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HEMATURIA

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HEMATURIA

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  1. HEMATURIA Dr. ShreedharPaudel April, 2009

  2. HEMATURIA • Microscopic hematuria • more than three erythrocytes per high-power field • HEME-POSITIVE    --Hemoglobin   --Myoglobin

  3. HEMATURIA…….. • Artificial food coloring • Beets • Berries • Chloroquine • Furazolidone • Hydroxychloroquine • Nitrofurantoin • Phenazopyridine • Phenolphthalein • Rifampin

  4. HEMATURIA…. • CAUSES OF HEMATURIA:- • A. RENAL • GLOMERULAR • RENOVASCULAR • B. HEMATOLOGICAL • C. URETERIC • D. PKCD, UTI, TUMOR

  5. HEMATURIA….. • CAUSES OF HEMATURIA:- • Severe dehydration--- Renal vein thrombosis • Myocardial infarction-- Renal artery embolus or thrombus • Atrial fibrillation--- Renal artery embolus or thrombus • Hypertension Glomerulosclerosis-- with or without proteinuria

  6. HEMATURIA…….. • EVALUATION OF PATIENT WITH HEMATURIA:- • H/O passage of clots → extraglomerular cause of hematuria • H/O recent trauma to the abdomen → hydronephrosis • H/O early-morning periorbital puffiness, weight gain, oliguria, the presence of dark-colored urine, and the presence of edema or hypertension suggests a glomerular cause.

  7. HEMATURIA…….. • EVALUATION OF PATIENT WITH HEMATURIA…. • Painless hematuria due to glomerular causes • H/O recent throat or skin infection → post infectious glomerulonephritis • H/O joint pains, skin rashes, and prolonged fever in adolescents → collagen vascular disorder

  8. HEMATURIA…….. • EVALUATION OF PATIENT WITH HEMATURIA…. • The presence of anemia cannot be accounted for by hematuria alone → in a patient with hematuria and pallor, other conditions such as systemic lupus erythematosus and bleeding diathesis should be considered • H/O fever, abdominal pain, dysuria, frequency, and recent enuresis in older children → UTI as the cause of hematuria

  9. HEMATURIA…….. • EVALUATION OF PATIENT WITH HEMATURIA…. • Skin rashes and arthritis → HSP and SLE • Information regarding exercise, menstruation, recent bladder catheterization, intake of certain drugs or toxic substances, or passage of a calculus may also assist in the differential diagnoses.

  10. HEMATURIA…….. • EVALUATION OF PATIENT WITH HEMATURIA…. • familial, Alport syndrome, collagen vascular diseases, urolithiasis, or PCKD • PHYSICAL EXAMINATION • INVESTIGATION

  11. HEMATURIA…….. • Indications of kidney biopsy in patients with hematuria:- • Significant proteinuria • Abnormal renal function • Recurrent persistent hematuria. • Serologic abnormalities (abnormal complement, ANA, or dsDNA levels). • Recurrent gross hematuria. • A family history of end-stage renal disease

  12. ACUTE GLOMERULNEPHRITIS (AGN) • CONDITIONS PRESENTING AS AGN • POST INFECTIOUS—streptococci, hepatitis B and C, bacterial endocarditis • SYSTEMIC VASCULITIS – HSP, SLE, Polyarteritis nodosa • MEMBRANOPROLIFERATIVE GN • IGA NEPHROPATHY • ALPORT SYNDROME

  13.  Acute Poststreptococcal Glomerulonephritis • Sudden onset of • Gross hematuria • Edema • Hypertension • renal insufficiency • most common glomerular causes of gross hematuria in children

  14. Acute Poststreptococcal Glomerulonephritis……… • Etiology:- • throat or skin infection by certain “nephritogenic” strains of group A β-hemolytic streptococci. ↓ streptococcal pharyngitis (serotype 12) streptococcal skin infections or pyoderma (serotype 49)

