the office evaluation of hematuria and proteinuria: case presentations debbie gipson, m.d., m.s....
TRANSCRIPT
![Page 1: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/1.jpg)
THE OFFICE EVALUATION OF
HEMATURIA AND PROTEINURIA:
CASE PRESENTATIONS
Debbie Gipson, M.D., M.S.University of North Carolina-Chapel Hill
![Page 2: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/2.jpg)
Case 1
A healthy appearing 5 year old boy was noted to have asymptomatic hematuria at a school examination. Physical exam was normal.
Urinalysis had 1+ hemoglobin, no protein
![Page 3: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/3.jpg)
Which of the following interpretations is correct?
1. The child has blood in urine and requires further evaluation
2. The test showed small amount of blood which is nothing to worry about
3. The test showed small amount of blood which may be normal and repeat testing is indicated
![Page 4: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/4.jpg)
Which of the following interpretations is correct?
1. The child has blood in urine and requires further evaluation
2. The test showed small amount of blood which is nothing to worry about
3. The test showed small amount of blood which may be normal and repeat testing is indicated
![Page 5: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/5.jpg)
How many children with microscopic hematuria do you see?
1. One semiannually
2. One a month
3. One a year
4. Never, the AAP recommends that we
do not do urinary screening
![Page 6: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/6.jpg)
You arrange dipstick screening to be done by school nurse on all 8th-graders. Abnormal results will be found in:
1. 0.1%
2. 1%
3. 10%
4. 20%
![Page 7: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/7.jpg)
You arrange dipstick screening to be done by school nurse on all 8th-graders. Abnormal results will be found in:
1. 0.1%
2. 1%
3. 10%
4. 20%
![Page 8: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/8.jpg)
AAP Urinary Screening Guidelines
1. Infancy
2. Early childhood
3. Late childhood
4. Adolescence
AAP Policy: Recommendations for Preventative Care, 1993
![Page 9: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/9.jpg)
Case 1 Continues
The healthy appearing 5 year old boy had persistent asymptomatic hematuria for six months.
There was no family history of renal disease; his father had urinary stones. His father also was found to have asymptomatic hematuria.
Physical exam was normal.
Urinalysis had 1+ hemoglobin, no protein
![Page 10: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/10.jpg)
Urinalysis of 5 year old with 1+ blood
![Page 11: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/11.jpg)
Which of the following tests would be expected to be diagnostic?
1. Serum complement levels
2. Urine culture
3. Urine uric acid excretion
4. Urine calcium excretion
5. Serum IgA concentrations
![Page 12: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/12.jpg)
Which of the following tests would be expected to be diagnostic?
1. Serum complement levels
2. Urine culture
3. Urine uric acid excretion
4. Urine calcium excretion
5. Serum IgA concentrations
![Page 13: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/13.jpg)
Normal calcium excretion in a 5 year old child is:
1. < 2 mg/kg/day
2. < 4 mg/kg/day
3. Uca/creat < 0.6
4. Uca/creat < 0.2 birth - 16 years
![Page 14: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/14.jpg)
Normal calcium excretion in a 5 year old child is:
1. < 2 mg/kg/day
2. < 4 mg/kg/day
3. Uca/creat < 0.6
4. Uca/creat < 0.2 birth - 16 years
![Page 15: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/15.jpg)
Do you have patients with hypercalciuria and hematuria in your practice?
1. Yes
2. No
![Page 16: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/16.jpg)
Do you refer a child with persistent isolated microscopic hematuria and a normal renal ultrasound to a pediatric nephrologist?
1. Yes
2. No
![Page 17: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/17.jpg)
Have you diagnosed hypercalciuria and hematuria in a child who later developed a urinary stone?
1. Yes
2. No
![Page 18: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/18.jpg)
How do you treat a child with hypercalciuria?
1. Dietary (fluids, low Na) alone
2. Hydrochlorothiazide
3. Citrate
4. Lasix
5. Decrease calcium intake
6. Nothing
![Page 19: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/19.jpg)
How do you treat a child with hypercalciuria?
