approach to haematuria
TRANSCRIPT
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Approach to HaematuriaDR.RAVI KUMAR1ST YEAR PGDEPT OF PEDIATRICS MGMCRI
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Case Scenario - 1 A 8 year old boy b/w c/o passing cola coloured urine with facial puffiness for 2days O/E
Alert, Active,AfebrileGeneralized facial puffiness +No pallorBP-140/90mmHg
S/E PA- Soft, mild distension+ BS+
Urine Routine>5 RBC/HPFRed cell casts +Dysmorphic RBCProtein 1+
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Case Scenario - 2 A 2 year old girl child b/w c/o crying during micturition, increased frequency,
high grade fever a/w chills & rigors and passing red coloured urine for past 4 days.
O/EAlert, Active,Febrile 102*F
S/E PA- Soft, Suprapubic tenderness+
Urine Routine>5 RBC/HPFPus cells - PlentyNo RBC CastsNil Protein
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Case Scenario - 3 A 12 year old child b/w c/o abdominal pain radiating to back & groin
a/w nausea, vomiting since yesterday night. h/o passing 2 episodes of red coloured urine for past 2days.
O/EAlert, Active,Afebrile
S/E PA- Soft, Tenderness+ over right lumbar region
Urine Routine>5 RBC/HPFNo RBC CastsCrystals +Nil Protein
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Contents
Introduction Etiology History Examination Investigation Management
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Introduction
Hematuria means blood in urine. Which can be either macroscopic or microscopic.
Gross or Macroscopic hematuria can be seen by naked eyes while Microscopic hematuria
are detected only in urine microscopy.
Microscopic hematuria is defined as the presence of >5 RBC per HPF in a centrifuged
sample.
Persistent hematuria is defined as presence of microscopic hematuria in >2 samples
over next 2-3 wks.
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Glomerular Hematuria
ISOLATED RENAL DISEASE PSGN IgA Nephropathy Alport syndrome MPGN Membranous Nephropathy Thin glomerular basement
membrane Nephropathy RPGN FSGS
MULTISYSTEM DISEASE Systemic lupus erythematosus
nephritis Henoch-Schönlein purpura nephritis Granulomatosis with polyangiitis
(formerly Wegener granulomatosis) Polyarteritis nodosa Goodpasture syndrome Hemolytic-uremic syndrome Sickle cell glomerulopathy HIV nephropathy
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Non-Glomerular Hematuria Hypercalciuria Hyperuricosuria Hyperoxaluria Renal stone disease Cystitis (viral hemmorrhagic, drug induced) Genitourinary anomalies with infection Tumors PCKD Trauma Foreign body Sickle cell hemoglobinopathy UTI
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Causes of Hematuria in Newborns
Renal vein thrombosis (Asphyxia, dehydration, shock) Renal artery thrombosis Autosomal recessive polycystic kidney disease Obstructive uropathy Urinary tract infection Bleeding and clotting disorders Trauma, bladder catheterization Cortical necrosis (Hypoxic/ischemic perinatal insult) Nephrocalcinosis (Frusemide in premature)
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History Age : 5 to 12 years – PSGN
Sex :
F>M – SLE Nephritis
M>F – X linked form of Alport syndrome
Discoloration of UrineDark yellow – Normal concentrated urineDark brown or black – Bile pigments, Homogentistic acid, melanin, tyrosinosis, methemoglobinemiaCola coloured – Glomerular hematuriaRed or Pink urine – Extraglomerular hematuria, haemoglobin, myoglobin, porphyrins, chloroquine, beets, blackberries, rifampicin, red dyes in food, urates.
