1. HEMATURIA DIAGNOSTIC APPROACH By Ahmad solimman, MD Benha university AHMAD SOLIMAN

2. Hematuria is defined as presen ce of five RBCs or more in 10 ml fresh voided urine Definition 1

3. Classification of hematuria 2

4. What is the most common causes of childhood hematuria? What is the most common causes of childhood hematuria? A) glomerular  Posinfectious (poststreptococcal GN)  Heridatry (alport syndrome)  IgA nephropathy  Familial recurrent haematuria  Vascuilits (lupus,HSP)  HUS.  Infective endocarditis  Shut nephropathy A) glomerular  Posinfectious (poststreptococcal 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 B) non glomerular  UTI.  Anomalies of urinary tract  Stones  Trauma  Sickle cell disease  Vascular  Excersie 3

5. What Is The Most Common Nephritis In Childhood? It is. Poststeptoccocal GN  It is immune nephritis  Occurs 2-5 weeks after strept infection  Preceding infection may be in form of ( pyo derma, pharyngitis, scarlet fever &mild com mon cold) 4

6. 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  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 5

7. Typically The Patient Develops  Dark urine usually described as cocola colored  Edema Most prominent around eye at early. Mornings then spreads to the lowe r limb and edema is minimal  Hypertension usually mild to moderate maybe sever leading to cardiac &neurological complication s  Oliguria collection. Of 24 hours urine collection is Recommended oliguria is considered when UOP is less than 1m/kg/h. however the patient may be totally asymptomatic except for hematuria which may be over microscopic

8. Are There Atypical Presentation Of APSGN ? Congestive Heart Failure Convulsion Respiratory Distress Congestive Heart Failure Convulsion Respiratory Distress 6

9. 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 re nal  Unexplained clinical manifestations can not intepreted as common disor ders  As hall mark of nephritis may be absent due to oligurea &anurea may be present. But child not complaints. And so the mother. 7

10. What Lines Of Treatments Of APSGN?  Overload Water restriction daily water intake equal urine out put and insensible water loss (insensible wat er 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.  Hypertension Diuretics, salt & water restriction in mild hypertension In 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 pe nicilline. 8

11. 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 9

12. 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 10

13. 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. 11

14.  HSP  It is most common vasculitis in childhood  It is combination of the following :  Purpuric eruptions mainly in the lower limbs and buttocks  Joint affection  Abdominal pain  GN (nephritis is common but not the first presentation, mild to mode rate proteinurea, severe proteinurea up to nephritic syndrome nephr itis, C3 is normal What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them? 12

15.  Lupus nephritis  Mainly in adolescence females  Can be presented by nephritis, nephritic,nephritic nephriti c  Marked by autoantibodies including ANA, and double stra nd DNA, low C3&C4  Biopsy is indicated What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them? 13

16.  Renal vasculitis  Poyarthritis nodosa and wegener disease  Renal involvement may occur  Presented by fever, malasie, wright loss, skin rash &arthr opathy with promient involvement of the respiratory tract i n wegener dis  ANCA (antineutrophil cytoplasmic antibodies)Are diagnos tic What Are Other Causes Of Nephritis In Childhood &How To Differentiate Between Them? 14

17. 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. 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. 15

18. 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 period, a hist ory of menarche is useful  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 period, a hist ory of menarche is useful 15

19. 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. 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. 16

20. URINE ANALYSIS GLOMERULAR RBCS Cast Dysmorphic RBCS 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 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 Non GLOMERULAR No RBCS Cast No Dysmorphic RBCS Urine culture Abd. USS, X RAY Abdominal CT (Trauma) Calcium /cr ratio 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 MRA (vascular anomalies) Adenovirus culture Doppler (especially if elevated renal parameters) Bleeding profile Review history for heavy exercise,drugs

21. C3 LOW C3 Systemic manifestations  SLE (C4,serology)+ (biopsy)  Shunt nephriris (clinical)  Bacterial endocarditis (clinical & echo) Systemic manifestations  SLE (C4,serology)+ (biopsy)  Shunt nephriris (clinical)  Bacterial endocarditis (clinical & echo) NO Systemic manifestations APSGN MPGN NO Systemic manifestations APSGN MPGN NORMAL C3 Systemic manifestations HUS(clinical) Vasculitis o HSP o PAN o WG o GPS Systemic manifestations HUS(clinical) Vasculitis o HSP o PAN o WG o GPS NO Systemic manifestations  Ig A Nehropathy (biopsy)  Alport syndrome(biopsy)  Familial hematuria(biopsy)  IRPGN NO Systemic manifestations  Ig A Nehropathy (biopsy)  Alport syndrome(biopsy)  Familial hematuria(biopsy)  IRPGN

22. Microscopic Hematuria

23.  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?

24. HEMATURIA DIAGNOSTIC APPROACH By Ahmad solimman, MD Benha university By Ahmad solimman, MD Benha university AHMAD SOLIMAN