1. Dietary (fluids, low Na) alone
2. Hydrochlorothiazide
3. Citrate
4. Lasix
5. Decrease calcium intake
6. Nothing
![Page 20: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/20.jpg)
Which of the following tests is most frequently abnormal in the patient with persistent, asymptomatic, isolated microscopic hematuria?
1. Renal/bladder ultrasound
2. Urine culture
3. BUN/creatinine
4. Serum complement
5. Urine calcium excretion
![Page 21: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/21.jpg)
Which of the following tests is most frequently abnormal in the patient with persistent, asymptomatic, isolated microscopic hematuria?
1. Renal/bladder ultrasound
2. Urine culture
3. BUN/creatinine
4. Serum complement
5. Urine calcium excretion
![Page 22: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/22.jpg)
Results of Referral Evaluation Of 83 Consecutive Children in Memphis, Tenn
(Stapleton, NEJM, 1984)
Unexplained 38 (46%)
Hypercalciuria 22 (27%)
Familial hematuria 7 (8%)
Post-inf GN 5 (6%)
IgA nephropathy 4 (5%)
Other 7 (8%)
![Page 23: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/23.jpg)
325 Consecutive Children with Isolated Microhematuria in Buffalo and
Philadelphia
1) Creatinine/BUN normal
2) Ultrasounds normal
3) Hypercalciuria (9%)
4) Complement studies abnormal in 12%; none had GN
![Page 24: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/24.jpg)
Cost of Evaluations in 325 Children with Microhematuria in Buffalo and
Philadelphia
• Total estimated cost $175,000
• Significant diagnoses: none
![Page 25: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/25.jpg)
Case 2
9 year old male brought to physician because of bloody urine 2 days prior. Patient was asymptomatic during the event. The urine spontaneously cleared.
Examination: healthy appearance. BP 98/62 and urinalysis normal.
![Page 26: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/26.jpg)
Case 2 continues...
The child was scheduled to return on 2 additional occasions for urinalysis. Although the history was consistent with transient recurrence of red urine, the urine samples were normal grossly, by dipstick and microscopic exam.
The child then brought in a urine that was red…. UA dipstick: Hg negative and Protein negative
![Page 27: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/27.jpg)
All of the following are causes of heme negative, red urine except:
1. Beets
2. Senna
3. Food coloring
4. Metronidazole
5. Red clover honey
6. Iodine
![Page 28: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/28.jpg)
All of the following are causes of heme negative, red urine except:
1. Beets
2. Senna
3. Food coloring
4. Metronidazole
5. Red clover honey
6. Iodine
![Page 29: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/29.jpg)
Urinalysis: Dipstick MethodologyBlood Indicator
Peroxidase dependent oxidation of the
indicator dye
Hemoglobin + peroxidase
Other oxidants lead to false positive
Povidone-iodine
Hypochlorite
Bacterial peroxidase
Myoglobin
![Page 30: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/30.jpg)
Case 3
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
![Page 31: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/31.jpg)
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
![Page 32: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/32.jpg)
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
![Page 33: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/33.jpg)
Appropriate tests 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
![Page 34: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/34.jpg)
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
![Page 35: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/35.jpg)
Hematuria + Proteinuria
Combination is an indicator of disease
Gross hematuria may have associated low grade proteinuria ( Up/c < 0.5)
![Page 36: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/36.jpg)
CASE 4
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
![Page 37: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/37.jpg)
![Page 38: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/38.jpg)
The most likely diagnosis is?
1. Hypercalciuria
2. Acute Post Strept GN
3. IgA nephropathy
4. Membranoproliferative GN
5. SLE
![Page 39: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/39.jpg)
The most likely diagnosis is?
1. Hypercalciuria
2. Acute Post Strept GN
3. IgA nephropathy
4. Membranoproliferative GN
5. SLE
![Page 40: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/40.jpg)
Which of the following tests will be most helpful in determining the diagnosis?
