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Yeah. Um Good afternoon and welcome. My name's Steven Marks. I'm professor of pediatric nephrology and transplantation at University College London. I lead the kidney transplantation program here as well as um being director of R N I H R Badged Great Ormond Street Hospital Clinical Research Facility where we do all high impact clinical trials and translational research. I'm really grateful for the honor of speaking to you all again. Um Again, this new term. So welcome back for those of you been before and welcome to those that are new. Um I've been working with crisis Rescue Foundation and the excellent work they're doing and really grateful for all the wonderful feedback. Um I know many of you have been dispersed um over time and uh um some of the lectures in the past have been tricky without internet and wifi going down. So our thoughts are with you all in your family's wherever you are in the world. So I'm going to start with a little bit of case presentations. Talk a little bit about does hematuria's actually matter. Um and then kind of concentrate on both microscopic and microscopic hematuria in together with a bit of protein urea and then putting it all together. So we'll start with some case presentations to really show you that very quickly. You can get enough clinical information to try and make a reasonable assessment. So this is a 12 year old boy. He was admitted with a four day history of severe left loin pain. He had a three week history of a Fabbro recurrent episodes of microscopic hematuria. He wasn't drinking as much. He had severe left line tenderness on examination and he was in renal dysfunction. Um sorry, normal renal function and albumin, but trace of protein on urine dipstick with four plus of hematuria and no cast. So does eman have any idea what this potentially could be if you want? You can just um mute Christy, I think even muted. Would it be post streptococcal glomerata? Yep. So post streptococcal or post infectious glomerulonephritis, obviously part of the differential diagnosis, but you, you've got a patient who's got loins tenderness. So, on one side, they've got pain. So this is painful, recurrent episodes of microscopic material. Yeah. So I think you're right as thinking about, do you actually have any evidence of nephrolithiasis? A renal calculi? And here you can see on this ultrasound as a demonstrating that you can see that there is this echogenic material in the middle. And then you can see there's what we call an acoustic shadow. So you can see where that black lines are going um from the middle down to the bottom of the screen. So that's evidence of a renal calculus. So, what about comparing with a three year old girl who has recurrent episodes of microscopic hematuria over the last six months and they tend to be associated with the viral upper respiratory tract infections. But she's otherwise eating and drinking. Normally she's not vomiting. There's no family or past medical history. There's normal examination and investigations reveal again, normal kidney function, normal serum albumin, there's no protein urea, but there is three plus of hematuria and no cast. And of course, this time on ultrasound, you've got no evidence of calculi. So these are this is description of a child who is relatively well, recurrent episodes of microscopic hematuria, not associated with fever is otherwise well but associated with an upper respiratory tract infection. So, um do you have any idea what that potentially maybe the B I G N nephropathy? Yeah, I think you're right. So I think the most likely with that kind of picture would be an iga nephropathy. So we've got new classification and many of you have heard of lotion on purpura or what we call now iga vasculitis, which is really is the same histopathological changes that we see in biopsy, especially in immunohistochemical tree with I G A staining. So, I mean a global in a staining. But the difference is with iga nephropathy, which is much more common and adults, the most common presentation is this recurrent episodes of microscopic hematuria, you can get in Children but very rare. But more commonly in adults are chris authentic glomerulonephritis due to iga nephropathy. Whereas in Children, we generally see him lotion and purple a with a typical prep eric rash which develops by the time you got any kidney involvement, which again can be associated with a rapidly progressive memory nephritis. And lastly, what about a six year old girl who developed a viral upper respiratory tract infection with sore throat and cough. Three weeks ago. Both parents and a younger sister also had an upper is virtue tract infection and she had a 40 hour history of vomiting with Coca Cola color urine and a 24 hour history of periorbital edema and oliguria. Examination revealed that she was hypovolemic signs of peripheral edema hypertension with the systolic BP of 1 30 millimeters of mercury. And she had evidence of renal