HematuriaHematuria

CONTINUITY CLINIC

ObjectivesObjectives

Plan the appropriate management of Plan the appropriate management of a child with microscopic hematuriaa child with microscopic hematuria

Recognize the differential diagnosis Recognize the differential diagnosis and prognosis of patients with and prognosis of patients with persistent microscopic hematuria persistent microscopic hematuria with and without proteinuriawith and without proteinuria

Plan the evaluation of a child with Plan the evaluation of a child with persistent microscopic hematuriapersistent microscopic hematuria

CONTINUITY CLINIC

DefinitionDefinition 5 to 10 RBC’s per high power 5 to 10 RBC’s per high power

microscopic field microscopic field Should be obtained from a Should be obtained from a

midstream voided urine samplemidstream voided urine sample

CONTINUITY CLINIC

Beware False Positives on Beware False Positives on Urine DipUrine Dip

Myoglobin produces Myoglobin produces the same color change the same color change on the dipstickon the dipstick

Drugs: ascorbic acid, Drugs: ascorbic acid, sulfonamides, iron sulfonamides, iron sorbitol, sorbitol, metronidazole, and metronidazole, and nitrofurantoinnitrofurantoin

Take home: Verify test Take home: Verify test results with results with microscopy!microscopy!

CONTINUITY CLINIC

History and Differential History and Differential DiagnosisDiagnosis

Pursue a diagnosis if > 1 Pursue a diagnosis if > 1 monthmonthHistoryHistory Suggestive Suggestive

of:of:Abdominal, back, or flank Abdominal, back, or flank pain when associated with pain when associated with bruisingbruising

Child AbuseChild Abuse

Jogging, bike riding, snow Jogging, bike riding, snow boardingboarding

Exercise Exercise inducedinduced

Dysuria, frequency, Dysuria, frequency, suprapubic painsuprapubic pain

UTI, cystitis, UTI, cystitis, calciuriacalciuria

Abdominal painAbdominal pain Abdominal Abdominal mass, mass, nephrolithiasis, nephrolithiasis, HSPHSP

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History and Differential History and Differential DiagnosisDiagnosis

HistoryHistory Suggestive Suggestive of:of:

Drug Ingestion: Aspirin, Drug Ingestion: Aspirin, NSAIDs, antibiotics, NSAIDs, antibiotics, methyldopamethyldopa

Drug inducedDrug induced

Edema, hypertension, skin Edema, hypertension, skin rash, pallor, joint findings, ab rash, pallor, joint findings, ab pain, bloody diarrheapain, bloody diarrhea

Parenchymal renal Parenchymal renal disease including disease including glomerulonephritiglomerulonephritis, HSP, Lupus, s, HSP, Lupus, HUSHUS

Preceding sore throat or Preceding sore throat or pyoderma (7-30 days)pyoderma (7-30 days)

Post-streptococcal Post-streptococcal acute acute glomerulonephritiglomerulonephritiss

Abdominal pain with URI Abdominal pain with URI symptomssymptoms

IgA NephropathyIgA Nephropathy

CONTINUITY CLINIC

History and Differential History and Differential DiagnosisDiagnosis

Without Proteinuria

With Proteinuria

UTIUTI UTIUTI

HypercalciuriaHypercalciuria Poststreptoccal Poststreptoccal glomerulonephritisglomerulonephritis

Thin Basement DiseaseThin Basement Disease IGA NephropathyIGA Nephropathy

Sickle cell disease or Sickle cell disease or traittrait

HSPHSP

Renal cystic diseaseRenal cystic disease Membranoproliferative Membranoproliferative glomerulonephritisglomerulonephritis

NephrolithiasisNephrolithiasis Lupus, Alport syndromeLupus, Alport syndrome

CONTINUITY CLINIC

Family HistoryFamily History

Hematuria without renal failureHematuria without renal failure thin basement membrane diseasethin basement membrane disease

Hematuria, renal failure, dialysis, or Hematuria, renal failure, dialysis, or transplant with hearing losstransplant with hearing loss Alport syndrome (high tone hearing loss)Alport syndrome (high tone hearing loss)

Nephrolithiasis or hypercalciuriaNephrolithiasis or hypercalciuria ADPKD – must be ruled out ADPKD – must be ruled out

radiologicallyradiologically Sickle cell or traitSickle cell or trait

CONTINUITY CLINIC

ExaminationExamination

Urine microscopyUrine microscopy RBCs from all areas other than RBCs from all areas other than

glomeruli will be normal in size or glomeruli will be normal in size or slightly small and eumorphicslightly small and eumorphic

Nonglomerular bleeding usually with Nonglomerular bleeding usually with normal protein and no RBC castsnormal protein and no RBC casts

CONTINUITY CLINIC

TestingTesting Urine CultureUrine Culture Sickle cell prep – if Sickle cell prep – if

African AmericanAfrican American Urinary calciumUrinary calcium Urinary creatinine Urinary creatinine

ratioratio Serum creatinineSerum creatinine C3C3 Streptozyme titerStreptozyme titer