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History Characteristics of Urine : Amount of urine : Reduced in AGN, ARF Clots in urine : Extraglomerular Increased freqency , dysuria, recent enuresis : UTI Frothy urine : proteinuria seen in glomerular disease Timing :
Hematuria in initial stream – UrethraHematuria in terminal stream – Bladder
Associated symptoms : Fever : Infections, SLE, AGN Generalised facial puffiness, Pedal edema : AGN
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History Hypertension : AGN, ARF Abdominal Pain : Urolithiasis, UTI, Nutcracker syndrome Painless : Glomerular Abdominal mass : Hydronephrosis, PKD, Wilm’s tumor Joint pain : HSP, SLE Rashes : HSP, SLE, PAN Jaundice : Obstructive Jaundice Recent URI, Skin infection : PSGN Trauma, Child abuse Drug ingestion : Rifampicin, Chloroquine, Metronidazole Vision or Hearing defects : Alport syndrome Family h/o : hereditary glomerular diseases(TGBMD), Sicklecell disease
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Examination Vitals:
Elevated BP : AGN, PKDHigh Temperature : UTI
Edema : AGN Pallor : Bleeding disorders, HUS, SLE JVP : Raised in CHF Per abdomen : Mass
Kidney: Hydronephrosis, wilms tumorBladder palpable : Distal obstruction
Skin lesions : Purpura(HSP), Butterfly rash(SLE), Bruises(Trauma,Abuse) Joint swelling, tenderness : HSP, SLE
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Investigations Urine Dipstick test : Based on oxidation of ortho-toluidine by organic peroxide
in presence of Hb that serves as a catalyst. The product of reaction has a blue colour, intensity is matched with colour chart
It can detect trace Amounts of Hb and myoglobin with 100% Sensitivity & 99% Specificity in detecting 1-5 RBC per HPF.
False + : Urine sample is concentrated or contaminated with povidone iodine
False - : High Ascorbic acid, pH- alkaline
Urine Albumin Urine M/E : Presence of >5 RBC per HPF in a centrifuged sample
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Investigations Urine C/S RFT CBC :
Reduced Hb : Bleeding, HUS, SLE, CRFAbnormal TC/DC : Infections, HUS
Platelet counts & Coagulation studies : Bleeding disorders, Sickle cell PS : Microangiopathic haemolytic anemia ESR, CRP : Infections 24 hrs Urinary protein, Spot PCR, Sr.Albumin, Sr.Cholesterol &
associated Proteinuria (Nephrotic) Urine Calcium : 24 hrs urinary ca >4mg/kg/dl or spot urine calcium
creatinine ratio >0.21(Hypercalciuria)
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Investigations Imaging Studies
Renal & Bladder sonogram : Ureter Anomalies, Urolithiasis X-Ray KUB : Calculi Doppler study of Renal vessels & IVC : Renal vein thrombosis Spiral CT Scan : Wilms tumor & PCKD
Renal Biopsy : Relative Indications : Significant Proteinuria 3+ or more Recurrent persistent Hematuria Abnormal Renal function, Persistent HTN No evidence of streptococcal infection Abnormal ANA or dsDNA levels Family H/O ESRD
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AlgorithmHistory & P/E
Urine Analysis
Hb/RBC absent RBC +/- Hb Hb only no RBC
Look for other causes of Red
UrineCheck RBC Morphology
Myoglobinuria or Hemoglobinuria
Glomerular Nonglomerular
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Cola/brown urine ?Proteinuria >30mg/dl ?
RBC casts ?Acute nephrotic syndrome ?
YES NOGlomerular Hematuria
• CBC• Sr.E, Ca• BUN, Creat• Sr.protein/albumin• Cholesterol• C3/C4• ASO/Anti-DNase B• ANA• Antineutrophil antibody• Throat/ skin culture• 24 hrs urine tot protein
creatinine clearance
Extraglomerular Hematuria
Step1 : urine c/sStep2 : urine ca/creat, Renal/bladder USGStep3 :
• Urine analysis : siblings, parents• Sr.E , Ca, Creat• If cystalluria, urolithiasis or
nephrocalcinosis : 24 hrs urine for Ca, Creat, Uric acid, Oxalate
• If hydronephrosis/pyelocaliectasis : Cystogram, renal scan
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Management Managed according to cause : Reassurance & Follow-up Use of Antibiotics : cystitis, pyelonephritis, AGN Supportive treatment : Diuretics, fluid & restriction, Anti-
hypertensives Monitoring – BP, I/O, Weight, Urine Routine To correct hyperkalaemia, ARF, CHF, Acidosis, Fluid overload, HTN
and its complications Use of Hydrochlorothiazide, Potassium citrate, Sodium restriction in
Idiopathic hypercalciuria Calculi : Plenty of water ESRD : Dialysis, Renal transplantation Renal vein thrombosis : Anti coagulant therapy or thrombectomy Surgical correction : PUJ obstruction, Wilms tumor.
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Thankyou