dysfunction with an elevated plasma crotan of 100 and 50 micromoles per liter, hypoalbuminemia 22 g per liter because she had nephrotic range proteinuria with three plus of protein, urea, three plus of hematuria and red cell casts. Stripping. Use. It's B S G N, isn't it? Yes. So this is much more likely a post infectious glomerulonephritis. As you said, initially, Christie, they can be obviously post streptococcal, but we see very many other bacteria viral pathogens which can cause a post infectious glomerulonephritis. And actually, it's a little bit of a misnomer because obviously, if you've got a post infectious glomerulonephritis by single marine arthritis, it sounds like histopathological diagnosis. But most Children who present in a typical way such as this with improvement with fluid and electrolyte management and improvement renal function actually wouldn't proceed to percutaneous renal biopsy. So let us consider now if um hematuria actually matters. So when we see blood in the urine, we call that frank or macroscopic hematuria. I think yes, we do need to investigate and understand why it happens. Whereas if you've got urine, which looks absolutely fine, but you've got a positive dipstick. As you can see here, I will try and tell you why. I think you don't need to investigate. In fact, probably stop over investigating these patient's. If you look at the epidemiology of hematuria with microscopic hematuria, invariably there's a clear diagnosis you can see here um that you have about one in 500 prevalence and the resolution varies. However, with microscopic hematuria, the definition varies. Um you can have a prevalence which is up to eight times that. So 1.5% of the population and what you'll find is that three quarters up to that will resolve by six months. So if we think about blood in the urine, we're only going to uh investigate if they've got these episodes of blood in the urine. And I think it's, if they've got recurrent microscopic hematuria, especially if we're in the situation that we have an issue that they've developed protein urea as soon as you've got protein in it, then that's one thing that you need to move on and investigate. I think it's important to exclude non glomerular causes as well. And thinking about if there's a familial disorder, and also we need to consider the future of the child, both occupation and insurance. So actually giving a diagnosis or label may do them a disfavor in the future. And obviously, it can have importance, for example, in thinking about getting a mortgage if you've got labeled as having a chronic condition. So how can I say this? Well, if we do renal biopsies for episodes of recurrent microscopic or intermittent microscopic hematuria that you can see here, you can see that over a quarter will have an all ports nephropathy. So these are a group of conditions. Um collagen opathy is as we call them the effect, the glomerular basement membrane and the thickness that you can see an electron microscopy together also within basement membrane, which has a more favorable prognosis, which happens in about one in six. But also you can see about a quarter of patient's will have evidence of an iga nephropathy and there'll be about a six that will be completely normal on biopsy. And about 1/5 where you may see some minor changes such as MS angio proliferation. But what you can detect in these patient's that you see here that unless they develop protein urea or hypertension or evidence of renal dysfunction. I currently do not have any drugs in my Armamentarium that I can give to treat. So these patient's can be monitored just for protein urea hypertension and renal dysfunction. I would say in my other role in we are looking at clinical trials. So this may change in the future. So in fact, you may want to have genetic results to show that you've got someone with Alport Syndrome because we may have treatments in the future. So let's concentrate. First of all about macroscopic hematuria. So this is where there's blood in the urine. We know the visual examination of the urine. They may contain very small amounts of blood. So if you take a liter of urine, you do your finger prick and you drop one drop of blood into the liter of urine, you'll in fact get rosy urine. So microscopic hematuria may contain significant numbers of red blood cells. Obviously, if you've got complete bright red staining, you've got clots, you've got heavy bleeding from trauma and coagulopathy. It's important to look at that. Excuse me. If however, you've got cloudy urine, then you need to consider if there's pus and that obviously will be associated with a your detract infection. So that although it's not common to present with a urinary tract infection, having microscopic hematuria, if you do have microscopic hematuria, it's really important that your new tract infection is excluded. Obviously, you can actually, um, save the urine and that will show you if there's any gravel associated with the formation of