Introduction to Renal Systemand Hematuria

Dr. Kalpana MallaMD Pediatrics

Manipal Teaching Hospital

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Contents

• Clinical anatomy of the renal system.• Hematuria – causes, evaluation and

treatment.

Causes of Kidney Disease

Inflammatory and degenerative disease Acute glomerulonephritis Nephrotic syndrome Chronic renal failure

Damage from other diseases Hypertension, diabetes mellitus

Infection and obstruction

Causes of Kidney Disease

Damage from other agents Environmental agents Malnutrition

Genetic defects

Renal Anatomy

• Paired retroperitoneal-

• 12 thoracic & 3rd lumbar vertebra

• Covered by perinephric fat extending to hilum

• Weight- 150gm, 11 cm in length, 6 cm in width, and 3 cm thick

                                                 Source

Kidney Anatomy

• Hilum -anteromedial side of kidney (VAP-anterior to posterior)

                                                                                                                                                                                     

Anatomy of kidney

• Newborn – length - 6cm, wt- 24 gms

• Cortex- glomeruli , PCT,DCT,CD

• Medulla- straight portion of tubules, loops of

Henle, vasa recta terminal collecting ducts

Nephrone

Structural and functional unit of kidney 1 million in each KidneyA. GlomerulusB. Renal tubules-Bowman’s capsule PCT Loop of Henle DCT CT Tubules

• Glomerulus–Cluster of branching capillaries–Cup-shaped membrane at the head of

each nephrone forms the Bowman’s capsule

–Filters waste products from blood

Glomerulus

• Tuft of capillaries invaginated in the Bowman’s capsule

Juxtaglomerular apparatus

• specialised muscle cells in wall of afferent arteriole + lacis cells +

macula densa – secretion of renin

Function of Kidney

Functions– Filtration of materials in blood– Filtrate includes –water, ions, urea,

glucose, amino acids,minerals, vitamins, drugs

– Reabsorption of substances - 99% of the filtrate components are reabsorbed actively or passively by tubular cells

– Secretion of hydrogen ions to maintain acid-base balance

Functions

– Water & Electrolyte balance– Excretes waste products-Urea, Uric acid,

Creatinine– Secretes erythropoietin-erythropoiesis– Renin secretion (for body water balance)– Regulates blood pressure– Excretion of drugs, various toxic substances– Vitamin D activation

Definition

Hematuria :Presence of an abnormal quantity of red blood

cells in the urine

Hematuria

Classification:A) Based on No of RBCs in urine:1. Macroscopic Hematuria -Gross Hematuria

visible to naked eye. Here RBC >106 (10 lakh) per ml of urine

2.Microscopic - >5RBCs/HPF in a sediment from 10ml of centrifuged freshly voided Urine

Microscopic hematuria without other symptoms - 2% of children

• More commonly found in girls

B) Based on site of bleeding: 1. Glomerular 2. Non glomerular

Urinary Hues

• Dark yellow – Conc urine, Bile pigment• Red- Hb, beets, blackberries, chloroquine, rifampicin, red food coloring• Dark brown /Black- Homogentisic acid, melanin

Causes of Hematuria1. Infection (UTI)- Bacterial , Viral Schistosomiasis, Tuberculosis

2. Glomerular diseases a) Recurrent gross hematuria IgA Nephropathy Benign familial idiopathic H (thin basement membrane disease)

Causes of hematuria

• Alport Syndrom b) APGNc) Membranous GNd) Secondary causes of GN – lupus

Nehpritis ,Henoch schonlein purpura, HUSe) Menbranoproloferative GNf) Rapid progressive GNg) Good Pasture DS

Causes of Hematuria3. Trauma4. Anatomical anomalies- PUJ obstruction, Polycystic Kidneys, Hydronephrosis 5. Vascular- Arteritis, Infarction, thrombosis6. Idiopathic hypercalciuria

Causes of Hematuria

7. Hematological- Coagulopathies, sickle cell Ds, Renal Vein thrombosis8. Drugs- Cyclophosphamide - Haemorrhagic

cystitis9. Acute interstitial nephritis

Glomerular vs extraglomerular hematuria:

Urinary finding Glomerular Extraglomerular

Color Red/brownCola/tea

Usually red

RBC cast Present Absent

Clots Absent May be +

Proteinuria >2 (+) Absent

Red cell morphology Dysmorphic Eumorphic

Casts in urine:

1 Physiological casts: Hyaline cast, granular cast2. Pathological casts: Lipid cast – Nephrotic syndrome RBC cast – Acute glomerulonephritis WBC cast – Pyelonephritis Crystal cast – Hypercalcemia Broad waxy cast – Chronic renal failure

• History• Physical examination • Lab tests

Presentation:

