Professional Documents
Culture Documents
Proteinuria in Children
Adi Alherbish
Objectives
• To be able to define and recognize hematuria
and proteinuria
Hemolytic Anemia
• Hematuria • Edema
• Hypertension • Nephrotic range
• Oliguria proteinuria
• Increased Cr • Low albumin
• Hypercholestrolemia
Rapidly Progressive
Glomerulonephritis (RPGN)
RPGN
Immune Complex Pauci- immune Anti- GBM
• Post- strep GN • Wegner’s • Goodpasture’s
• IgA nephropathy granulomatosis disease
• Lupus • Microscopic
• HSP polyangiitis
• Polyartritis nodosa
RPGN
Immune Complex Pauci- immune Anti- GBM
• Post- strep GN • Wegner’s • Goodpasture’s
• IgA nephropathy granulomatosis disease
• HSP • Microscopic
• Lupus polyangiitis
• Polyartritis nodosa
• Management: supportive
• Prognosis: Excellent (Vog et. Al: 137 cohort-
ESRD: none, high Cr 10%)
IgA nephropathy
• Typical presentation: intermittent gross
hematuria that happen during colds
• Other: gross hematuria
microscopic hematuria
nephritis
nephrotic syndrome
ESRD
IgA nephropathy
• Diagnosis: clinical suspicion
IgA level 20% sensitivity!
Kidney biopsy- IgA in Immunoflorecence
• Clinical: persistent
microscopic hematuria,
hearing loss, lenticonus
Benign familial hematuria
(thin basment membrane
nephropathy)
• Autosomal dominant
• Hetrozygous mutation in type IV collagen
• Microscopic hematuria
• Screen the parents’ urine
• Benign course
Work up for hematuria
(History is important!)
1. Gross hematuria: onset, duration, progression, aggravating, relieving factors,
associated symptoms
2. UTI symptoms: dysuria, frequency, urgency, urge incontinence
3. Food intake: beet
4. Drugs: rifampin, nitrofurantoin, ibuprofen
5. IgA: gross hematuria onset while having colds
6. post strep: history of sore throat, tonsillitis, skin infection
7. HUS: diarrhea, pallor, fatigue, SOB
8. HSP: pupuric skin rash over legs and buttocks (palpable), join swelling/pain, abdominal
pain/bloody stools
9. Goodpasture/Wegners: hemoptysis, cough, SOB
10. SLE/ vasculitis: butterfly rash, discoid rash, mouth ulcers, photosensitivity, CNS
seizures/psychosis, join swelling
11. Kidney stones: renal colic, radiation to groins, past history or family history of stones
12. Anatomic: antenatal U/S, single umbilical artery, abdominal swelling
13 Hereditary: family history of deafness, family member with hematuria
14. Bleeding diathesis: hemarthrosis, epistaxis, petechaie, heavy periods in older girls
15. Problems with high blood pressure
16. Family history: nephritis, kidney failure, transplant, deafness, stones, hematuria,
consanguinity
Work up for hematuria
• Nephritis: ASO, C3, C4, anti-ds DNA,
ANA, ANCA, anti- GBM
• Kidney and bladder U/S
• Stone work up: urine Ca, Cr, oxalate,
citrate, cystine, uric acid
• Urinalysis in both parents
• Bleeding tendency: PT, PTT, INR
Proteinuria (Urine dip)
• Negative < 10 mg/dl
• Trace 10- 20 mg/dl
• 1+ 30 mg/dl
• 2+ 100 mg/dl
• 3+ 300 mg/dl
• 4+ 1000 mg/dl
Proteinuria (Quantitative)
Non- nephrotic Nephrotic
• What next?
Case 1
• 8 am: urine prot/Cr ratio- 10 mg/mmol
• 4 pm: urine prot/Cr ratio- 50 mg/mmol
Orthostatic proteinuria
Non Persistant Proteinuria
• Fever
• Strenuous exercise
• Cold exposure
• Epinephrine infusion
• Orthostatic
Case 2
• 1 year old infant with failure to thrive. Both
height and weight are below the 3rd
percentile. He has sings of rickets in
exam.
• Urine dip: Prot 3+ , Glu 2+
Derakhshan Ali et al. Saudi J Kidney Dis Transpl. 2007 Oct-Dec;18(4):585-9.
Fanconi Synrome
• PCT defect
• Proximal renal tubular
acidosis (type II RTA)
• Glucosuria
• Aminoaciduria
• Phosphaturia
• hypokalemia
Proteinuria
Glomerular Tubualr absorption Protein overload
• Hematuria
• Increased Cr (when intravasculary repleted)
• Low complement
• Positive lupus serology