Lecture 6.0 - Nephritic Syndrome Notes 2024 PDF

HAEMATURIA TO NEPHRITIC SYNDROME DR S CHIBA DEPARTMENT OF NEPHROLOGY HELEN JOSEPH HOSPITAL  DEFINITIONS MICROSCOPIC HAEMATURIA VS. GROSS HAEMATURIA Microscopic haematuria Defined as >2rbc/high power field in a spun urine sediment No “safe”lower li...

HAEMATURIA TO NEPHRITIC SYNDROME DR S CHIBA DEPARTMENT OF NEPHROLOGY HELEN JOSEPH HOSPITAL  DEFINITIONS MICROSCOPIC HAEMATURIA VS. GROSS HAEMATURIA Microscopic haematuria Defined as >2rbc/high power field in a spun urine sediment No “safe”lower limit below which significant disease can be excluded Gross haematuria Suspected because of presence of red or brown urine Color change doesn’t necessarily reflect the degree of blood loss 1ml of blood/1l of urine can cause a visible color change Copyrights apply Copyrights apply Detection Examination of urine sediment under a microscope is the gold standard Urine dipsticks for Hb detects 1-2rbc/hp field—very sensitive -more false positive results False negative results are unusual—negative dipsticks excludes abnormal haematuria  Aetiology Haematuria may be a symptom of underlying Disease Causes vary with age Most common causes: -inflammation or infection of the prostate or bladder -stones -malignancy or BPH in older patients - (glomerulonephrinitis) Copyrights apply  Are there any clues Does the haematuria from the history or Is the haematuria represent glomerular Initial evaluation physical examination transient or or extraglomerular that suggest a persistent? bleeding? specific diagnosis?  HISTORICAL CLUES Concurrent pyuria and dysuria,indicative of UTI A recent URTI suggesting either postinfectious GN or IgAN A positive family history for renal disease Unilateral flank pain,which may radiate to the groin,suggestive of ureteral obstruction,due to calculus or blood clot Flank pain that is persistent or recurrent can also be part of the rare loin pain haematuria syndrome Symptoms of prostatic obstruction in older men, such as hesitancy and dribbling Recent vigorous exercise or trauma History of bleeding disorder or bleeding from multiple sites due to uncontrolled anticoagulation Cyclic haematuria in women that is more prominent during and shortly after menstruation,suggesting endometriosis of the urinary tract Medications that can cause nephritis  Identification of Patients with clear glomeruli as source of evidence of glomerular Glomerular vs. bleeding is important haematuria do not have Extraglomerular both prognostically and to be evaluated for bleeding to optimize the potentially serious subsequent evaluation urological disease Copyrights apply Copyrights apply Glomerulonephritis = inflammation of the glomerulus Inflammation implies immune system activation Immune system is activated in response to: Antigens present in glomerulus normally (endogenous) Antigens deposited in the glomerulus (exogenous) - In both cases antibody binding is required Immune complex (antigen already bound to antibody) deposition Activation of neutrophils directly leading to respiratory burst (ANCA) Loss of regulation of complement Glomerular haematuria Urinary patterns -Focal nephitic -Diffuse nephritic  Focal GN Inflammatory lesions in50% loss of renal function within weeks to months Some: insidious onset, initial symptoms fatigue and oedema Most: have Scr of >264micromol/l at presentation -if renal failure is severe---manifestations of uremia (nausea,dyspnoea,pericarditis) Pulmonary renal syndrome -some pts may present with haemoptysis  Hypocomplementemia Postinfectious GN Lupus nephritis Membranoproliferative Mixed Commonly noted histological lesions cryoglobulinemia Less than 15y of age Postinfectious GN, membranoproliferative GN 15-40y of age Postinfectious GN, lupus, Crescentic GN, Fibrillary GN, membranoproliferative GN More than 40y of age Crescentic GN, Mixed cryoglobulinemia, Serologic findings Fibrillary GN, Postinfectious GN Antistreptococcal Abs in poststreptococcal GN ANF in Lupus nephritis Anti-GBM Abs in Anti-GBM Ab disease Circulating cryoglobulins in Mixed cryoglobulinemia Anti neutrophil cytoplasmic Abs (ANCA) in ANCA associated vasculitides Copyrights apply  Crescentic GN - types Type 1 – anti GBM Ab disease Type 2 – Immune complex Type 3 – Pauci-immune (ANCA positive) Type 4 – double ab positive Copyrights apply POSTSTREPTOCOCCAL GLOMERULONEPHRITIS  The role of renal biopsy Usually not done in: Postinfectious GN, mixed cryoglobulinemia, and anti-GBM ab Dx (serologic diagnosis is sufficient) Generally required in: Lupus nephritis Small vessel vasculitis  Transient or persistent haematuria It is reasonable to repeat an abnormal urinalysis in a few days If haematuria is transient, no obvious etiology identified in the majority of cases, however potential causes include ▪ fever ▪ infection ▪ trauma ▪ exercise  Malignancy risk in older patients with transient haematuria One study of 1032 pts evaluated by US,IVP, urinary cytology and cystoscopy Incidence of malignancy(bladder,kidney or prostate) was 2.4% -neither cytology nor IVP reliably detected all the tumors -US was very accurate for renal tumors -cystoscopy was required to reliably diagnose bladder or prostatic Ca -all but one tumor occurred in pts>50y of age  Radiologic tests If glomerular bleeding has been excluded in one with ongoing unexplained haematuria, the diagnostic work up should include a search for lesions in the kidney, collecting system, ureters and bladder The diagnostic yield increases with age and is higher for gross haematuria(up to 23%), than for microscopic haematuria(up to 14%) Multidetector CT urography preferred initial imaging modality - combines the benefits of conventional CT with those of IVP - in combination with cystoscopy provides complete evaluation of the GU system - increased sensitivity and specificity in detecting renal masses, calculi, pelvicalyceal and ureteric transitional cell Ca, compared to other modalities  RADIOLOGICAL INVESTIGATIONS If there is no clue to a specific diagnosis IVP or US: looking for stones, renal mass or polycystic disease IVP: first choice in young patients -can detect medullary sponge kidney -in older pts: detect lesions in the renal pelvis and ureters If contraindications to IVP, do an US Young pts with normal IVP do not need an US (yield of significant findings is low) Older pts with a normal IVP should undergo US or helical CT scan (better visualization of small renal tumors) Urine cytology In patients at low risk for urothelial Ca (50y of age and those with specific risk factor: prolonged, heavy phenacetin use, heavy smoking, long term cyclophos, exposure to certain dies, analgesic users are also at risk for renal Ca Urine cytology Urine specimen for cytology should be sent in pts at increased risk for urothelial Ca Sensitivity of urine cytology -greatest for Ca in situ of the bladder(90%) -limited for upper tract transitional Ca (>65% false negative rate)  Unexplained haematuria Glomerular Dx in at least 50% of cases (IgAN or Thin basement membrane Dx) Hypercalciuria or hyperuricosuria AVM or fistulas -rare cause of haematuria (usually with gross haematuria, high output cardiac failure and HPT, confirmed by arteriography or CT scanning) Loin pain-haematuria syndrome is a poorly defined disorder characterized by: flank pain that is often severe and unrelenting -haematuria with dysmorphic red cell (in some pts due to thin GBM Dx -possible psychological component) Screening for haematuria NOT recommended in patients who have no symptoms of urinary tract disease THANK YOU FOR YOUR ATTENTION