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Clinical Approach to a Child with Hematuria

Clinical Approach to a Child with Hematuria. Careful history, physical examination, urinary dipstick & urinalysis. To determine the level of hematuria Upper vs. lower urinary tract To determine the urgency of evaluation. Urinary dipstick. False positive Presence of menstrual blood

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Clinical Approach to a Child with Hematuria

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  1. Clinical Approach to a Child with Hematuria Careful history, physical examination, urinary dipstick & urinalysis

  2. To determine the level of hematuria • Upper vs. lower urinary tract • To determine the urgency of evaluation

  3. Urinary dipstick • False positive • Presence of menstrual blood • Alkaline urine (pH>9) • Contamination with agents used to clean the perineum prior to collection of specimen • False negative • Presence of formalin as urine preservative • High urinary concentrations of ascorbic acid

  4. Upper Urinary Tract Hematuria • Originate from the glomerulus, convuluted or collecting tubules and interstitium • Associated with brown, cola-colored or burgundy urine, proteinuria > 100 mg/dL, RBC casts and dysmorphic RBCs (within glomerulus) • Presence of leukocyte or renal tubular epithelial cell casts (within convoluted or collecting tubules)

  5. Lower Urinary Tract Hematuria • Originate from pelvocalyceal system, ureter, bladder and urethra • Associated with gross hematuria, terminal hematuria, blood clots, normal urinary RBC morphology and minimal proteinuria (<100 mg/dL)

  6. Common conditions associated with HEMATURIA in children • Glomerular and extraglomerular diseases • IgA nephropathy • Urinary tract infection • Poststreptococcalglomerulonephritis • Multisystemic disease • SLE nephritis • Hemolytic-uremic syndrome

  7. IgA Nephropathy • Most common chronic glomerular disease worldwide • Predominance of IgA with mesangial deposits of the glomerulus in the absence of systemic diseases • Light microscopy: focal & segmental mesangial proliferation and increased mesangial matrix • Electron microscopy: electron dense mesangial deposits

  8. Clinical & laboratory presentation • Associated with upper respiratory or gastrointestinal infection • Gross hematuria • Proteinuria • Mild to moderate hypertension • Normal C3 levels

  9. SLE Nephritis • Kidney disease is one of the most common and sometime only manifestation of SLE • Fever, rash, hematologic abnormalities, arthritis & involvement of heart, CNS & kidneys • Manifestations are mediated by immune complexes

  10. Clinical presentation • Common in adolescent females • Class II: hematuria, normal renal function, proteinuria • Class III & IV: hematuria,proteinuria, reduced renal function, nephrotic syndrome, ARF • Class V: nephrotic syndrome

  11. Detection of circulating antinuclear antibodies • Demonstration of antibodies that react with native dsDNA • Depressed C3 & C4 levels

  12. Hemolytic-Uremic Syndrome • Most common cause of acute renal failure in young children (younger than 4 years of age). • Triad: microangiopathic hemolytic anemia, thrombocytopenia, uremia • Etiology: Shiga-like toxin-producing E. coli (80% in developed countries)initiating endothelial cell injury • Transmitted by undercooked meat or unpasteurized milk

  13. Clinical Manifestations • Onset usually preceded by gastroenteritis (fever, vomiting, abdominal pain and diarrhea) • May present after an URTI • Sudden onset of pallor, irritability, weakness, lethargy and oliguria (5-10 days after initial GI or respiratory illness) • PE: dehydration, edema, petechiae, hepatospenomegaly, marked irritability

  14. Laboratory Criteria • Anemia (acute) - with microangiopathic changes (i.e. schistocytes, burr cells, or helmet cells) on Peripheral blood smear • Renal injury (acute) - evidenced by hematuria, proteinuria or elevated creatinine level (>/=1.0 mg/dl in child younger than 13y or >/=1.5 mg/dl in 13y or older or >/=50% increase from the baseline) • Platelet <150,000/mm3 w/in 7 days after onset of GI illness

  15. Urinary Tract Infection • Caused mainly by colonic bacteria. • Females: 75-90% caused by E. coli; Males < 1y/o: Proteus • Considered an important risk factor for development of renal insufficiency or ESRD in children • 3 Forms: Pyelonephritis, Cystitis, Asymptomatic Bacteriuria

  16. Clinical Manifestations • Pyelonephritis: abdominal or flank pain, fever, malaise, nausea, vomiting, occassionally diarrhea; involvement of renal parenchyma (acute pyelonephritis) • Cystitis: bladder involvment; dysuria, urgency, frequency, suprapubic pain, incontinence and malodorous urine (does not result in renal injury) • Asymptomatic bacteriuria: positive urine culture w/o any signs of infection; common in girls, benign, does not cause renal injury

  17. Laboratory diagnosis of UTI • Proper urine sample (urinalysis) • Culture showing >100,000 colonies of a single pathogen or 10,000 colonies and with symptoms

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