Ultrasound – to rule Ultrasound – to rule out polycystic kidney out polycystic kidney disease, tumor, disease, tumor, ureteropelvic junction ureteropelvic junction obstruction, and obstruction, and stonesstones

Urinary protein Urinary protein excretion when protein excretion when protein elevatedelevated for 12-24 hour period for 12-24 hour period

OROR Spot urine protein:urine Spot urine protein:urine

creatine ratiocreatine ratio

CONTINUITY CLINIC

Testing for ProteinuriaTesting for Proteinuria

Protein excretion of less than 4 Protein excretion of less than 4 mg/mmg/m22 per hour is normal per hour is normal

Protein excretion of more than 40 Protein excretion of more than 40 mg/mmg/m22 per hour is considered in the per hour is considered in the nephrotic nephrotic

Urine protein: urine creatinine ratio Urine protein: urine creatinine ratio > 0.2 abnormal, > 1.0 nephrotic> 0.2 abnormal, > 1.0 nephrotic

CONTINUITY CLINIC

Further Testing if Further Testing if Glomerulonephritis LikelyGlomerulonephritis Likely

CBCCBC C3, C4C3, C4 ASLO ASLO Streptozyme titerStreptozyme titer Chem 7 (BUN.Cre)Chem 7 (BUN.Cre) AlbuminAlbumin Testing for lupusTesting for lupus Hepatitis B Hepatitis B

ScreeningScreening

RENAL BIOPSY RENAL BIOPSY WHEN TESTING WHEN TESTING

NONDIAGNOSTICNONDIAGNOSTIC

CONTINUITY CLINIC

Hematuria & Hematuria & HypercalciuriaHypercalciuria

Idiopathic hypercalciuriaIdiopathic hypercalciuria Urinary calcium: urinary creatinine ratio > Urinary calcium: urinary creatinine ratio >

0.210.21 24 hour urinary calcium excretion of > 4 mg/kg24 hour urinary calcium excretion of > 4 mg/kg

Hypercalciuria in a child with hematuria Hypercalciuria in a child with hematuria should not exclude the consideration of should not exclude the consideration of other etiologiesother etiologies HyperparathyroidismHyperparathyroidism ImmobilizationImmobilization Vitamin D intoxicationVitamin D intoxication Furosemide useFurosemide use

CONTINUITY CLINIC

CONTINUITY CLINIC

Etiology of Gross Etiology of Gross HematuriaHematuria

UTI most UTI most commoncommon

Perineal Perineal irritationirritation

Meatal stenosis Meatal stenosis with ulcerationwith ulceration

TraumaTrauma

Recent surgeryRecent surgery Clotting Clotting

AbnormalitiesAbnormalities NephrolithiasisNephrolithiasis GlomerulonephGlomeruloneph

ritisritis

1/1000 visits to pediatric ER

CONTINUITY CLINIC

Gross HematuriaGross Hematuria

Of 58 adolescents who had a biopsy Of 58 adolescents who had a biopsy in one study, 52% had IgA in one study, 52% had IgA nephropathy, most others had other nephropathy, most others had other mesangial lesionsmesangial lesions

Approximately 15% of children who Approximately 15% of children who have isolated persistent hematuria have isolated persistent hematuria for more than 12 months will have for more than 12 months will have IgA nephropathyIgA nephropathy

CONTINUITY CLINIC

Renal Structural Renal Structural Abnormalities Associated Abnormalities Associated

with Hematuriawith Hematuria Polycystic kidney diseasePolycystic kidney disease Uteropelvic junction obstructionUteropelvic junction obstruction Vesicoureteral refluxVesicoureteral reflux Renal or bladder stones, diverticulae Renal or bladder stones, diverticulae

or tumorsor tumors Renal arteriovenous fistula Renal arteriovenous fistula Foreign bodiesForeign bodies

CONTINUITY CLINIC

Follow-Up:Follow-Up:After Pathologic Causes After Pathologic Causes

Ruled OutRuled Out Patients should be followed at 6-12 Patients should be followed at 6-12

month intervalsmonth intervals Assess linear growth, blood pressure, Assess linear growth, blood pressure,

and UAand UA 10-50% of children with persistent 10-50% of children with persistent

hematuria may develop progressive hematuria may develop progressive renal diseaserenal disease

CONTINUITY CLINIC

When to ReferWhen to Refer Red blood cell casts on microscopic urine Red blood cell casts on microscopic urine

examexam Significant proteinuriaSignificant proteinuria Hypertension; edemaHypertension; edema Abnormal renal function; decreased C3Abnormal renal function; decreased C3 Persistent hematuria for more than 1 yearPersistent hematuria for more than 1 year HypercalciuriaHypercalciuria Renal structure abnormalityRenal structure abnormality Family history of hereditary nephritis or Family history of hereditary nephritis or

polycystic renal diseasepolycystic renal disease

CONTINUITY CLINIC