HEMATURIA D I A G N O S T I C A P P R O A C H

By Ahmad solimman ,

MD Benha university

AHMAD

SOLIMAN

Hematuria is defined as presence of five RBCs or more in 10 ml fresh voided urine

Definition 1

Classification of hematuria

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What is the most common causes of childhood hematuria?A) glomerular

Posinfectious (poststreptococ-cal GN)

Heridatry (alport syndrome) IgA nephropathy Familial recurrent haematuria Vascuilits (lupus ,HSP) HUS . Infective endocarditis Shut nephropathy

B) non glomerular UTI. Anomalies of urinary tract Stones Trauma Sickle cell disease Vascular Excersie

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What Is The Most Common Nephritis In Childhood?

It is. Poststeptoccocal GN It is immune nephritis Occurs 2-5 weeks after strept infec-

tion Preceding infection may be in form

of ( pyoderma, pharyngitis, scarlet fever &mild common cold)

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What Is Typical Clinical Presentation Of APSGN? Achild between 2- 6 years Evedience of poststreptococcal infection Skin infection is most common during

summer Sore throat is most common during winter

months latent period about 2up to 6 weeks

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Typically The Patient Develops Dark urine

usually described as cocola colored Edema

Most prominent around eye at early. Mornings then spreads to the lower limb and edema is minimal

Hypertension usually mild to moderate maybe sever leading to cardiac &neurological complications

Oliguriacollection. Of 24 hours urine collection is Recommended oliguria is con-sidered when UOP is less than 1m/kg/h. however the patient may be to-tally asymptomatic except for hematuria which may be over micro-scopic

Are There Atypical Presen-tation Of APSGN ?•Congestive Heart Failure•Convulsion •Respiratory Distress

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Why You Think In Nephritis In Above Three Cases ?

Because Previously healthy child Age around 5 years Hypertension and hypertension most common causes in

childhood is renal Unexplained clinical manifestations can not intepreted as

common disorders As hall mark of nephritis may be absent due to oligurea &a-

nurea may be present . But child not complaints . And so the mother.

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What Lines Of Treatments Of APSGN? Overload

Water restriction daily water intake equal urine out put and insensible water loss (insensible water loss equal 400cc/30kg ,In case of sever oligurea less than 1ml/kg/h , iv furoseamide at dose of 1m/kg can be given twice daily.

  HypertensionDiuretics , salt & water restriction in mild hypertensionIn case of moderate hypertension use antihypertensives with diuretics combination of lasix oral or iv with neifidipene is a good choice Treatment of streptococcal infection Benzathine penicilline 600000 iu/ im or oral penicilline for 10 days Erythromycine 30 mg/kg/d or cephalexine 50 mg/kg/d for 10 days in case

of allergy to penicilline.

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What About The Prognosis Of APSGN?

The prognosis for recovery is excellent almost all children with APSGN appears to recover completely

Microscope haematuria disappears after one month Second attack is rare Prophylaxis is not recommend 5% of cases may develop CKD It is advisable to follow up the patient . From one to six

months for next two years

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What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them?

IgA nephropathy It is immune complex nephritis Occurs 3-5 days after upper URTI recurrent attacks of hematuria The attack not associated with hypertension or edema Microscopic hematuria persist in between the attacks C3 is normal , no evidence of streptococcal infection Renal biopsy is indicated

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What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them?

Alport syndrome It is X linked recessive disorder. Presentation as IgA nephropathy Associated with: nerve deafness and ocular

defects The mother may have hematuria Renal biopsy is diagnostic .

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HSP It is most common vasculitis in childhood It is combination of the following : Purpuric eruptions mainly in the lower limbs and but-

tocks Joint affection Abdominal pain GN (nephritis is common but not the first presentation ,

mild to moderate proteinurea , severe proteinurea up to nephritic syndrome nephritis , C3 is normal

What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them?

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Lupus nephritis Mainly in adolescence females Can be presented by nephritis ,

nephritic,nephritic nephritic Marked by autoantibodies including ANA, and

double strand DNA, low C3&C4 Biopsy is indicated

What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them?

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Renal vasculitis Poyarthritis nodosa and wegener disease Renal involvement may occur Presented by fever, malasie, wright loss, skin

rash &arthropathy with promient involvement of the respiratory tract in wegener dis

ANCA (antineutrophil cytoplasmic antibodies)Are diagnostic

What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them?

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What Points You Must Stress In History During Evaluation Of Child With Haematuria?

Stress on Recent respiratory or skin infections, GIT Associated symptoms to look for should

include fever, dysuria, urinary frequency and urgency, back pain, skin rashes, joint symptoms, and face and leg swelling.

Recurrency Recent trauma, exercise. Medications .

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What Points You Must Stress In History During Evaluation Of Child With Haematuria?

Passage of urinary stones. Family history should be searched

for documented hematuria, hypertension, renal stones, renal failure, deafness, and coagulopathy.

• For girls in the peripubertal pe-riod, a history of menarche is use-ful

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What Points You Must Stress During Examination Of A Child With Haematuria?

Stress on hypertension and edema suggesting acute

nephritic syndrome Associated rashes or arthritis may indicate

hematuria due to systemic lupus erythematosus or Henoch-Schِnlein nephritis.

The presence of fever or loin pain may point to pyelonephritis.

A palpable and ballotable renal mass will require radiolo investigations to exclude hydronephrosis, polycystic kidney, or renal tumor.

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URINE ANALYSIS

GLOMERULAR• RBCS Cast• Dysmorphic RBCS

• BUN , serum creatinine• C3 • Serum electrolytes • Total protein in 24 hours

urine• CBC• Abd USS• Review indications of renal

biopsy

Review the C3 algorism

Non GLOMERULAR• No RBCS Cast• No Dysmorphic RBCS

• Urine culture• Abd . USS , X RAY• Abdominal CT (Trauma)• Calcium /cr ratio

• MRA (vascular anomalies)• Adenovirus culture• Doppler (especially if elevated renal

parameters)• Bleeding profile • Review history for heavy

exercise,drugs

C3

LOW C3

Systemic manifestations

SLE (C4,serology)+ (biopsy)

Shunt nephriris (clinical)

Bacterial endocarditis (clinical & echo)

NO Systemic manifestation

sAPSGNMPGN

NORMAL C3

Systemic manifestations

• HUS(clinical)• Vasculitis

o HSP o PANo WGo GPS

NO Systemic manifestations

Ig A Nehropathy (biopsy)

Alport syndrome(biopsy)

Familial hematuria(biopsy)

IRPGN

Microscopic Hematuria

Progressive illness Age is less than 4 years or above 15 years No evidence of streptococcal infection Presistance of macroscopic haematuria more than one

month Recurrence Hypocomplementemia more than 10 weeks AKI

What Is The Indication Of Renal Biopsy In Nephritis?

HEMATURIA D I A G N O S T I C A P P R O A C H

By Ahmad solimman ,

MD Benha university

AHMAD

SOLIMAN

AHMAD

SOLIMAN