the office evaluation of hematuria and proteinuria: case presentations
DESCRIPTION
THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS. Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill. Case 1. A healthy appearing 5 year old boy was noted to have asymptomatic hematuria at a school examination. Physical exam was normal. - PowerPoint PPT PresentationTRANSCRIPT
THE OFFICE EVALUATION OF
HEMATURIA AND PROTEINURIA:
CASE PRESENTATIONS
Debbie Gipson, M.D., M.S.University of North Carolina-Chapel Hill
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
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
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
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
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%
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%
AAP Urinary Screening Guidelines
1. Infancy
2. Early childhood
3. Late childhood
4. Adolescence
AAP Policy: Recommendations for Preventative Care, 1993
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
Urinalysis of 5 year old with 1+ blood
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
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
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
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
Do you have patients with hypercalciuria and hematuria in your practice?
1. Yes
2. No
Do you refer a child with persistent isolated microscopic hematuria and a normal renal ultrasound to a pediatric nephrologist?
1. Yes
2. No
Have you diagnosed hypercalciuria and hematuria in a child who later developed a urinary stone?
1. Yes
2. No
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
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
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
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
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%)
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
Cost of Evaluations in 325 Children with Microhematuria in Buffalo and
Philadelphia
• Total estimated cost $175,000
• Significant diagnoses: none
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.
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
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
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
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
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
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
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
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
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
Hematuria + Proteinuria
Combination is an indicator of disease
Gross hematuria may have associated low grade proteinuria ( Up/c < 0.5)
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
The most likely diagnosis is?
1. Hypercalciuria
2. Acute Post Strept GN
3. IgA nephropathy
4. Membranoproliferative GN
5. SLE
The most likely diagnosis is?
1. Hypercalciuria
2. Acute Post Strept GN
3. IgA nephropathy
4. Membranoproliferative GN
5. SLE
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
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
The streptozyme titer is elevated
and the serum complement (C3)
is decreased
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
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
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
Do you hospitalize most children with acute post streptococcal glomerulonephritis?
1. Yes
2. No
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.
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
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%)
Do you have patients with IgA nephropathy?
1. Yes
2. No
Current treatments for IgA nephropathy
1. Prednisone
2. Fish oil
3. Vitamin E
4. ACE inhibitors
5. Nothing
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
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
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.
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
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
Evaluation of Isolated Macroscopic Hematuria (without Casts)
Urine culture
Renal ultrasound
Urine calcium excretion
Family urinalyses
Sickle cell status
Cystoscopy (occasional)
Angiogram
Evaluation of Hematuria with Proteinuria
Serum creatinine, albumin
Urine protein excretion
Streptococcal antibody screen
Serum complement
Family urinalyses
ANA, hepatitis studies (selected)
Evaluation of Non-orthostatic Proteinuria is Similar to that of
Hematuria With Proteinuria*
(*Exception: vesicoureteral reflux-induced nephropathy)