stones such as carl same urate system or even struvite. There are instances where you will see bloody urine but there's not actually blood present. Mhm. And some of the causes may in fact be, for example, food coloring or foods itself. So, I've seen some Children that have had food fads, the parents are trying to get them to eat fruit and vegetables. They're very conscious about getting five a day in and they are having difficulties. And all of a sudden, a kid likes beetroot soup and they take a huge intake of beetroot and their urine turns red. So I wouldn't worry about that as I would worry about if you identify food coloring. And in fact, we had Sunny Delight, which was an orange drink, which contained a food coloring and actually made children's urine change color. Many of you will be aware that our fam person can cause red tiers and that can in fact stain your contact lenses. But many don't realize that they can also produce a red discoloration to your urine and that has no consequence whatsoever. Children are much less likely than adults to have a hemoglobinuria, a myoglobinuria even prefer or other inborn errors of metabolism. However, in the natal practice, it's very common to have your eight crystals. This is where you see orange discoloration in the app the nappy initially. And of course, we need to be very mindful of the condition that we see, which is called factitious hematuria. So this is where a child does not have blood in the urine. But we're in the situation where actually there are, there is blood available and that can sometimes be put in by a member of the family such as a parent or a step parent. So the old terminology of factitious illness and previously of Munchausen syndrome by proxy, it's important to make that diagnosis in one way. Of course, is to make sure you've got uh command change so that you know that the urine being sent has been witnessed being given by the parent or family member and is traced all the way to the laboratory so that it cannot be mixed up. So it's really important to involve your local safeguarding team in ensuring the sample is handled. You can also speak to the laboratory in testing what the blood group is of the red cells. Of course, the perpetrator may have the same blood group as the child. And in which case, you can actually do DNA testing to look to see whether the cells in the urine correspond to that of the child. But the bottom line and important messages, you must always confirm the presence of red blood cells on your um microscopy. So here you can see a stone coming down the urine new chat. And of course, it can get stuck at various points. So as it comes down, it can get stuck initially at the Pelvis, you're a Terek junction, laterally, the vehicle, you're a territory junction. So the physical ureteric junction or even in urethra. And of course, if you've got another kidney which is working normally, then you'll be fine. But of course, if you've got a sultry kidney here with a P U J obstruction or here with a V U G obstruction or even at the urethra, then of course, that can have catastrophic effects with acute kidney injury and the timing of the microscopic hematuria is important. So, looking at if it's throughout maturation, a renal cause a bladder cause of its terrible hematuria or non specific your arthritis and the urethra cause whether it happens at the start of maturation. So if we look at the overall causes of microscopic hematuria and recently Julie Ingo Finger, who now is uh one of the editors of the England Journal of Medicine was in London and I told her I still show her slide which is um coming up for 45 years old from the pediatrics. You can see that nearly a half for either proven or suspected during the tract infections. Some may be due to irritation or trauma or glomerulonephritis or cure a Glow Pathy. And sometimes as you can see nephro with isis but very rarely tumour. And if you've got blood in the urine, it's about thinking when it happens, how it happens, could it be exercise induced? What we called March hematuria. So, if you relatively dehydrated, you undergo really aggressive exercise, do a marathon, you can induce a microscopic hematuria. And you can also see this with a loin pain hematuria's syndrome. We sometimes see hemorrhagic cystitis, which can be instituted by each heterogenic lee from using, for example, cyclophosphamide therapy but hypercalciuria. So having a high calcium excretion is very often in the developed world due to a high sodium intake. So our diet has really changed with increased salt intake, promoting increased calcium excretion. And we can also see this in hyper you crazy area but very rarely with bladder tumors such as a rhabdomyosarcoma. But what I want to highlight is that the tests you need to do are very minimal. So get a midstream sample of urine from my crossfit culture and sensitivity. If you've got evidence of a urinary tract infection, if you think you've got hypercalciuria by doing a urine calcium