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HematuriaFor the boards...

Gital Karamchandani-Patel, MD

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Definition

Macroscopic (gross) Hematuria any discolored urine visible to the

human eye Microscopic Hematuria

>5 RBC/hpf seen under microscope

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Hematuria

Patient comes to your office complaining that their urine is reddish in color...

What is your first step?

– Good H+P

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Hematuria

Is it really blood? Urine Dipstick

Detects Hgb, myoglobin Detects protein

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Hematuria

Urinalysis Definitive for the presence of RBC

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Hematuria

Upper urinary tract

glomerulus collecting tubules interstitium

Lower urinary tract

calyx pelvis ureter bladder urethra

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What PREP wants you to know...

Know the differential diagnosis of a child with gross hematuria

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Differential D iagnosis

g lo m eru la r*prompt eval for kidney dz

w ithp ro te in u ria

e x trag lo m eru la r

w ith o u tp ro te in u ria

+ R B C s

H gbm yo g lo b in

h e m e +

d ru gsd yes

h e m e -

- R B C s

M a cro sco p ic H em a tu riao b ta in U /A

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Glomerular Hematuria

brown, tea colored urine proteinuria deformed urinary RBCs RBC casts

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Glomerular Hematuria

RENAL

IgA nephropathy Alport syndrome Thin glomerular BM

disease Post infectious MPGN

MULTI-SYSTEM

SLE nephritis HSP nephritis Wegener syndrome Goodpasture syndrome HUS Sickle cell Disease

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W/u for Glomerular Hematuria CBC C3, C4 antistreptolysin-O titer, streptozyme titer serum electrolytes, BUN, serum Cr,

serum albumin test for lupus Hep B antinuclear cytoplasmic antibody titer

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Extraglomerular Hematuria Hematuria from lower urinary tract

terminal hematuria blood clots nl urinary RBCs minimal proteinuria

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Extraglomerular Hematuria

UPPER URINARY TRACT

pyelonephritis ATN papillary necrosis nephrocalcinosis thrombosis malformation SCD tumor PCKD

LOWER URINARY TRACT

cystitis urethritis urolithiasis trauma coagulopathy heavy excersise UPJ obstruction ureterocele Munchausen, MBP

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W/u for Extraglomerular Hematuria serum creatinine urine culture sickle cell preparation in AA urinary Ca/Cr ratio C3,C4 U/S of kidneys/bladder to R/O polycystic

kidney disease, tumor, ureteropelvic junction obstruction, and stones

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Proteinuria For the boards...

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Proteinuria

Occurs in 10% of kids 8-15 yrs differentiate between

renal disease transient benign

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Proteinuria

Dipstick detects mostly ALBUMIN negative (0 mg/dL) trace (10-20 mg/dL) 1+ (30 mg/dL) 2+ (100 mg/dL) 3+ (300 mg/dL) 4+ (1000-2000 mg/dL)

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D iffe re n tia l D ia g n o s is

o rth os ta tic tra n sie n t

b e n ign

g lo m eru la r tu bu la r

f ixed

P ro te in u ria

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Proteinuria

A child comes into your office for a routine visit

Screening urine dipstick reveals 1+ protein

What is your next step?

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Proteinuria

R/O benign conditions sg >1.020 pH >7.5 mucoproteins acute illness

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Proteinuria

Next step is to determine if this is transient or fixed R/O orthostatic proteinuria

first am U/A W/u for persistent fixed proteinuria

alb, C3, 24 hr urine protein Pr/Cr ratio

W/u for glomerular hematuria if + RBCs

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Quiz TimeLet’s see who has been paying attention...

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Quiz time #1

10 yr old boy coming in for school physical. Found to have 30 RBC/hpf on microscopic analysis.

Fam Hx reveals uncle used to have “blood in his urine”

What is your diagnosis?

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Quiz time #1

Familial Causes of Hematuria Polycystic kidney disease

Thin basement membrane disease

Alport syndrome (hereditary nephritis with deafness)

Hypercalciuria with family history of nephrolithiasis

Sickle Cell

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Quiz time #2

Gross hematuria following a URI C3 is wnl

What is your diagnosis?

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IgA Nephropathy (Berger’s Disease) IgA deposits seen on renal biopsy nl C3 elevated IgA in 15% often hypertensive need long-term f/u

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Quiz time #3

This kid was in your office 2 weeks ago. Mom is calling and saying his urine looks like coca-cola.

What is your diagnosis?

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Acute Post-Infectious Glomerulonephritis Caused by nephritogenic GAS

infections of the pharynx or skin Most children recover complete renal

function C3 levels LOW initially, then return to

NL after 6-8 wks may have BP, proteinuria,

hematuria for up to 3 mos after initial presentation

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Quiz time #4

3 yr old F with diarrhea 6 days later develops a rash,

abdominal pain on PE, you note pallor and purpura

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Quiz time #4

What is your diagnosis?

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Hemolytic-Uremic Syndrome MCC of ARF in children Caused by shiga toxin producing

E.coli O157:H7

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Quiz time #5

Infant comes in with hematuria h/o constipation h/o TEF repair

What is your diagnosis?

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VATER association

V vertebral anomalies A anal atresia T E R radial limb anomalies

TEF

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Quiz time #6

14yo female with hematuria More “tired” lately

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Quiz time #6

What is your diagnosis? What labs will you order?

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SLE nephritis

C3 and C4 will be LOW Sometimes will only manifest as

kidney disease WHO staging of nephritis

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Quiz time #7

11 yr old boy with gross hematuria, edema.

Initial labs reveal LOW C3 and C4

What is your diagnosis? How do you make definitive dx?

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Membranoproliferative Glomerulonephritis

MPGN is the MCC of chronic glomerulonephritis in children

renal biopsy confirms dx

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Confused about complement? What three conditions cause

hypocomplementemia? P post infectious GN

M membrano proliferative GN

S SLE

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Quiz time #8

It is 10pm. You are the intern on call for purple. A 5th floor nurse pages you to tell you that ortho has just consulted you on one of their patients for hematuria.

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Quiz time #8

You look through the chart and the all you can decipher is that she was in a car crash 2 weeks ago.

You go to examine her and note she is in a full body cast, o/w NAD and afebrile.

What is the one test you will order before you go back to your call room?

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Quiz time #8

Answer: Urine Ca/Cr ratio!! urinary calcium:urinary creatinine

ratio of > 0.21 24-hour urinary calcium excretion

of >4 mg/kg

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Hypercalciuria

Idiopathic 30% 15% go on to have renal stones

Immobilization Hyperparathyroidism Furosemide Vit D intoxication

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Thank you for your attention!

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PREP specs

Plan the evaluation of hematuria in a child with sickle cell disease.

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PREP 2005 #70

A previously healthy 10 yr old AA boy reports a 2 day history of back pain and gross hematuria. There is no history of trauma or passed kidney stones. His vital signs are normal, and PE reveals R CVA tenderness. His older brother has several similar episodes when he was younger, as did his mother when she was a child.

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PREP 2005 #70

You suspect that this boy has sickle cell trait and papillary necrosis.

Of the following, the BEST test to confirm the diagnosis is: A. abdominal xray B. CT C. intravenous pyelography D. renal scintigraphy E. renal U/S

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PREP 2005 #70

Correct Answer: C