THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS

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)