to creatinine ratio and doing a Doppler renal ultrasound to exclude calculi hydronephrosis, populating necrosis and a renal venous thrombosis. But it would also detect other abnormalities such as bladder abnormalities. And obviously, for individual patient's, we'd want to exclude if they had an overwhelming Coca Cola urine. Uh for example, a glomerulonephritis such as lupus nephritis iga nephropathy. But the important thing and the management of microscopic hematuria is to confirm the presence of red blood cells of microscopy by looking and seeing with the patient full physical examination, including measurement of manual BP and sending off a sample for a midstream sample of urine, especially in adolescent and treating if they have evidence of a urinary tract infection. If you're not sure, make sure you take a full family history, think about repeating the your analysis and doing further investigations, checking. Have they dropped their hemoglobin? Are they thrombocytopenic? Do you have a quick neuropathy? Is evidence of inflammation with an elevated esr and c reactive protein. Do they have renal dysfunction? Are the leaking protein? Do they have nephrotic proteinuria with or without albumin urine hypoalbuminemia? Do they have evidence of a post infectious glomerulonephritis with an elevated antistreptolysin old teeter or an anti DNA is be or do they have evidence of hypocomplementemia? But also looking at the serum immunoglobulins and IGA being elevated may be supportive of the diagnosis of an iga nephropathy but taking a urine dipstick, I'm sending off for microscopy and culture. I'm seeing if there's albumin urea and thinking about your eight excretion and calcium excretion by doing a urine calcium to creatinine ratio. And we would do a full renal tract ultrasound invariably in the past many would do abdominal lecturing because it can sometimes be difficult to see stones, especially the physical your doubt junction, but very often we can get by. And of course, it's important to refer to pediatric nephrology if there's evidence of renal impairment, protein urea and hypertension. So, what about microscopic hematuria? Well, we know that urine dipsticks are convenient. They're very widespread. We store them in a dry environment. They have automated results with the print out and they're detected by using blood, for example, by paroxys like Axion and it detects very small quantities. So a negative result in fact, does not exclude hematuria. Whereas protein urea is detected by the better binding of albumin by using tetra bromo funeral. So if you've got microscopic hematuria and you've got normal kidney function and you don't have protein urea and you've got normal BP and it's a symptomatic. You really want to just check whether it goes away, especially if you've got it during it into a current infection. But it's important that if it's happening without any symptoms and signs is to think about families screening because actually other family members may have microscopic hematuria with a white protein urine, especially if it was a parent, you would want to investigate them first, especially if your child is more likely to have the lack of protein urea, renal dysfunction or hypertension. If the child does have symptoms and are signs thinking of fever, lethargy, hypertension adama that potentially would warrant acute pediatric review to try and work out what the underlying etiology. But if they all resolve and you've got microscopic hematuria remaining without protein urea without hypertension and without renal dysfunction, then you'd want at least an annual review to check to see that they have resolution of they're microscopic hematuria. Obviously, one could now consider in 2023 doing genetic tests. But I think it's important to counsel the family about what you may or may not find. If you've got a child with urinary tract symptoms, such as the syria urgency frequency and enuresis. It's important to move forward and to investigate, to exclude a urinary tract infection. But if they have non urinary tract symptoms such as rash, purple, arthritis, John decide gastrointestinal, then you may want to think about a vasculitis or an underlying cause. Remember that fever, illness, trauma and extreme exertion can all induce microscopic hematuria. But remember that if it's not related to the kidneys, then you'd be in the situation that it will get better and it will resolve as soon as what the initial problem is. If you really have a kidney problem, the hematuria will almost always persist. So what we want to do is to demonstrate resolution and discharge if it resolves, especially in a case where um it's resolved very quickly. It may be intermittent over about six months. In which case, you might want to think about dips, sticking the urine of both parents and considering ultrasound and urine calcium to creatinine ratio. But obviously, if there is protein urea or persistent microscopic immaterial, then we'd be happy to see the family