Hematuria,Proteinuria AND

Nephrotic Syndrome

By:Dr.Leena Hafeez

HEMATURIA

DefinitionMore than 3 red blood cells present in the

centrifuged urine per high power field microscopy (>3 RBCs/HPF ).

It indicates bleeding from anywhere in the renal tract.

ClassificationOn the basis of amount of RBCs in the urine Hematuria can be classified into two categories

Macroscopic Hematuria: Hematuria visible to the naked eyeMicroscopic Hematuria: Invisible and detected on dipstick tests

EtiologyDiseases of Urinary system-most common

cause

Glomerular: IgA nephropathy Glomerulonephritis

Interstitial: Renal cystic disease Tuberculosis Acute pyelonephritis

Etiology Uroepithelium:• Malignancy• Trauma• Papillary necrosis• Cystitis/prostatitis/Urethritis• Stone Vascular:• Renal vein thrombosis• Arterial Emboli or thrombosis

EtiologySystemic Causes-Less common Diabetes Mellitus Hypertensive Nephropathy Hematological Disorders

InvestigationComplete urine examinationRenal Parameters-urea and creatinineUltrasoundIVUCystoscopyRenal Biopsy

Approach to the patient with Hematuria

Interpretation of Dipstick positive hematuria

Hematuria with WBCs-Infection

Hematuria with Abnormal epithelial cells-Tumor

Hematuria with RBC casts-Glomerular bleeding

Hemoglobinuria-Intravascular Hemolysis

Myoglobinuria-Rhabdomyolysis

TreatmentManagement of hematuria involves the

treatment of underlying cause.

Polyuria

DefinitionPassing large volume of urine (>3L per day )

is called polyuria.

Causes of PolyuriaExcessive fluid intake

Osmotic:Hyperglycemia,Hypercalcemia

Cranial diabetes insipidus:Reduced ADH secreation,secondary to trauma,tumor,or idiopathic.

Nephrogenic diabetes insipidus: Genetic tubular defects Drugs/toxins-Lithium, Diuretics Interstitial renal disease Hypokalemia,Hypercalcemia

Investigations24 hour urinary collectionSerum electrolytesSerum calciumSerum glucose levelsRenal parameters

Proteinuria

DefinitionThe presence of abnormal quantities of

protein in the urine is called proteinuria.

Causes Transient proteinuria

UTIFeverHeavy exercisePregnancyOrthostatic proteinuria - not found in early

morning sample, uncommon over age of 30 years

Vaginal mucus

CausesPersistent Proteinuria: Primary renal disease

Glomerular – GNTubular

Secondary renal diseaseDMCTDVasculitisAmyloidosisMyelomaCCFHypertension

Evaluation of ProteinuriaHistory:• Symptoms of renal Failure• Arthralgia, Mouth ulcers, Rashes indicating

connective tissue disease• Past History of DM,HTN,CCF• Drug History-NSAIDs,Captopril• Family History of Polycystic kidney disease,

Reflux nephropathy

Examination• Look for signs of Nephrotic syndrome• Signs of multisystem disease – rashes,

splinter hemorrhage, bruits.• B.P• Urine dipstick test to check for microscopic

hematuria – if + go for urine microscopy.• Rule out Diabetes and UTI

Quantification of Proteinuria24 hour urine

collectionSpot urine protein to

creatinine ratio(PCR)Albumin to creatinine

ratio(ACR)More than 150 mg in

24h or PCR of 15 mg/mmol is abnormal

Nephrotic range - >3.5 g/24h or a ratio > 3500 - check for serum albumin and cholesterol.

Approach to a patient with proteinuria

Microalbuminuria

Microalbuminuria describes the urinary excretion of small amounts of albumin.

Microalbuminuria indicates glomerular disease e.g diabetic nephropathy

Bence Jones proteinuria

Patients with a clone of B lymphocytes secreting free immunoglobulin light chains filter these freely into the urine, and this can be identified as ‘Bence Jones protein.

• A feature of multiple myeloma and amyloidosis

Nephrotic Syndrome

Definition• Nephrotic syndrome is a condition

characterized by

• Nephrotic range proteinuria• Hypoalbuminemia• Hyperlipidemia • Edema

Clinical FeaturesClinical features of Nephrotic syndrome include:

Edema: Dependent edema of lower limbs,Genitalia,acities and facial edema more prominent in children.Hypercholesterolemia: Increased incidence of atherosclerosisHypercoagulability: Leading to venous thromboembolismInfections: pneumococcal Infections

Pathogenesis Edema:• Urinary protein losses exceeds synthetic capacity of liver Reduced oncotic pressure edema • Secondary hypoaldosteronism Sodium Retention Edema Hypercholesterolemia: Non-specific increase in lipoprotein synthesis by liver in response to low oncotic pressure

Pathogenesis Hypercoagulability:Relative loss of inhibitors of coagulation (e.g. antithrombin III,protein C and S)and increase in liver synthesis of procoagulant factors.

Infections:Hypogammaglobulinaemia due to urinary losses.

Management• High dose steroids in children with nephrotic

syndrome sec.to minimal change glomerulonephritis

• Diuretics• Low sodium diet• Lipid Lowering drugs(HMG CoA reducatase

Inhibitors)• Anticoagulation prophylaxis for

thromboembolism• Consider vaccination for Pneumococcal

Infections

Thank You