1. Serum BUN/creatinine
2. Serum complement & streptozyme
3. Serum IgA
4. Renal ultrasound
5. Serum albumin
![Page 41: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/41.jpg)
Which of the following tests will be most helpful in determining the diagnosis?
1. Serum BUN/creatinine
2. Serum complement & streptozyme
3. Serum IgA
4. Renal ultrasound
5. Serum albumin
![Page 42: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/42.jpg)
The streptozyme titer is elevated
and the serum complement (C3)
is decreased
![Page 43: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/43.jpg)
Which one of the following is not associated with depressed serum complement values?
1. Acute post strept GN
2. Membranoproliferative GN
3. IgA nephropathy
4. SLE
![Page 44: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/44.jpg)
Which one of the following is not associated with depressed serum complement values?
1. Acute post strept GN
2. Membranoproliferative GN
3. IgA nephropathy
4. SLE
![Page 45: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/45.jpg)
POST-STREPTOCOCCAL GN• Most common type of acute GN• May present with minimal symptoms • Complications often due to fluid overload• Complement levels may be depressed
longer than previously recognized• Persistent microscopic hematuria up to
one year is common• Prognosis is excellent
![Page 46: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/46.jpg)
Do you hospitalize most children with acute post streptococcal glomerulonephritis?
1. Yes
2. No
![Page 47: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/47.jpg)
CASE 5
A 12 year old girl has a sore throat and that same day notices that her urine turns brown.
She generally 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.
![Page 48: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/48.jpg)
![Page 49: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/49.jpg)
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
![Page 50: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/50.jpg)
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
![Page 51: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/51.jpg)
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
![Page 52: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/52.jpg)
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
![Page 53: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/53.jpg)
DIAGNOSIS OF 56 BIOPSIES IN TEENAGERS WITH GROSS HEMATURIA
IgA glomerulonephropathy 28 (50%)
Minimal lesion 10 (16%)
Diffuse mesangial prolif. 6 (7%)
Proliferative nephritis 4 (6%)
MPGN 3 (5%)
Focal sclerosis 3 (5%)
Crescentic GN 2 (4%)
![Page 54: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/54.jpg)
Do you have patients with IgA nephropathy?
1. Yes
2. No
![Page 55: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/55.jpg)
Current treatments for IgA nephropathy
1. Prednisone
2. Fish oil
3. Vitamin E
4. ACE inhibitors
5. Nothing
![Page 56: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/56.jpg)
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
![Page 57: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/57.jpg)
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
![Page 58: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/58.jpg)
CASE 6
A 12 year old girl has a sore throat and that same day notices that her urine turns brown.
She generally 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, and no RBC casts.
![Page 59: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/59.jpg)
Appropriate tests include each of the following except:
1. Urine culture
2. Renal ultrasound
3. Urine for calcium excretion
4. Serum complement
5. Test for sickle cell trait
![Page 60: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/60.jpg)
Appropriate tests include each of the following except:
1. Urine culture
2. Renal ultrasound
3. Urine for calcium excretion
4. Serum complement
5. Test for sickle cell trait
![Page 61: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/61.jpg)
Evaluation of Isolated Macroscopic Hematuria (without Casts)
Urine culture
Renal ultrasound
Urine calcium excretion
Family urinalyses
Sickle cell status
Cystoscopy (occasional)
Angiogram
![Page 62: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/62.jpg)
Evaluation of Hematuria with Proteinuria
Serum creatinine, albumin
Urine protein excretion
Streptococcal antibody screen
Serum complement
Family urinalyses
ANA, hepatitis studies (selected)
![Page 63: THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill](https://reader036.vdocuments.us/reader036/viewer/2022062516/56649e6c5503460f94b6b086/html5/thumbnails/63.jpg)
Evaluation of Non-orthostatic Proteinuria is Similar to that of
Hematuria With Proteinuria*
(*Exception: vesicoureteral reflux-induced nephropathy)