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HematuriaFor the boards...
Gital Karamchandani-Patel, MD
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Definition
Macroscopic (gross) Hematuria any discolored urine visible to the
human eye Microscopic Hematuria
>5 RBC/hpf seen under microscope
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Hematuria
Patient comes to your office complaining that their urine is reddish in color...
What is your first step?
– Good H+P
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Hematuria
Is it really blood? Urine Dipstick
Detects Hgb, myoglobin Detects protein
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Hematuria
Urinalysis Definitive for the presence of RBC
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Hematuria
Upper urinary tract
glomerulus collecting tubules interstitium
Lower urinary tract
calyx pelvis ureter bladder urethra
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What PREP wants you to know...
Know the differential diagnosis of a child with gross hematuria
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Differential D iagnosis
g lo m eru la r*prompt eval for kidney dz
w ithp ro te in u ria
e x trag lo m eru la r
w ith o u tp ro te in u ria
+ R B C s
H gbm yo g lo b in
h e m e +
d ru gsd yes
h e m e -
- R B C s
M a cro sco p ic H em a tu riao b ta in U /A
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Glomerular Hematuria
brown, tea colored urine proteinuria deformed urinary RBCs RBC casts
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Glomerular Hematuria
RENAL
IgA nephropathy Alport syndrome Thin glomerular BM
disease Post infectious MPGN
MULTI-SYSTEM
SLE nephritis HSP nephritis Wegener syndrome Goodpasture syndrome HUS Sickle cell Disease
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W/u for Glomerular Hematuria CBC C3, C4 antistreptolysin-O titer, streptozyme titer serum electrolytes, BUN, serum Cr,
serum albumin test for lupus Hep B antinuclear cytoplasmic antibody titer
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Extraglomerular Hematuria Hematuria from lower urinary tract
terminal hematuria blood clots nl urinary RBCs minimal proteinuria
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Extraglomerular Hematuria
UPPER URINARY TRACT
pyelonephritis ATN papillary necrosis nephrocalcinosis thrombosis malformation SCD tumor PCKD
LOWER URINARY TRACT
cystitis urethritis urolithiasis trauma coagulopathy heavy excersise UPJ obstruction ureterocele Munchausen, MBP
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W/u for Extraglomerular Hematuria serum creatinine urine culture sickle cell preparation in AA urinary Ca/Cr ratio C3,C4 U/S of kidneys/bladder to R/O polycystic
kidney disease, tumor, ureteropelvic junction obstruction, and stones
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Proteinuria For the boards...
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Proteinuria
Occurs in 10% of kids 8-15 yrs differentiate between
renal disease transient benign
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Proteinuria
Dipstick detects mostly ALBUMIN negative (0 mg/dL) trace (10-20 mg/dL) 1+ (30 mg/dL) 2+ (100 mg/dL) 3+ (300 mg/dL) 4+ (1000-2000 mg/dL)
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D iffe re n tia l D ia g n o s is
o rth os ta tic tra n sie n t
b e n ign
g lo m eru la r tu bu la r
f ixed
P ro te in u ria
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Proteinuria
A child comes into your office for a routine visit
Screening urine dipstick reveals 1+ protein
What is your next step?
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Proteinuria
R/O benign conditions sg >1.020 pH >7.5 mucoproteins acute illness
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Proteinuria
Next step is to determine if this is transient or fixed R/O orthostatic proteinuria
first am U/A W/u for persistent fixed proteinuria
alb, C3, 24 hr urine protein Pr/Cr ratio
W/u for glomerular hematuria if + RBCs
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Quiz TimeLet’s see who has been paying attention...
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Quiz time #1
10 yr old boy coming in for school physical. Found to have 30 RBC/hpf on microscopic analysis.
Fam Hx reveals uncle used to have “blood in his urine”
What is your diagnosis?
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Quiz time #1
Familial Causes of Hematuria Polycystic kidney disease
Thin basement membrane disease
Alport syndrome (hereditary nephritis with deafness)
Hypercalciuria with family history of nephrolithiasis
Sickle Cell
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Quiz time #2
Gross hematuria following a URI C3 is wnl
What is your diagnosis?
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IgA Nephropathy (Berger’s Disease) IgA deposits seen on renal biopsy nl C3 elevated IgA in 15% often hypertensive need long-term f/u
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Quiz time #3
This kid was in your office 2 weeks ago. Mom is calling and saying his urine looks like coca-cola.
What is your diagnosis?
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Acute Post-Infectious Glomerulonephritis Caused by nephritogenic GAS
infections of the pharynx or skin Most children recover complete renal
function C3 levels LOW initially, then return to
NL after 6-8 wks may have BP, proteinuria,
hematuria for up to 3 mos after initial presentation
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Quiz time #4
3 yr old F with diarrhea 6 days later develops a rash,
abdominal pain on PE, you note pallor and purpura
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Quiz time #4
What is your diagnosis?
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Hemolytic-Uremic Syndrome MCC of ARF in children Caused by shiga toxin producing
E.coli O157:H7
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Quiz time #5
Infant comes in with hematuria h/o constipation h/o TEF repair
What is your diagnosis?
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VATER association
V vertebral anomalies A anal atresia T E R radial limb anomalies
TEF
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Quiz time #6
14yo female with hematuria More “tired” lately
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Quiz time #6
What is your diagnosis? What labs will you order?
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SLE nephritis
C3 and C4 will be LOW Sometimes will only manifest as
kidney disease WHO staging of nephritis
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Quiz time #7
11 yr old boy with gross hematuria, edema.
Initial labs reveal LOW C3 and C4
What is your diagnosis? How do you make definitive dx?
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Membranoproliferative Glomerulonephritis
MPGN is the MCC of chronic glomerulonephritis in children
renal biopsy confirms dx
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Confused about complement? What three conditions cause
hypocomplementemia? P post infectious GN
M membrano proliferative GN
S SLE
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Quiz time #8
It is 10pm. You are the intern on call for purple. A 5th floor nurse pages you to tell you that ortho has just consulted you on one of their patients for hematuria.
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Quiz time #8
You look through the chart and the all you can decipher is that she was in a car crash 2 weeks ago.
You go to examine her and note she is in a full body cast, o/w NAD and afebrile.
What is the one test you will order before you go back to your call room?
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Quiz time #8
Answer: Urine Ca/Cr ratio!! urinary calcium:urinary creatinine
ratio of > 0.21 24-hour urinary calcium excretion
of >4 mg/kg
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Hypercalciuria
Idiopathic 30% 15% go on to have renal stones
Immobilization Hyperparathyroidism Furosemide Vit D intoxication
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Thank you for your attention!
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PREP specs
Plan the evaluation of hematuria in a child with sickle cell disease.
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PREP 2005 #70
A previously healthy 10 yr old AA boy reports a 2 day history of back pain and gross hematuria. There is no history of trauma or passed kidney stones. His vital signs are normal, and PE reveals R CVA tenderness. His older brother has several similar episodes when he was younger, as did his mother when she was a child.
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PREP 2005 #70
You suspect that this boy has sickle cell trait and papillary necrosis.
Of the following, the BEST test to confirm the diagnosis is: A. abdominal xray B. CT C. intravenous pyelography D. renal scintigraphy E. renal U/S
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PREP 2005 #70
Correct Answer: C