2006 Renal Week Lecture 3
Hematuria and
Glomerulonephritis
Debbie Gipson
UNC Kidney Cener
debbie_gipson@med.unc.edu
website: www.uncpeds.org
password: pediatriclib
Program Announcements
• UNC Nephrology Fellowship
– 1 position each year
– accepting applications for 2007 and 2008
• Educational and Meeting Opportunities
– Univ. Miami: Pediatric Nephrology
Seminar (Clinical), Miami Beach, 2007
– American Society of Nephrology
– American Society of Pediatric Nephrology
Renal Week Evaluations
• Please complete the evaluation
– Topics
– Format
– Presentations and presenters
• Return to envelope in back of room
or via campus mail to Rowena
Brown, CB 7155
Case 1
• A 17 year old previously healthy African
American female presents for a well child
visit.
• Dipstick evaluation reveals moderate blood
and 3+ proteinuria. Microscopic
examination of the urinary sediment
reveals 10 RBC/hpf and no casts.
• Physical examination is unremarkable
Your assessment and plan is:
• 1. Microscopic hematuria. Repeat UA x 2
• 2. Asymptomatic proteinuria and
hematuria. Requires no additional
evaluation
• 3. Proteinuria and hematuria. Additional
evaluation indicated
Your assessment and plan is:
• 1. Microscopic hematuria. Repeat UA x 2
• 2. Asymptomatic proteinuria and
hematuria. Requires no additional
evaluation
• 3. Proteinuria and hematuria. Additional
evaluation indicated
Appropriate tests may include each of
the following except:
1. AM Urine for protein & creatinine
2. Serum chemistries for creatinine,
albumin, and cholesterol
3. Urine for calcium excretion
4. Serum complement
5. Consider hepatitis and HIV serologies
6. Renal ultrasound
Appropriate tests include each of
the following except:
• 1. 24 hour urine for protein and creatinine
• 2. Serum chemistries for creatinine,
albumin, and cholesterol
• 3. Urine for calcium excretion
• 4. Serum complement
• 5. Consider hepatitis and HIV serologies
• 6. Renal ultrasound
Hematuria + Proteinuria
• Combination is an indicator of
disease
• Gross hematuria may have
associated low grade proteinuria
( Up/c < 0.5)
CASE 2
• A six year old girl develops a puffy face and
notices that her urine has turned brown.
• No family history of renal disease. A sister
complained of a sore throat one week before
the onset of dark urine.
• Physical exam shows generalized edema and a
blood pressure of 135/ 83 mmHg.
• Urinalysis contains: large hemoglobin, 2+
protein
The most likely diagnosis is?
1.
2.
3.
4.
5.
Hypercalciuria
Acute Post Strept GN
IgA nephropathy
Membranoproliferative GN
Systemic Lupus Erythematosis
The most likely diagnosis is?
1.
2.
3.
4.
5.
Hypercalciuria
Acute Post Strept GN
IgA nephropathy
Membranoproliferative GN
Systemic Lupus Erythematosis
Which of the following tests will be most
helpful in determining the diagnosis?
1.
2.
3.
4.
5.
Serum BUN & creatinine
Serum complement & streptozyme
Serum IgA
Renal ultrasound
Serum albumin
Which of the following tests will be most
helpful in determining the diagnosis?
1.
2.
3.
4.
5.
Serum BUN & creatinine
Serum complement & streptozyme
Serum IgA
Renal ultrasound
Serum albumin
Post-infectious GN
Classic Group A Streptococci
Anticedent illness
– Pharyngitis (7-21 d) or impetigo (14-21 d)
– Nephritogenic strain of streptococcus
– Rheumatic fever and nephritis rarely concurrent
– Peak age 2 to 6 years
– Males > females
– Epidemics
• Attack rates 10-15%
• 38% Household contacts
Post infectious GN
Hematuria
70% microscopic
30% macroscopic
Proteinuria
common
Hypertension 75%
Edema
Congestive Heart Failure (elderly)
Encephalopathy (children)
Post-infectious GN
• Laboratory
– Low C3 (x 6-8 weeks)
– ASO or streptozyme titers acute rise if Strep.
