HEMATURIA Dr. Shreedhar Paudel April, 2009. HEMATURIA Microscopic hematuria – more than three...
-
Upload
buck-morris -
Category
Documents
-
view
229 -
download
2
Transcript of HEMATURIA Dr. Shreedhar Paudel April, 2009. HEMATURIA Microscopic hematuria – more than three...
HEMATURIA
Dr. Shreedhar PaudelApril, 2009
HEMATURIA• Microscopic hematuria – more than three erythrocytes per high-power field
• HEME-POSITIVE --Hemoglobin --Myoglobin
HEMATURIA……..• Artificial food coloring – Beets – Berries – Chloroquine – Furazolidone – Hydroxychloroquine – Nitrofurantoin – Phenazopyridine – Phenolphthalein – Rifampin
HEMATURIA….
• CAUSES OF HEMATURIA:-– A. RENAL• GLOMERULAR• RENOVASCULAR
– B. HEMATOLOGICAL– C. URETERIC– D. PKCD, UTI, TUMOR
HEMATURIA…..• CAUSES OF HEMATURIA:-– Severe dehydration--- Renal vein thrombosis – Myocardial infarction-- Renal artery embolus or
thrombus – Atrial fibrillation--- Renal artery embolus or
thrombus – Hypertension Glomerulosclerosis-- with or
without proteinuria
HEMATURIA……..• EVALUATION OF PATIENT WITH HEMATURIA:-– H/O passage of clots → extraglomerular cause of
hematuria
– H/O recent trauma to the abdomen → hydronephrosis
– H/O early-morning periorbital puffiness, weight gain, oliguria, the presence of dark-colored urine, and the presence of edema or hypertension suggests a glomerular cause.
HEMATURIA……..• EVALUATION OF PATIENT WITH HEMATURIA….– Painless hematuria due to glomerular causes
– H/O recent throat or skin infection → post infectious glomerulonephritis
– H/O joint pains, skin rashes, and prolonged fever in adolescents → collagen vascular disorder
HEMATURIA……..
• EVALUATION OF PATIENT WITH HEMATURIA….– The presence of anemia cannot be accounted for
by hematuria alone → in a patient with hematuria and pallor, other conditions such as systemic lupus erythematosus and bleeding diathesis should be considered
– H/O fever, abdominal pain, dysuria, frequency, and recent enuresis in older children → UTI as the cause of hematuria
HEMATURIA……..
• EVALUATION OF PATIENT WITH HEMATURIA….
– Skin rashes and arthritis → HSP and SLE
– Information regarding exercise, menstruation, recent bladder catheterization, intake of certain drugs or toxic substances, or passage of a calculus may also assist in the differential diagnoses.
HEMATURIA……..
• EVALUATION OF PATIENT WITH HEMATURIA….– familial, Alport syndrome, collagen vascular
diseases, urolithiasis, or PCKD
– PHYSICAL EXAMINATION
– INVESTIGATION
HEMATURIA……..Indications of kidney biopsy in patients with
hematuria:-• Significant proteinuria • Abnormal renal function • Recurrent persistent hematuria. • Serologic abnormalities (abnormal
complement, ANA, or dsDNA levels). • Recurrent gross hematuria. • A family history of end-stage renal disease
ACUTE GLOMERULNEPHRITIS (AGN)• CONDITIONS PRESENTING AS AGN– POST INFECTIOUS—streptococci, hepatitis B and C,
bacterial endocarditis
– SYSTEMIC VASCULITIS – HSP, SLE, Polyarteritis nodosa
– MEMBRANOPROLIFERATIVE GN
– IGA NEPHROPATHY
– ALPORT SYNDROME
Acute Poststreptococcal Glomerulonephritis
• Sudden onset of – Gross hematuria
– Edema–Hypertension– renal insufficiency
• most common glomerular causes of gross hematuria in children
Acute Poststreptococcal Glomerulonephritis………
• Etiology:-– throat or skin infection by certain “nephritogenic”
strains of group A β-hemolytic streptococci.↓
streptococcal pharyngitis (serotype 12)
streptococcal skin infections or pyoderma (serotype 49)
Acute Poststreptococcal Glomerulonephritis………
• Pathology:-– kidneys → symmetrically enlarged– light microscopy → enlarged glomeruli– Immunofluorescence → granular deposits
of IgG–electron microscopy• Lumpy deposits on the subepithelial side
of the capillary basement membrane
Acute Poststreptococcal Glomerulonephritis………
• Clinical Manifestations:-– 5–12 yr and uncommon before the age of 3 yr. – acute nephritic syndrome 1–2 wk after an
antecedent streptococcal pharyngitis or 3–6 wk after a streptococcal pyoderma.