  15.  Acute Poststreptococcal Glomerulonephritis……… • Pathology:- • kidneys → symmetrically enlarged • light microscopy → enlarged glomeruli • Immunofluorescence → granular deposits of IgG • electron microscopy • Lumpy deposits on the subepithelial side of the capillary basement membrane

  16.  Acute Poststreptococcal Glomerulonephritis……… • Clinical Manifestations:- • 5–12 yr and uncommon before the age of 3 yr. • acute nephritic syndrome 1–2 wk after an antecedent streptococcal pharyngitis or 3–6 wk after a streptococcal pyoderma. • asymptomatic microscopic hematuria with normal renal function to acute renal failure

  17. Acute Poststreptococcal Glomerulonephritis……… • Clinical Manifestations:- • Edema (puffiness around eyes and pedal edema) • Hypertension • Oliguria (cola colored urine) • encephalopathy and/or heart failure owing to hypertension or hypervolemia • malaise, lethargy, abdominal or flank pain, and fever are common

  18. Acute Poststreptococcal Glomerulonephritis……… • Clinical Manifestations:- • The acute phase generally resolves within 6–8 wk • urinary protein excretion and hypertension usually normalize by 4–6 wk after onset • persistent microscopic hematuria may persist for 1–2 yr after the initial presentation

  19.  Acute Poststreptococcal Glomerulonephritis……… • Diagnosis:- • Urinalysis → • red blood cells (RBCs) • RBC casts • proteinuria(1+ to 2+) • polymorphonuclear leukocytes (indicative of glomerular inflammation) • mild normocytic anemia (due to hemodilution)

  20.  Acute Poststreptococcal Glomerulonephritis……… • Diagnosis:- • ↓ed serum C3 level • ↑ed antistreptolysin O (ASO) • ↑ ed serum urea and creatinine (reflecting degree of renal impairment)

  21. Acute Poststreptococcal Glomerulonephritis……… • Complications:- • Hypertension • Acute renal dysfunction • Hypertensive encephalopathy • Heart failure • Hyperkalemia • Hyperphosphatemia • Hypocalcemia • Acidosis • Seizures • Uremia

  22. Acute Poststreptococcal Glomerulonephritis……… • Treatment:- • Patient with mild oliguria and normal BP → can be managed at home • Close monitoring of Blood pressure and dietary intake • 10-day course of systemic antibiotic therapy with penicillin (once AGN occurred penicillin treatment has no effect on course of disease----may be given if active pharyngitis or pyoderma present)

  23. Acute Poststreptococcal Glomerulonephritis……… • Treatment:- • DIET • Protein, sodium and potassium restricted till serum urea reduce to normal and urinary output increases • Fluid intake restricted to amount equal to insensible loss + urinary loss • Overhydration-- ↑es HTN and precipitates LVF

  24. Acute Poststreptococcal Glomerulonephritis……… • Treatment:- • WEIGHT • Weighed daily • Should lose about 0.5 % BW/ Day – due to endogenous catabolism • Gain in weight requires– fluid restriction • DIURETICS • Not indicated (since edema is rarely massive and comes to normal with return of renal function) • Used in presence of pulmonary edema (iv frusemide)

  25. Acute Poststreptococcal Glomerulonephritis……… • Treatment:- • HTN • Mild—controlled by salt and water restriction • Malignant HTN – prompt treatment ( iv nitroprusside) • LVF • Control HTN • iv frusemide • Prognosis:- • Complete recovery occurs in 95% of cases

  26. Henoch-Schönlein Purpura • Small vessel vasculitis • Mild renal involvement– microscopic hematuria, mild proteinuria • Clinical features:- • purpuric rash ( extensor surface) • Arthritis • abdominal pain • Rarely presents with nephritic or nephrotic syndrome, HTN, azotemia

  27. Henoch-Schönlein Purpura…

  28. Henoch-Schönlein Purpura…

  29. Henoch-Schönlein Purpura…. • TREATMENT:- • Most patients recover without any specific treatment • Long-term observation– to detect insidious renal damage • Combination of steroids and azathioprine recommended • But long-term outcome may not be satisfactory