and UTIs, symptoms like urinary tract infections and renal calculi, and management options such as urine analysis and renal biopsy.

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Understanding Hematuria in Children: Causes, Symptoms, and Management

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  1. Red urine • Hemoglobinuria • Myoglobinuria • Drugs (rifampicin),food • Inborn errors of metabolism(porphyria) • Urate crystals • Hematuria • Do dipstick,microscopy (>5cells/ul in fresh uncentrifuged urine, >3 cells/HPF in centrifuged sediment.

  2. Red if fresh(bladder), or brown color as Hb converted to acid haematin by urinary acids • Early hematuria:urethral cause • Terminal hematuria:bladder cause • Microscopy:dysmprhic RBC,RBC cast:glomerular bleeding • Prevelance of .5-1.6% in school children

  3. RBC casts

  4. RBC casts

  5. History • Fever,urinary symptoms….infection • Colicky loin pain,lower tract symptoms…..renal calculus • Rash,arthritis…HSP,SLE • Preceding URTI…..PSGN,IgA nephropathy • Coagulopathy,trauma,tumor,exercise • FH of hematuria,deafness,renal failure…Alport • O/E:HTN,kidneys,genitalia,rash

  6. Investigations • Urine protein/creat ratio • EUC,albumin • ASOT,C3,C4,ANA • FBC,clotting studies • Urine calcium/creat ratio • U/S ,XRAY,CT • Urine analysis on parents • IgA,cystoscopy • Renal biobsy

  7. Macroscopic hematuria • Most common cause is infection,then perineal irritation,trauma • Viral infections,adenovirus 11,12 may cause hemorrhagic cystitis • Exercise induced hematuria not associated with renal disease. • Recurrent gross hematuria as IgA nephropathy,Alport,nut cracker (thin,loin pain,compression of renal vein bet aorta,SMA

  8. Causes of hematuria • 1.Glomerular causes • Familial benign hematuria • GN:primary as postinfectious,MPGN,IgA nephropathy • secondary GN as SLE,HSP. • HUS,interstital nephritis,renal vein thrombosis,cystic renal disease • Alport

  9. Non glomerular causes • UTI • Hypercalcuria,renal calculi • Trauma,exercise • Coagulpathy as sickle • Vascular malformations • Nut cracker syndrome • Menarche • Malignancy as nephroblastoma of the kidney or bladder tumors

  10. Persistent MA without proteinuria : • 1.Beningn familial hematuria • 2.idiopathic hypercalcuria • 3.IgA nephropathy • 4.Alport syndrome

  11. Persistent MA without proteinuria : • 1.Beningn familial hematuria • 2.idiopathic hypercalcuria • 3.IgA nephropathy • 4.Alport syndrome

  12. Alport Syndrome • 80% XL,20% AR • Renal failure,sensorineural deafness higher frequencies,ocular changes(anterior lenticonus,retinal changes • Present as micro and rarely macroscopic hematauria with URTI • Proteinura,HTN later age

  13. Diagnosis by EM:Thinning of GBM,split and duplicated lamina densa,basket weave • Males progress to ESRD,deafness by 30y • ACEI may delay progression to ESRD • Defiency of α5 of type 4 collagen

  14. Benign Familial Hematuria(TBMN) • AD inheritance • Present as microscopic hematuria,no proteinuria or renal failure • EM:thinning of GBM • Follow up for proteinuria,HTN

  15. GBM in Alport syndrome

  16. GBM in Alport syndrome

  17. IgA nephropathy • Recurrent macroscopic hematuria,loin pain 1-2 days following URTI,last < 3 days. • Persistent microscopic hematuria ±proteinuria • Nephritic,nephrotic syndrome rare • Present second decade,more in males

  18. Familial cases reported • IgA high in 35-50% • Diagnosis:LM:focal or diffuse mesangial cell proliferation,expansion of mesangial matrix • IM:IgA,C3 deposits • Prognosis for children better than adults • Young children without macroscopic hematuria have the best long term outcome

  19. Heavy proteinuria is a risk factor for progression to ESKD. • Progression to ESRD is slow(25% need dialysis in 20y) • Children with nephrotic syndrome are treated with steriods • ACEI are used to delay progression,decrease proteinuria • Fish oil

  20. IF showing mesangial depostis

  21. Normal glomerulus

  22. IgA deposits

  23. Thin glomerular basement membrane disease

  24. PROTEINURIA • DIPSTICK values • .trace (.15g/l),+1 (.3g/l),+2 (1g/l),+3 (3g/l),+4 (20g/l) • False postive when urine concentarted,alkaline urine • Children excrete 150 mg/day of protein or 60-240 mg/m2/day • 40 % of normal urinary protein is tissue rather than plasma as tamm-horsfall (a gp secreted in TALH ) • Almost of the flitered smaller proteinare absorbed in the proximal CT.

  25. Protein-creatinine ratio to estimate protein excretion

  26. Urine protein/creat ratio correlates with measurement of protein in 24 hour collection. • Most normal subjects have a ratio below.02 mg/umole (.2g/g) in above 2y,.05 in children 6-24 m • Micoalbuminuria ranges 30-300 mg albumin/g creat • B2-microglobulin in urine indicates proximal tubular injury

  27. Classification • 1-Functional:seen in stress,fever,cold,exercise,CHF • 2-Idiopathic transient or intermittent • 3-postural:in adolesents,males,less than 2g/day,proteinuria in upright position but not when recumbent • Decrease in amount with age • Has a good outcome

  28. 4-pathologic:increase permeability of GBM,loss of anions(nephrotic,GN) • Loss of nephron mass:single kid,cystic disease from hyperfilteration • secretory,overflow:UTI,in newborns as tam

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