Hematuria

CONTINUITY CLINIC Objectives Plan the appropriate management of a child with microscopic hematuria Plan the appropriate management of a child with microscopic hematuria Recognize the differential diagnosis and prognosis of patients with persistent microscopic hematuria with and without proteinuria Recognize the differential diagnosis and prognosis of patients with persistent microscopic hematuria with and without proteinuria Plan the evaluation of a child with persistent microscopic hematuria Plan the evaluation of a child with persistent microscopic hematuria

CONTINUITY CLINIC Definition 5 to 10 RBC’s per high power microscopic field 5 to 10 RBC’s per high power microscopic field Should be obtained from a midstream voided urine sample Should be obtained from a midstream voided urine sample

CONTINUITY CLINIC Beware False Positives on Urine Dip Myoglobin produces the same color change on the dipstick Myoglobin produces the same color change on the dipstick Drugs: ascorbic acid, sulfonamides, iron sorbitol, metronidazole, and nitrofurantoin Drugs: ascorbic acid, sulfonamides, iron sorbitol, metronidazole, and nitrofurantoin Take home: Verify test results with microscopy! Take home: Verify test results with microscopy!

CONTINUITY CLINIC History and Differential Diagnosis Pursue a diagnosis if > 1 month History Suggestive of: Abdominal, back, or flank pain when associated with bruising Child Abuse Jogging, bike riding, snow boarding Exercise induced Dysuria, frequency, suprapubic pain UTI, cystitis, calciuria Abdominal pain Abdominal mass, nephrolithiasis, HSP

CONTINUITY CLINIC History and Differential Diagnosis History Suggestive of: Drug Ingestion: Aspirin, NSAIDs, antibiotics, methyldopa Drug induced Edema, hypertension, skin rash, pallor, joint findings, ab pain, bloody diarrhea Parenchymal renal disease including glomerulonephritis, HSP, Lupus, HUS Preceding sore throat or pyoderma (7-30 days) Post-streptococcal acute glomerulonephritis Abdominal pain with URI symptoms IgA Nephropathy

CONTINUITY CLINIC History and Differential Diagnosis Without ProteinuriaWith Proteinuria UTIUTI Hypercalciuria Poststreptoccal glomerulonephritis Thin Basement Disease IGA Nephropathy Sickle cell disease or trait HSP Renal cystic disease Membranoproliferative glomerulonephritis Nephrolithiasis Lupus, Alport syndrome

CONTINUITY CLINIC Family History Hematuria without renal failure Hematuria without renal failure thin basement membrane disease thin basement membrane disease Hematuria, renal failure, dialysis, or transplant with hearing loss Hematuria, renal failure, dialysis, or transplant with hearing loss Alport syndrome (high tone hearing loss) Alport syndrome (high tone hearing loss) Nephrolithiasis or hypercalciuria Nephrolithiasis or hypercalciuria ADPKD – must be ruled out radiologically ADPKD – must be ruled out radiologically Sickle cell or trait Sickle cell or trait

CONTINUITY CLINIC Examination Urine microscopy Urine microscopy RBCs from all areas other than glomeruli will be normal in size or slightly small and eumorphic RBCs from all areas other than glomeruli will be normal in size or slightly small and eumorphic Nonglomerular bleeding usually with normal protein and no RBC casts Nonglomerular bleeding usually with normal protein and no RBC casts

CONTINUITY CLINIC Testing Urine Culture Urine Culture Sickle cell prep – if African American Sickle cell prep – if African American Urinary calcium Urinary calcium Urinary creatinine ratio Urinary creatinine ratio Serum creatinine Serum creatinine C3 C3 Streptozyme titer Streptozyme titer Ultrasound – to rule out polycystic kidney disease, tumor, ureteropelvic junction obstruction, and stones Ultrasound – to rule out polycystic kidney disease, tumor, ureteropelvic junction obstruction, and stones Urinary protein excretion when protein elevated Urinary protein excretion when protein elevated for hour period OR for hour period OR Spot urine protein:urine creatine ratio Spot urine protein:urine creatine ratio