and discuss and exclude complex disease, especially if there's a family history. If we have microscopic hematuria without protein urea, again, we would probably just do a ministry in sample of urine, a urine calcium creatinine ratio and a renal ultrasound to exclude your knee shots, infection, hypercalciuria, renal calculi and hydronephrosis is, would we want to do a biopsy? We'll um one of my colleagues asked me this very question yesterday and I have not undertaken a percutaneous renal biopsy for just microscopic hematuria in the last decade. And the reason is that although parents may want to push for a diagnosis, avoid later investigations may lead them to genetic counseling. Maybe reassuring may be able to be discharged. It's still an invasive procedure doing a biopsy and very often there's no treatment unless they develop proteinuria hypertension, a renal dysfunction. And how can we be sure of this will every year Japan's kids undergo screening through the schools program? So 100 and 60,000 Children of which they detected. Um as you can see here, about one in 500 having microscopic hematuria over half of which were asymptomatic. And you can see here that the others happened because they're either completely normal kids that resolved or potentially it was related or was directly related to menstruation. Many kids with non kidney problems will come up, especially if they had a concurrent infection or we know to have evidence of hyper calcerea of which one patient out of five here, you can see had evidence of nephrolithiasis. But some actually for iga vasculitis, ahealon, Charlyne and purple and nephritis. You could actually get this information from the past medical history because they were known an ongoing persistent microscopic hematuria and the absence of protein urea hypertension renal dysfunction is very reassuring hydronephrosis and polycystic kidney disease, of course may also be picked up. So what if you follow kids up between six and 13 years? They have? Um you can see here, the majority will do well and many kids will not develop hypertension renal dysfunction, but very rarely, you may develop a bit of protein urea. So this is a schema that I devised when I worked in the North America. Thinking about looking at the urine microscopy and seeing how many red blood cells they were. If as you detect, there are red blood cells doing a family history and screen and if there's microscopic hematuria without protein urea, then thinking about those three tests, urine microsphere culture and sensitivity, you're in costume to grant an issue and ultrasound. Whereas if you've got microscopic hematuria, you'd want to do further investigations. Um, as you can see here, making sure they've got normal renal function as well as potentially other investigations. Looking at the immune system trying to exclude glomerulonephritis, complement C three C four in an anchor. But if you have evidence of micro or microscopic hematuria with protein urea, then doing an early morning urine albumin to creatine ratio in North America, very often a 24 hour urine protein to creatinine ratio. They would do and investigating the immune system and considering renal biopsy, especially if it's evidence of renal dysfunction. So here you can see the schema if you've got protein urea, which is persistent and heavy with your hematuria, we'd proceed to a biopsy. If there was very negligible protein urea, we would only do a biopsy. If there was continuous e materia. If there was a family history, then you may want to do a biopsy. But depending on what genetic testing, we would do that more readily if there is intermittent hematuria and there's nothing in the family but you have persistent microscopic hematuria without protein urea hypertension, a renal dysfunction, we would reassure and as I said, in the last decade, that hasn't been rejected by families to allow me to proceed to a biopsy. They've understood the reasoning. But obviously, most of the time you can reassure families um and talk about follow up. So what about if you do develop protein urea? Well, it's important to make sure that you check if there's evidence of protein Europe, but not whilst adolescent girls are menstruating. Um It is important if you've got microscopic hematuria at other times, evidence of a demand or hypertension. But what we would do is do a bedside testing by the early morning, urine samples are concentrated urine sample first in the day. And potentially we could then investigate for orthostatic protein urea. So this is looking at the development of protein urea during the day. It's important to consider whether it's tubular glomerular protein urea is what we call nephrotic range proteinuria, which can be in an early morning urine albumin to creatine ratio. But also looking at the serum albumin and checking to see if there's any evidence of renal dysfunction before proceeding to percutaneous renal biopsy. And I put this up to show you the rough normal values. So you