– asymptomatic microscopic hematuria with normal renal function to acute renal failure
Acute Poststreptococcal Glomerulonephritis………
• Clinical Manifestations:- – Edema (puffiness around eyes and pedal edema)– Hypertension– Oliguria (cola colored urine)– encephalopathy and/or heart failure owing to
hypertension or hypervolemia– malaise, lethargy, abdominal or flank pain, and fever are
common
Acute Poststreptococcal Glomerulonephritis………
• Clinical Manifestations:- – The acute phase generally resolves within 6–8 wk
– urinary protein excretion and hypertension usually normalize by 4–6 wk after onset
– persistent microscopic hematuria may persist for 1–2 yr after the initial presentation
Acute Poststreptococcal Glomerulonephritis………
• Diagnosis:-– Urinalysis → • red blood cells (RBCs)• RBC casts• proteinuria(1+ to 2+)• polymorphonuclear leukocytes (indicative of
glomerular inflammation)
– mild normocytic anemia (due to hemodilution)
Acute Poststreptococcal Glomerulonephritis………
• Diagnosis:-– ↓ed serum C3 level
– ↑ed antistreptolysin O (ASO)
– ↑ ed serum urea and creatinine (reflecting degree of renal impairment)
Acute Poststreptococcal Glomerulonephritis………
Complications:- – Hypertension – Acute renal dysfunction– Hypertensive encephalopathy – Heart failure– Hyperkalemia– Hyperphosphatemia– Hypocalcemia– Acidosis– Seizures– Uremia
Acute Poststreptococcal Glomerulonephritis………
• Treatment:-
– Patient with mild oliguria and normal BP → can be managed at home
– Close monitoring of Blood pressure and dietary intake
– 10-day course of systemic antibiotic therapy with penicillin (once AGN occurred penicillin treatment has no effect on course of disease----may be given if active pharyngitis or pyoderma present)
Acute Poststreptococcal Glomerulonephritis………
• Treatment:-
– DIET
• Protein, sodium and potassium restricted till serum urea reduce to normal and urinary output increases
• Fluid intake restricted to amount equal to insensible loss + urinary loss
• Overhydration-- ↑es HTN and precipitates LVF
Acute Poststreptococcal Glomerulonephritis………
• Treatment:-
– WEIGHT• Weighed daily• Should lose about 0.5 % BW/ Day – due to endogenous
catabolism• Gain in weight requires– fluid restriction
– DIURETICS• Not indicated (since edema is rarely massive and
comes to normal with return of renal function)• Used in presence of pulmonary edema (iv frusemide)
Acute Poststreptococcal Glomerulonephritis………
• Treatment:-
– HTN• Mild—controlled by salt and water restriction• Malignant HTN – prompt treatment ( iv nitroprusside)
– LVF• Control HTN• iv frusemide
• Prognosis:-– Complete recovery occurs in 95% of cases
Henoch-Schönlein Purpura• Small vessel vasculitis • Mild renal involvement– microscopic
hematuria, mild proteinuria• Clinical features:-– purpuric rash ( extensor surface)– Arthritis– abdominal pain– Rarely presents with nephritic or nephrotic
syndrome, HTN, azotemia
Henoch-Schönlein Purpura…
Henoch-Schönlein Purpura…
Henoch-Schönlein Purpura….
• TREATMENT:-– Most patients recover without any specific
treatment– Long-term observation– to detect insidious renal
damage– Combination of steroids and azathioprine
recommended – But long-term outcome may not be satisfactory