May present in one of three ways1 Onset as gross hematuria2 Onset with urinary or other symptoms3. Incidental finding during a health

evaluation

Approach:

• Age: Preschool age- Wilm’s tumor School age – PIGN• Sex: Females- lupus nephritis Males – Alport syndrome• Race: Blacks- Sickle cell disease Caucasians- Hypercalciuria

History:

• H/O passage of clots- extraglomerular cause• Fever, dysuria, abdominal pain, recent

enuresis, frquency- UTI• Recent trauma to abdomen- hydronephrosis• Early morning periorbital puffiness, weight

gain, oliguria, dark-coloured urine, edema and hypertension- glomerular cause

History:• Painless hematuria- glomerular• Recent h/o skin or sore throat infection- PSGN• Prolonged fever, joint pain, skin rashes-

connective tissue disease• Anemia – SLE or bleeding disorder• Skin rash and arthritis- HSP, SLE• Similar family history- SLE, Alport syndrome,

urolithiasis, Polycystic kidney disease

History:• Timing of the hematuria Initial (urethral bleeding)

Terminal (bladder)Throughout (no localizing value)

• Also important- h/o passage of calculi per urethra, exercise, ingestion of drugs or toxic agents, menstruation, recent bladder catheterisation

Physical examination:

• Edema- periorbital and pedal• Blood pressure, weight• Skin- purpura• Abdomen- palpable kidneys (Wilm’s tumor,

hydronephrosis)• Genitalia

Lab Tests

Step 1- Must be done in all Patients• CBC• Urine R/E, Urine C/S• S. Creatinine, B. Urea• C3 Level• USG Or IVP

Confirmation of Hematuria:

Urinalysis: • Uncentrifuged (fresh) urine specimen- >5

RBCs/ cu.mm

• Centrifuged sample -> 5 RBCs/HPF RBC casts- glomerulotubular origin WBC/ WBC casts- UTI

Red cell morphology: Look for presence of “dysmorphic RBCs” in

fresh urine specimen by light or phase contrast microscopy

- > 60-80% dysmorphic RBCs indicates glomerular cause

- Eumorphic RBCs indicate origin in renal pelvis or lower urinary tract

Phase-contrast microscopy:

Non-glomerular /Eumorphic RBCs

Confirmation of hematuria-

Dipstick test :Test is negative when “red urine” is due to

beeturia and drugs (rifampicin, phenazopyridine)

Pseudoperoxidase activity of Haemoglobin or myoglobin catalyzes a reaction between hydrogen peroxide and tetramethyl benzidine - to produce an oxidized chromogen having green-blue colour

- Detects 5-10 intact RBCs per cu.mm (~ 2-5 RBCs per HPF)

Step 2

• ASO titre / anti-DNAse B Titre• Throat C/S• ANA, ds-DN• Urine Electrolytes• Coagulation studies• MCU

Step 2

Hb electrophoresis (HbS)Urinary calcium excretion (> 4 mg/kg/day or urinary

calcium to creatinine ratio > 0.21)Urine Calcium Excretion (normal <4 mg/kg/day) Urine Calcium to Creatinine ratio (normal <0.2-0.25) Urinalysis of a Family Member

Step 2 - Imaging tests:

• USG (KUB region) • Spiral CT scan- Urolithiasis, Wilm’s tumor,

polycystic kidney disease• Voiding cystourethrogram• Radionuclide studies- calculi• IVP

Step 3

Renal Biopsy• Persistent High grade microscopic hematuria• Microscopic Hematuria + decre R.function• ,, ,, +Protenuria +++• ,, ,, + Hypertension• Second episode of gross hematuriaCystocopy

Referral Criteria

• Concurrent systemic signs – Hypertension, edema, Arthritis

• Abnormal RFT , ↓C3 • Significant Proteinuria • Episodes of Gross Hematuria• Persistant hematuria > 1yr • Hypercalciuria • Parental anxiety

Referral Criteria

• Evidence of nephrolithiasis• F/H/O hereditary nephritis• RBC cast on microscopic urine examination

Spectrum of Anomalies

• Renal disorders • Horseshoe Kidney• Renal Agenesis and Dysplasia• Polycystic Kidneys• Prune Belly

• Urinary Tract Obstructions• Antenatal Renal Pelvi-caliceal Dilatation• VUR• PUJO, VUJO• Posterior Urethral Valves• Ureterocoeles, Megaureter• Calculi

VUR

PUJO, VUJO

Posterior Urethral Valves

Ureterocoeles

• Abnormalities of Genitalia • Phimosis, Paraphimosis, Circumcision• Labial Fusion• Abnormalities of Bladder • Voiding dysfunction and Wetting • Neurogenic• Sacral Agenesis and Neural Tube Defects

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