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Hematuria

For the boards...

Gital Karamchandani-Patel, MD
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Definition
Macroscopic (gross) Hematuria
anydiscolored 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 Lower urinary
tract tract
glomerulus calyx
collecting tubules pelvis
interstitium 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 Diagnosis

Macroscopic Hematuria
obtain U/A

+ RBCs - RBCs

with without heme + heme -


proteinuria proteinuria

glomerular* extraglomerular Hgb drugs


prompt eval for kidney dz myoglobin dyes

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Glomerular Hematuria
brown, tea colored urine
proteinuria
deformed urinary RBCs
RBC casts

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Glomerular Hematuria
RENAL MULTI-SYSTEM

IgA nephropathy SLE nephritis


Alport syndrome HSP nephritis
Thin glomerular BM Wegener syndrome
disease Goodpasture syndrome
Post infectious HUS
MPGN 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 LOWER URINARY
TRACT TRACT

pyelonephritis cystitis
ATN urethritis
papillary necrosis urolithiasis
nephrocalcinosis trauma
thrombosis coagulopathy
malformation heavy excersise
SCD UPJ obstruction
tumor ureterocele
PCKD 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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Differential Diagnosis

Proteinuria

benign fixed

orthostatic transient glomerular tubular

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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/ufor glomerular hematuria if +


RBCs

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Quiz Time
Lets 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
(Bergers 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 TEF
E
R radial limb anomalies

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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

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