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
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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. Alports Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome

The most likely diagnosis is?

1. Acute Post Strept GN
2. Hypercalciuria
3. Alports 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. Alports 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. Alports Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
6. Henoch Schonlein Purpura

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