can see that usually in single figures, milligrams, minimal urine albumin to creatine ratio would be normal over most of the different age groups. So it's important with protein urea to always look at the specific gravity and try and quantify the protein urea. Um if you've got three plus or four plus, um especially good to do in an early morning urine sample, but it almost as indicative of pathological protein urea. Remember, you can have a little bit of protein urea up to about 60 mg for me to square per day and arrested a federal child. So, orthostatic protein urea touched on this is protein urea that developed during the upright position. And you may actually see a difference if you do a split 24 hour urine collection between the day and the night. But if you do have glomerular disease, you're going to develop and have protein urea, which happens all through the day and night. Orthostatic protein. You is more common in adolescent men tends to be transient and variable nature and very often is less than 1 to 2 g per day. And although previously benign condition, if you do biopsies, you will see subtle abnormalities of the glomar alli, some of those may go on to develop more pathological protein urea with time. So if you've got microscopic or microscopic hematuria with protein urea, we'd want to exclude the glomerulonephritis screen, check on the renal function. The complement C three C four, you don't expect if you, for example, had post infectious glomerulonephritis, a low complement C three. But remember that about a quarter of the population of C four null. Although a low complement C three and C 4 may suggest a patient with systemic lupus erythematosus and lupus nephritis where you may have a positive A N A may have a positive double stranded D N A. But we would consider doing a percutaneous renal biopsy if there was evidence of renal dysfunction. So part of my training in North America but also North England, we used to actually spin the urine in the accident emergency department. And actually, if you see this under your microscope, you see a red blood cell cast, you know there's a glimmer nephritis going on. So here you can see the difference between nephritic and nephrotic syndrome. Nephritic syndrome with microscopic hematuria and protein urea. Um oleg urea with an acute kidney injury, salt and fluid overload and water retention and high BP as a result. Whereas nephrotic syndrome is where you have a much larger degree of protein urea, what we call nephrotic range proteinuria above 1 g per meter square per day, which is enough to drop your serum albumin below 25 g per liter. And may be associated with peripheral edema hyperlipidemia. Remember the commonest cause of an impure nephritic syndrome as opposed to infectious glomerulonephritis. Whereas the commonest cause of a nephrotic syndrome with minimal change disease. Whereas if you've got mixed nephritic a nephrotic picture, then most likely it's a post infectious glomerulonephritis. So if we consider having urinary protein urea with nephrotic range proteinuria academia, you'd want to check the renal function check of the hype ob anemia. I consider referring if they're abnormal features. So a child above 10 years of age of the systemic disease, hypertension development of microscopic hematuria. But ordinarily, we would treat as a new presentation of idiopathic nephrotic syndrome with oral prednisoLONE, up to 60 mg of prednisoLONE at a 2 mg per kilogram per day. And that for at least a consideration for um the initial four weeks, many people will also consider 60 mg per meter squared per day. But again, historically, people have used maximum of 80 mg, even 100 mg, but I wouldn't use more than 60 mg. So I think it's really important to oversee and examine your patient's carefully and try and work out what's the correct way of going. So, if you look at this here, if we do a dipstick test, what you have to consider when you're doing it is to repeat it. And if you've still got ongoing persistent proteinuria, consider doing an orthostatic test that we described and actually giving urine dipstick testing for the family to dipstick every single urine over the weekend, over uh 24 hour, 40 hour period is very, very helpful. If you've transient proteinuria, which goes away, then it's usually reassuring. But you should re evaluate it a year. And if you do have persistent protein urea, thinking about glomerulonephritis, if they've got um glomerular protein urea, but with an increased early morning urine albumin to creatine ratio. But if you've got tubular protein urea, which you may be able to test for a urine um retina binding protein or an N amino D clucosamine. Today's um being elevated, you may have a tubal in sitio nephritis. So looking at your phosphate to see if that's low, if you've got tubular re absorption of phosphate has been impaired. If there's evidence of glycosuria, aminoacidemia phosphate losing, as I described little chilled acidosis, an impaired urinary