1. Introduction to Renal System
and Hematuria
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. Contents
• Clinical anatomy of the renal system.
• Hematuria – causes, evaluation and
treatment.

3. 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

4. Causes of Kidney Disease
 Damage from other agents
 Environmental agents
 Malnutrition
 Genetic defects

5. 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

7. Kidney Anatomy
• Hilum -anteromedial side of kidney (VAP-
anterior to posterior)

8. 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

9. Nephrone
Structural and functional unit of kidney
1 million in each Kidney
A. Glomerulus
B. Renal tubules-Bowman’s capsule
PCT
Loop of Henle
DCT
CT Tubules

10. • Glomerulus
–Cluster of branching capillaries
–Cup-shaped membrane at the head of
each nephrone forms the Bowman’s
capsule
–Filters waste products from blood

11. Glomerulus
• Tuft of capillaries invaginated in the
Bowman’s capsule

12. Juxtaglomerular apparatus
• specialised
muscle cells in wall of afferent arteriole + lacis cells +
macula densa – secretion of renin

14. Function of Kidney

15. 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

16. 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

18. Definition
Hematuria :
Presence of an abnormal quantity of red blood
cells in the urine

19. 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

20. Microscopic hematuria without other symptoms
- 2% of children
• More commonly found in girls
B) Based on site of bleeding:
1. Glomerular
2. Non glomerular

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

23. Causes of Hematuria
1. Infection (UTI)- Bacterial , Viral
Schistosomiasis, Tuberculosis
2. Glomerular diseases
a) Recurrent gross hematuria
IgA Nephropathy
Benign familial idiopathic H
(thin basement membrane disease)

24. Causes of hematuria
• Alport Syndrom
b) APGN
c) Membranous GN
d) Secondary causes of GN – lupus Nehpritis
,Henoch schonlein purpura, HUS
e) Menbranoproloferative GN
f) Rapid progressive GN
g) Good Pasture DS

25. Causes of Hematuria
3. Trauma
4. Anatomical anomalies- PUJ obstruction,
Polycystic Kidneys, Hydronephrosis
5. Vascular- Arteritis, Infarction, thrombosis
6. Idiopathic hypercalciuria

26. Causes of Hematuria
7. Hematological- Coagulopathies,
sickle cell Ds, Renal Vein thrombosis
8. Drugs- Cyclophosphamide - Haemorrhagic
cystitis
9. Acute interstitial nephritis

27. Glomerular vs extraglomerular
hematuria:
Urinary finding Glomerular Extraglomerular
Color Red/brown Usually red
Cola/tea
RBC cast Present Absent
Clots Absent May be +
Proteinuria >2 (+) Absent
Red cell morphology Dysmorphic Eumorphic

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

30. • History
• Physical examination
• Lab tests

31. Presentation:
May present in one of three ways
1 Onset as gross hematuria
2 Onset with urinary or other symptoms
3. Incidental finding during a health
evaluation

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

33. 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

34. 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

35. 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

36. Physical examination:
• Edema- periorbital and pedal
• Blood pressure, weight
• Skin- purpura
• Abdomen- palpable kidneys (Wilm’s
tumor, hydronephrosis)
• Genitalia

38. 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

39. 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

40. 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

41. Phase-contrast microscopy:
Non-glomerular /Eumorphic RBCs

42. 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)

43. Step 2
• ASO titre / anti-DNAse B Titre
• Throat C/S
• ANA, ds-DN
• Urine Electrolytes
• Coagulation studies
• MCU

44. 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

45. Step 2 - Imaging tests:
• USG (KUB region)
• Spiral CT scan- Urolithiasis, Wilm’s
tumor, polycystic kidney disease
• Voiding cystourethrogram
• Radionuclide studies- calculi
• IVP

46. Step 3
Renal Biopsy
• Persistent High grade microscopic
hematuria
• Microscopic Hematuria + decre R.function
• ,, ,, +Protenuria +++
• ,, ,, + Hypertension
• Second episode of gross hematuria
Cystocopy

47. Referral Criteria
• Concurrent systemic signs –
Hypertension, edema, Arthritis
• Abnormal RFT , ↓C3
• Significant Proteinuria
• Episodes of Gross Hematuria
• Persistant hematuria > 1yr
• Hypercalciuria
• Parental anxiety

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

49. Spectrum of Anomalies
• Renal disorders
• Horseshoe Kidney
• Renal Agenesis and Dysplasia
• Polycystic Kidneys
• Prune Belly

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

51. VUR

52. PUJO, VUJO

53. Posterior Urethral Valves

54. Ureterocoeles

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

56. Thank you
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