haematuria

haematuria

urine red in colour or tests +ve for Hb on urine sticks
1. examine under microscope to confirm haematuria
  1. (>10 RBC per high power field)
glomerular haematuria
1. suggested by
  1. presence of brown urine
  2. presence of deformed RBCs
    1. pass through basement mb
  3. casts
2. often accomp by proteinuria
causes
1. non-glomerular
  1. infection
    1. bacterial
      1. UTI
        commonest cause
      2. TB
    2. viral
    3. schistosomiasis
  2. trauma to genitalia, urinary tract or kidneys
  3. stones
  4. tumours
  5. sickle cell disease
  6. bleeding disorders
  7. renal vein thrombosis
  8. hypercalciuria
2. glomerular
  1. acute glomerulonephritis (usually w/ proteinuria)
  2. chronic glomerulonephritis (usually w/ proteinuria)
  3. IgA nephropathy
  4. familial nephritis e.g. Alport syn
  5. thin basement mb disease
hx & examn may suggest diag
lower urinary tract haematuria
1. usually red
2. occurs @ beginning & end of stream
3. not accomp by proteinuria
4. unusual in kids
Ix
1. all patients
  1. urine microscopy (w/ phase contrast) & culture
  2. protein & Ca excretion
  3. kidney & UT US
  4. plasma urea, electrolytes, Cr, Ca2+, PO4 2-, albumin
  5. FBC, platelets, clotting screen, sickle cell screen
  6. if suggestive of glomerular haematuria
    1. ESR, complement levels & anti-DNA antibodies
    2. throat swab & antistreptolysin O/ anti-DNAse B titres
    3. hepatitis B & C screen
    4. renal biopsy if indicated
      1. indicated if
        sig persistent proteinuria
        recurrent macroscopic haematuria
        abnormal renal function
        complement levels persistently abnormal
    5. test mum's urine for blood
      1. if ?Alport syn
    6. hearing test
      1. if ?Alport syn
acute nephritis
1. post-infectious (incl strep)
  1. usually follows strep sore throat or skin infection
  2. diag by evidence of recent strep infection + low C3 levels that return to normal after 3-4 weeks
    1. evidence of strep infection
      1. culture of org
      2. raised ASO/anti-DNAse B titres
  3. common in developing countries
  4. good long term prognosis
2. vasculitis
  1. Henoch Schonlein purpura
    1. combo of ff features
      1. characteristic skin rash
      2. arthralgia
      3. periarticular oedema
      4. abdo pain
      5. glomerulonephritis
    2. occurs 3-10 years old
    3. 2x common in boys
    4. peaks in winter months
    5. often preceded by upper resp infection
    6. cause unknown
      1. thought that genetic predisposition & antigen exposure increase circulating IgA levels & disrupt IgG prod
        IgA & IgG interact to make complexes that activate complement
        complexes deposited in affected organs
        ppting inflamm response w/ vasculitis
    7. clinical findings
      1. presentation
        fever
        rash
        symmetrical
        site
        buttocks
        extensor surfaces of arms & legs
        ankles
        trunk spared unless lesions induced by trauma
        initially urticarial quickly becoming maculopapular & purpuric
        characteristically palpable
        can recur over several weeks
        1st clinical sign
        & cornerstone of diag (clinical)
        joint pain
        in 2/3rds of pts
        esp of knees & ankles
        periarticular oedema
        no long term damage to joints
        sx resolve before rash goes
        colicky ado pain
        common
        if severe treat w/ corticosteroids
        GI petechiae->
        haematemesis
        melaena
        intussuception possible
        rare complications
        ileus
        protein-losing enteropathy
        orchitis
        CNS involvement
        renal involvement
        common
        but rarely 1st sx
        80% have micro/macroscopic haematuria or mild proteinuria
        usually completely recover
        if proteinuria more severe-> nephrotic syn
        risk factors for progressive renal disease
        heavy proteinuria
        oedema
        hypertension
        deteriorating renal function
        if present, renal biopsy to determine if rx necessary
        follow up for 1 yr
        to detect those w/ persisting urinary abnormalities (5=10%)
        vital because HTN & declining renal func may develop after period of several years
    8. commonest vasculitis to involve kidneys
  2. rarely
    1. Wegener granulomatosis
      1. fever
      2. malaise
      3. weight loss
      4. skin rash
      5. arthropathy
      6. prominent involvement of resp tract
    2. microscopic polyarteritis
    3. polyarteritis nodosa
      1. renal arteriography
        presence of aneurysms
    4. antineutrophil cytoplasm antibodies (ANCA) present & diagnostic of these
    5. renal involvement severe & rapidly progressive
    6. Mx
      1. steroids
      2. plasma exchange
      3. iv cyclophosphamide
  3. SLE
    1. presentation mainly in teenage girls & young women
    2. commoner in Asians & Afro-Caribbeans than Caucasians
    3. characterised by presence of multiple antibodies
      1. antibodies to dsDNA
    4. low C3 & C4, esp during active phases
    5. haematuria & proteinuria present
      1. renal biopsy
        immunosuppression always needed & intensity depends on severity of renal involvement
3. IgA nephropathy
  1. presentation
    1. episodes of macroscopic haematuria
      1. often in assoc w/ upper resp tract infections
  2. histological findings & Mx like HSP
    1. HSP probably a variant of same pathological process but not restricted to kidney
  3. prognosis in kids better than adults
4. mesangiocapillary glomerulonephritis
5. anti-glomerular basement mb disease (Goodpasture syn)
  1. very rare
6. increased glomerular cellularity restricts glomerular blood flow, so filtration reduced. ->
  1. decreased urine output & vol overload
  2. oedema, characteristically periorbital
  3. HTN, which may cause seizures
  4. haematuria & proteinuria
7. Mx
  1. attention to water & electrolyte balance
    1. diuretics if needed
  2. renal biopsy fb immunosuppression & plasma exchange
    1. to prevent irreversible renal failure
8. may be rapid deterioration in renal func (rapidly progressive glomerulonephritis)
  1. can occur w/ any cause but uncommon if post-streptococcal cause
9. if untreated-> irreversible renal failure over weeks & months
10. familial nephritis
  1. Alport syndrome
    1. commonest type of FN
    2. X-linked recessive
    3. progressive to end stage renal failure by early adult life in males
    4. assoc w/ nerve deafness & ocular defects
    5. mum may have haematuria

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	Created by v.djabatey over 10 years ago