concentration. However, if we've got a patient and they were on immuno suppression for an active glomerulonephritis, um it's really important to look at the patient overall. However, if there is evidence of protein urea without inflammation, then we'd be considering using an ace inhibitor and or an angiotensin receptor blocker, we generally don't use both due to the risks of renal dysfunction with inter current infections as recommended by the MHR A. But both of them will treat hypertension and protein urea by efferent arterial dilatations, reduces glomerular pressure. We would generally start with the use of an ace inhibitor with enalapril lisinopril at 0.1 mg per kilogram per day with the check of the potassium and plasma crown in at least one week after commencing. And although you may be in the situation, if you increase the dose, you may only need to test it. Um a fortnight later, always worth checking that they don't develop hyperkalemia, renal dysfunction. But you may accept a small change in the renal function if it overall improves the proteinuria but warning the patient and family about the development potentially of a non productive cough and other potential to tear estrogens. So in summary, if you have microscopic hematuria, if you have recurrent in confirmed red blood cells, check the timing during the urinary stream, try to help isolate a cause, try and exclude your new tract infections, renal calculi or nephrolithiasis iss if you have continuous and confirmed red blood cells as part of your dipstick, positive microscopic hematuria. Think about looking at the parents, other family members, excluding protein, urine hypertension and discussed with the family. What the options maybe which may be an annual urine dipstick to check, they don't develop protein urea on top of their continuous microscopic hematuria, making sure that you check, they've got normal BP and you don't develop renal dysfunction. Protein urea should always be investigated if it's persistent or non orthostatic and always consider nephrotic syndrome and glomerulonephritis in those instances. Thank you very much for your time and I'll be very happy to answer any questions. Thank you. I see. They're already some comments coming in in the chat. So please um do state um who your name is where you are currently? And which medical school you're at? And warm. Welcome to all of you around the world. And I'm happy to answer any questions if the patient's are coming with microhematuria and you find know uh renal pathology um other is there going to be a plan to follow up? How long you follow up? So if, if a child, I think very good question, Chris, if a child has microscopic hematuria, so they don't have frank microscopic hematuria, they don't have protein urea. There's no evidence of high BP, a renal dysfunction, but they still have ongoing microscopic hematuria for a year. I would say that they would require annual BP and urine dipstick monitoring at least. Um and check of renal function if they develop microscopic hematuria or renal dysfunction or hypertension. Um There is a move to do more genetic testing which of course we can do to try and reassure these patient's. Um that is something that you can consider and counseling the families because of course, you may get unifying diagnosis. Um but I would, if it's an older child, then of course, that adolescent follow up could be the primary care. So, with your general practitioner, but I would tell them it's on their onus to go every year to get their BP and their urine dipstick and sending off for urine albumin to creatine ratio if you do have significant protein urea and then check of the renal function. But please note that as adults, I know we don't all do it, but we probably all should be having our BP protect our urine dipstick check and a check of a renal function every year. Okay. Thank you. Thank you, Christy. Where are you from? Southern India? But I London, as I say, where are you physics here in London at the moment? I'm in London. I work in London. So where are you working Qing scholarship? Okay. Excellent. Well done. Welcome. Any other questions? Well, please remember to put all your comments on the chat and um please also remember um to contact if you've got any problems and I look forward to giving you further lectures in the future. Remember to send your feedback back. That's really important does help us um change how things are. And you can just see in the chat, they put it in the link on the docks, you'll also see the chat. There's the, if you're just the last one under crisis Rescue Foundation to put the certificates. So you've got that for your attendance and for your records. If there's nothing else, then I will leave you to it and I wish you all the best. Thank you. Thank you. Take care. We'll see you all soon. Thank you very much, professor, your doctor. A pleasure and apologies about the I T issues. I think I've hopefully sorted it for next time. All the best. Thank you have.