CONTINUITY CLINIC Testing for Proteinuria Protein excretion of less than 4 mg/m 2 per hour is normal Protein excretion of less than 4 mg/m 2 per hour is normal Protein excretion of more than 40 mg/m 2 per hour is considered in the nephrotic Protein excretion of more than 40 mg/m 2 per hour is considered in the nephrotic Urine protein: urine creatinine ratio > 0.2 abnormal, > 1.0 nephrotic Urine protein: urine creatinine ratio > 0.2 abnormal, > 1.0 nephrotic

CONTINUITY CLINIC Further Testing if Glomerulonephritis Likely CBC CBC C3, C4 C3, C4 ASLO ASLO Streptozyme titer Streptozyme titer Chem 7 (BUN.Cre) Chem 7 (BUN.Cre) Albumin Albumin Testing for lupus Testing for lupus Hepatitis B Screening Hepatitis B Screening RENAL BIOPSY WHEN TESTING NONDIAGNOSTIC

CONTINUITY CLINIC Hematuria & Hypercalciuria Idiopathic hypercalciuria Idiopathic hypercalciuria Urinary calcium: urinary creatinine ratio > 0.21 Urinary calcium: urinary creatinine ratio > hour urinary calcium excretion of > 4 mg/kg 24 hour urinary calcium excretion of > 4 mg/kg Hypercalciuria in a child with hematuria should not exclude the consideration of other etiologies Hypercalciuria in a child with hematuria should not exclude the consideration of other etiologies Hyperparathyroidism Hyperparathyroidism Immobilization Immobilization Vitamin D intoxication Vitamin D intoxication Furosemide use Furosemide use

CONTINUITY CLINIC

Etiology of Gross Hematuria UTI most common UTI most common Perineal irritation Perineal irritation Meatal stenosis with ulceration Meatal stenosis with ulceration Trauma Trauma Recent surgery Recent surgery Clotting Abnormalities Clotting Abnormalities Nephrolithiasis Nephrolithiasis Glomerulonephritis Glomerulonephritis 1/1000 visits to pediatric ER

CONTINUITY CLINIC Gross Hematuria Of 58 adolescents who had a biopsy in one study, 52% had IgA nephropathy, most others had other mesangial lesions Of 58 adolescents who had a biopsy in one study, 52% had IgA nephropathy, most others had other mesangial lesions Approximately 15% of children who have isolated persistent hematuria for more than 12 months will have IgA nephropathy Approximately 15% of children who have isolated persistent hematuria for more than 12 months will have IgA nephropathy

CONTINUITY CLINIC Renal Structural Abnormalities Associated with Hematuria Polycystic kidney disease Polycystic kidney disease Uteropelvic junction obstruction Uteropelvic junction obstruction Vesicoureteral reflux Vesicoureteral reflux Renal or bladder stones, diverticulae or tumors Renal or bladder stones, diverticulae or tumors Renal arteriovenous fistula Renal arteriovenous fistula Foreign bodies Foreign bodies

CONTINUITY CLINIC Follow-Up: After Pathologic Causes Ruled Out Patients should be followed at 6-12 month intervals Patients should be followed at 6-12 month intervals Assess linear growth, blood pressure, and UA Assess linear growth, blood pressure, and UA 10-50% of children with persistent hematuria may develop progressive renal disease 10-50% of children with persistent hematuria may develop progressive renal disease

CONTINUITY CLINIC When to Refer Red blood cell casts on microscopic urine exam Red blood cell casts on microscopic urine exam Significant proteinuria Significant proteinuria Hypertension; edema Hypertension; edema Abnormal renal function; decreased C3 Abnormal renal function; decreased C3 Persistent hematuria for more than 1 year Persistent hematuria for more than 1 year Hypercalciuria Hypercalciuria Renal structure abnormality Renal structure abnormality Family history of hereditary nephritis or polycystic renal disease Family history of hereditary nephritis or polycystic renal disease

CONTINUITY CLINIC