1. THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill

2. 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

3. 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

4. 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

5. 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

6. 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%

7. 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%

8. AAP Urinary Screening Guidelines 1. Infancy 2. Early childhood 3. Late childhood 4. Adolescence AAP Policy: Recommendations for Preventative Care, 1993

9. 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

10. Urinalysis of 5 year old with 1+ blood

11. 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

12. 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

13. 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

14. 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

15. Do you have patients with hypercalciuria and hematuria in your practice? 1. Yes 2. No

16. Do you refer a child with persistent isolated microscopic hematuria and a normal renal ultrasound to a pediatric nephrologist? 1. Yes 2. No

17. Have you diagnosed hypercalciuria and hematuria in a child who later developed a urinary stone? 1. Yes 2. No

18. 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

19. 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

20. 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

21. 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

22. Results of Referral Evaluation Of 83 Consecutive Children in Memphis, Tenn (Stapleton, NEJM, 1984) Unexplained38(46%) Hypercalciuria22(27%) Familial hematuria 7(8%) Post-inf GN 5(6%) IgA nephropathy 4(5%) Other 7(8%)

23. 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

24. Cost of Evaluations in 325 Children with Microhematuria in Buffalo and Philadelphia Total estimated cost $175,000 Significant diagnoses: none

25. 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.

26. 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

27. 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

28. 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

29. Urinalysis: Dipstick Methodology Blood Indicator Peroxidase dependent oxidation of the indicator dye Hemoglobin + peroxidase Other oxidants lead to false positive Povidone-iodine Hypochlorite Bacterial peroxidase Myoglobin

30. 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

31. 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

32. 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

33. 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

34. 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

35. Hematuria + Proteinuria Combination is an indicator of disease Gross hematuria may have associated low grade proteinuria ( Up/c < 0.5)

36. 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

38. The most likely diagnosis is? 1.Hypercalciuria 2.Acute Post Strept GN 3.IgA nephropathy 4.Membranoproliferative GN 5.SLE

39. The most likely diagnosis is? 1.Hypercalciuria 2.Acute Post Strept GN 3.IgA nephropathy 4.Membranoproliferative GN 5.SLE

40. 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

41. 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

42. The streptozyme titer is elevated and the serum complement (C 3 ) is decreased

43. 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

44. 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

45. 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

46. Do you hospitalize most children with acute post streptococcal glomerulonephritis? 1. Yes 2. No

47. 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.

49. What does this patient have? 1. Glomerular hematuria 2. Non-glomerular hematuria

50. What does this patient have? 1. Glomerular hematuria 2. Non-glomerular hematuria

51. The most likely diagnosis is? 1. Acute Post Strept GN 2. Hypercalciuria 3. Alport’s Syndrome 4. IgA nephropathy 5. Hemolytic Uremic Syndrome

52. The most likely diagnosis is? 1. Acute Post Strept GN 2. Hypercalciuria 3. Alport’s Syndrome 4. IgA nephropathy 5. Hemolytic Uremic Syndrome

53. DIAGNOSIS OF 56 BIOPSIES IN TEENAGERS WITH GROSS HEMATURIA IgA glomerulonephropathy28 (50%) Minimal lesion10 (16%) Diffuse mesangial prolif. 6 (7%) Proliferative nephritis 4 (6%) MPGN 3 (5%) Focal sclerosis 3 (5%) Crescentic GN 2 (4%)

54. Do you have patients with IgA nephropathy? 1. Yes 2. No

55. Current treatments for IgA nephropathy 1. Prednisone 2. Fish oil 3. Vitamin E 4. ACE inhibitors 5. Nothing

56. 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

57. 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

58. 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.

59. 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

60. 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

61. Evaluation of Isolated Macroscopic Hematuria (without Casts) Urine culture Renal ultrasound Urine calcium excretion Family urinalyses Sickle cell status Cystoscopy (occasional) Angiogram

62. Evaluation of Hematuria with Proteinuria Serum creatinine, albumin Urine protein excretion Streptococcal antibody screen Serum complement Family urinalyses ANA, hepatitis studies (selected)

63. Evaluation of Non-orthostatic Proteinuria is Similar to that of Hematuria With Proteinuria* (*Exception: vesicoureteral reflux- induced nephropathy)