– May increase serum Cr; uncommon renal failure
– Hematuria (1 year), Proteinuria, RBC casts
• Pathology
Proliferative GN
Classic subepithelial humps
Starry Night pattern (C3>IgG)
Acute Postinfectious GN
Subepithelial Humps
Which one of the following is not
associated with depressed serum
complement values?
1.
2.
3.
4.
Acute post strept GN
Membranoproliferative GN
IgA nephropathy
SLE
Which one of the following is not
associated with depressed serum
complement values?
•
•
•
•
1.
2.
3.
4.
Acute post strept GN
Membranoproliferative GN
IgA nephropathy
SLE
CASE 5
• A 12 year old girl has a sore throat and that
same day notices that her urine turns brown.
• She feels well and without specific symptoms.
• She has not had previous urinalyses. There is
no family history of renal disease.
• Her examination is normal.
• The urinalysis contains large hemoglobin and
1+ protein.
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
IgA Nephropathy
Mesangial IgA
Mesangial hypercellularity
Which of the following
suggests a serious prognosis?
1. Family history
2. Proteinuria
3. Elevated serum IgA values
4. Low serum complement values
5. Abdominal pain
Which of the following
suggests a serious prognosis?
1. Family history
2. Proteinuria
3. Elevated serum IgA values
4. Low serum complement values
5. Abdominal pain
IgA Nephropathy
(Bergers Disease)
• Most common cause of GN world wide
• Forms:
– Idiopathic
– Familial 10%
– Secondary (liver disease, chronic lung or GI
d/o)
• Age 15 - 30 yo
• Asian > Caucasian > African Americans
IgA Nephropathy
Clinical Findings
• Presentation
– 40% asymptomatic hematuria
– 40% gross hematuria (more frequent in
children)
– 10% nephrotic syndrome
– 10% renal failure (including rare patients with
RPGN)
– 5% Malignant HTN
• Increase in symptoms with infection
IgA Nephropathy
Prognosis
Indicators
- proteinuria > 1 gm
- nephrotic syndrome
- sustained HTN
- male
+ gross hematuria
2%/year progress to ESRD
Overall 20-40% progress to ESRD
IgA Therapy
• ACEi (proven)
• Corticosteroids
• Mycophenolate (trials)
• Fish Oil
• Lipid control
Next Case
• 6 year old male
• Crampy abdominal pain without
rebound
• Rash on buttocks and lower
extremities
• Urine with 2+ blood and 2+ protein
• Serum Complements are normal
The most likely diagnosis is?
1. Acute Post Strept GN
2. Systemic Lupus Erythematosis
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
6. Henoch Schonlein Purpura
The most likely diagnosis is?
1. Acute Post Strept GN
2. Systemic Lupus Erythematosis
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
6. Henoch Schonlein Purpura
Henoch-Schönlein Purpura
Vasculitis with IgA-dominant immune deposits
affecting small vessels, i.e. capillaries, venules, or
arterioles. Typically involves skin, gut & glomeruli,
and is associated with arthralgias or arthritis.
HSP Clinical Features
• Most common 4-5 years
• Males > females
• Clinical
– sudden onset extensor surface rash
– edema of hands, feet, face, scalp
– arthralgia 70%
– abdominal pain, vomiting 60%
– Intussusception, protein losing enteropathy
– nephritis 40 - 60 %
– CNS symptoms
HSP Prognosis
• Chronic renal failure 2 to 5%
• Indicators
– acute nephritis
– persistent nephrotic syndrome
– older age
– glomerular crescents
• Therapy
– Rapidly progressive GN
– The cocktail: steroids/cytoxan/pharesis