Paeds: Haematuria Flashcards
Presentation
- Episode of marcoscopic haematuria (causes alarm to child/family)
- Incidental finding
- Family screening and routine urinalysis
Other causes of ‘red urine’:
- Haemoglobinuria/myoglobinuria.
- Foods – colouring (e.g. beetroot)
- Drugs (e.g. rifampicin)
- Urate crystals (in young infants, usually ‘pink’ nappies).
- External source (e.g. menstrual blood losses).
- Fictitious –consider if no cause found.
Causes of haematuria:
Non-glomerular or glomerular
Non-glomerular
- Infection (bacterial, viral, TB, schistomiasis)
- Trauma to genitalia, urinary tract or kidneys
- Stones
- Tumours
- Sickle cell disease
- Bleeding disorders
- Renal vein thrombosis
Hypercalciuria
Glomerular
- Acute glomerulonephritis (usually with proteinuria)
- Chronic glomerulonephritis (usually with proteinuria)
- IgA nephropathy, Henoch-Schonlein purpura, SLE
- Familial nephritis e.g. Alport syndrome, thin basement membrane
Thin basement membrane disease
Other way to differentiate the causes
Urinary tract infections Glomerular Urinary tract stones Trauma Other renal tract pathology Vascular Haematological Drugs Exercise-induced
Urinary tract infections
Bacterial
Viral (e.g. adenovirus in outbreaks);
Schistosomiasis (hx of foreign travel)
TB
Glomerular
- Postinfectious glomerulonephritis
- Henoch-Schonlein purpura IgA nephropathy, SLE
Hereditary – thin basement membrane, Alport’s syndrome
Urinary tract stones
E.g. due to hypercalciuria
Other renal tract pathology
- Renal tract tumour
Polycystic kidney disease
Vascular
- Renal vein thrombosis
Arteritis
Haematological
Coagulopathy/sickle cell disease
Drugs
Cyclophosphamide
Hx
UTI Renal stones: Glomerular Coagulopathy Trauma Family Hx
UTI symptoms
fever/freqeuncy/dysuria
Renal stones:
colicky abdominal pain
Glomerular
Sore throat/rashes
Coagulopathy
Easy bruising
Family Hx
Haematuria
Deafness (Alport’s)
Sickle cell disease
Brown urine:
Glomerular haematuria – often accompanied with proteinuria
Red urine:
Lower urinary tract haematuria – beginning or end of stream, no proteinuria –Unusual in children!
Examination:
- BP
- Abdomen: palpable masses
- Skin: rashes
- Joints: pain/swelling
Investigations:
During acute illness: exclude UTI by urine culture.
***Asymptomatic or ‘benign haematuria’ in children without growth failure, hypertension, oedema, proteinuria, urinary casts or renal impairment is a frequent finding.
Investigation list
Urine Bloods US urinary tract Urinalysis of parents (hereditary causes). Cystoscopy; rarely indicated in children
Urine
- Microscopy (look for cats –suggestive of nephritis) and culture;
- Protein excretion: creatinine ratio (normal,
Bloods
- U&E/creatinine/albumin,
- FBC/clotting
- Complement – C3/C4, ASOT titres;
ANA/anti-dsDNA
ASOT titres
help determine whether a recent strep infection with group AStreptococcus:
• Is the cause of a person’s orglomerulonephritis, a form ofkidney disease
• Causedrheumatic feverin a person with signs and symptoms
Treatment:
- If obvious cause (e.g. UTI) treat
- Complex diagnosis (impaired renal function, proteinuria, or family Hx) refer to paediatric nephrology unit
When do you monitor until it resolves
- If no cause found and normal renal function, BP, and no proteinuria monitor until resolves
If no resolution after 6 months or change in any of above parameters
refer
Post-streptococcl and post-infectious nephritis:
Description
Usually follows a streptococcal sore throat or skin infection
Post-streptococcl and post-infectious nephritis: Diagnosis
Evidence of a recent streptococcal infection
Culture of the organism
Raised ASO/anti-DNAse B titres
Low Complement C3 levels (return to normal after 3-4 weeks)
Post-streptococcl and post-infectious nephritis: Epi
Common in developing countries
Post-streptococcl and post-infectious nephritis: Prognosis
Good
Henoch-Schnolein purpura: Signs and Symptoms
- Preceded by URTI
- Characteristic skin rash
- Arthralgia
- Peri-articular oedema
- Abdominal pain
Glomerulonephritis
Henoch-Schnolein purpura:
Aetiology
- Between the ages of 3 and 10 years
- 2:1 boys:girls
Peaks during winter months
Henoch-Schnolein purpura:
Presentation
Increase in circulating IgA and IgG interact to produce complexes that activate complement and are dposited in affected organs, precipitating an inflammatory response with vasculitis.
Henoch-Schnolein purpura: Presentation
Rash
- Buttocks
- Extensor surfaces of legs and arms
- Ankles
Joint pain and swelling: knees and ankles
Abdominal pain:
- Haematemesis and melaena (gastrointestinal petechiae)
- Intussusception
Renal
- Microscopic/macroscopic haematuria (80%)
Nephrotic syndrome (rare)
Henoch-Schnolein purpura:
Rash type
Initially uticarial, rapidly becoming maculopapular and purpuric.
Characteristically palpable and may recur over several weeks.
Henoch-Schnolein purpura: Rare complications
Ileus
Protein-losing enteropathy
Orchitis
Occasionally CNS involvement
Henoch-Schnolein purpura: Prognosis
Children without risk factors for progressive renal disease make a full recovery
Henoch-Schnolein purpura:
Risk factors for progressive disease
Heavy proteinuria
Oedema
Hypertension
Deteriorating renal function
Henoch-Schnolein purpura:
Treatment
Severe cases can be treated with corticosteroids
Vasculitis: Causes
Henoch-schlonein purpura Renal involvement in: - Polyarteritis nodosa - Microscopic polyarteritis Wegener gramulomatosis
Vasculitis: Characteristic symptoms
Fever Malaise Weight-loss Skin rash Arthropathy with prominent involvement of the respiratory tract in Wegener disease
Vasculitis: Diagnosis
- ANCA are present and diagnostic in these disease
Renal arteriography, to demonstrate the presence pf aneurysms, will diagnose polyarteritis nodosa
Vasculitis:
Treatment
Steroids
Plasma exchange
IV cyclophosphamide
