1. Red urine Hemoglobinuria Myoglobinuria Drugs (rifampicin),food
Inborn errors of metabolism(porphyria)
Urate crystals
Hematuria
Do dipstick,microscopy (>5cells/ul in fresh uncentrifuged urine, >3 cells/HPF in centrifuged sediment.

2. Red if fresh(bladder), or brown color as Hb converted to acid haematin by urinary acids
Early hematuria:urethral cause
Terminal hematuria:bladder cause
Microscopy:dysmprhic RBC,RBC cast:glomerular bleeding
Prevelance of % in school children

3. RBC casts

4. RBC casts

5. History Fever,urinary symptoms….infection
Colicky loin pain,lower tract symptoms…..renal calculus
Rash,arthritis…HSP,SLE
Preceding URTI…..PSGN,IgA nephropathy
Coagulopathy,trauma,tumor,exercise
FH of hematuria,deafness,renal failure…Alport
O/E:HTN,kidneys,genitalia,rash

9. Investigations Urine protein/creat ratio EUC,albumin ASOT,C3,C4,ANA
FBC,clotting studies
Urine calcium/creat ratio
U/S ,XRAY,CT
Urine analysis on parents
IgA,cystoscopy
Renal biobsy

10. Macroscopic hematuria
Most common cause is infection,then perineal irritation,trauma
Viral infections,adenovirus 11,12 may cause hemorrhagic cystitis
Exercise induced hematuria not associated with renal disease.
Recurrent gross hematuria as IgA nephropathy,Alport,nut cracker (thin,loin pain,compression of renal vein bet aorta,SMA

11. Causes of hematuria 1.Glomerular causes Familial benign hematuria
GN:primary as postinfectious,MPGN,IgA nephropathy
secondary GN as SLE,HSP.
HUS,interstital nephritis,renal vein thrombosis,cystic renal disease
Alport

12. Non glomerular causes UTI Hypercalcuria,renal calculi Trauma,exercise
Coagulpathy as sickle
Vascular malformations
Nut cracker syndrome
Menarche
Malignancy as nephroblastoma of the kidney or bladder tumors

13. Persistent MA without proteinuria :
1.Beningn familial hematuria
2.idiopathic hypercalcuria
3.IgA nephropathy
4.Alport syndrome

14. Figure 10-1 Algorithm for investigating hematuria.

16. Persistent MA without proteinuria :
1.Beningn familial hematuria
2.idiopathic hypercalcuria
3.IgA nephropathy
4.Alport syndrome

17. Alport Syndrome 80% XL,20% AR
Renal failure,sensorineural deafness higher frequencies,ocular changes(anterior lenticonus,retinal changes
Present as micro and rarely macroscopic hematauria with URTI
Proteinura,HTN later age

18. Diagnosis by EM:Thinning of GBM,split and duplicated lamina densa,basket weave
Males progress to ESRD,deafness by 30y
ACEI may delay progression to ESRD
Defiency of α5 of type 4 collagen

19. Benign Familial Hematuria(TBMN)
AD inheritance
Present as microscopic hematuria,no proteinuria or renal failure
EM:thinning of GBM
Follow up for proteinuria,HTN

20. GBM in Alport syndrome

22. GBM in Alport syndrome

23. IgA nephropathy
Recurrent macroscopic hematuria,loin pain 1-2 days following URTI,last < 3 days.
Persistent microscopic hematuria ±proteinuria
Nephritic,nephrotic syndrome rare
Present second decade,more in males

24. Familial cases reported
IgA high in 35-50%
Diagnosis:LM:focal or diffuse mesangial cell proliferation,expansion of mesangial matrix
IM:IgA,C3 deposits
Prognosis for children better than adults
Young children without macroscopic hematuria have the best long term outcome

25. Heavy proteinuria is a risk factor for progression to ESKD.
Progression to ESRD is slow(25% need dialysis in 20y)
Children with nephrotic syndrome are treated with steriods
ACEI are used to delay progression,decrease proteinuria
Fish oil

26. IF showing mesangial depostis

27. Normal glomerulus

28. IgA deposits

29. Thin glomerular basement membrane disease

31. PROTEINURIA DIPSTICK values
.trace (.15g/l),+1 (.3g/l),+2 (1g/l),+3 (3g/l),+4 (20g/l)
False postive when urine concentarted,alkaline urine
Children excrete 150 mg/day of protein or mg/m2/day
40 % of normal urinary protein is tissue rather than plasma as tamm-horsfall (a gp secreted in TALH )
Almost of the flitered smaller proteinare absorbed in the proximal CT.

32. Protein-creatinine ratio to estimate protein excretion

33. Urine protein/creat ratio correlates with measurement of protein in 24 hour collection.
Most normal subjects have a ratio below.02 mg/umole (.2g/g) in above 2y,.05 in children 6-24 m
Micoalbuminuria ranges mg albumin/g creat
B2-microglobulin in urine indicates proximal tubular injury

34. Classification
1-Functional:seen in stress,fever,cold,exercise,CHF
2-Idiopathic transient or intermittent
3-postural:in adolesents,males,less than 2g/day,proteinuria in upright position but not when recumbent
Decrease in amount with age
Has a good outcome

35. 4-pathologic:increase permeability of GBM,loss of anions(nephrotic,GN)
Loss of nephron mass:single kid,cystic disease from hyperfilteration
secretory,overflow:UTI,in newborns as tam