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When It Looks Like Kool-Aid: a brief look at hematuria

When It Looks Like Kool-Aid: a brief look at hematuria. John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine April 8, 2010. Objectives. Define hematuria Discuss workup and management hematuria Discuss some common diagnoses presenting with hematuria. Definitions.

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When It Looks Like Kool-Aid: a brief look at hematuria

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  1. When It Looks Like Kool-Aid: a brief look at hematuria John Cheng, MD PEM Fellows’ Conference Emory University School of Medicine April 8, 2010

  2. Objectives • Define hematuria • Discuss workup and management hematuria • Discuss some common diagnoses presenting with hematuria

  3. Definitions • The presence of blood in urine • Gross: visible with the naked eye • Microscopic: visible on urinalysis (≥ 5 RBC/hpf) Renal anatomy Bowman’s Capsule Figures 508-1 and 508-4. Davis, ID and ED Avner. “Part XXII, Section 1: Glomerular Disease.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. pp2164-65.

  4. Epidemiology • Gross hematuria • Incidence: 0.13% • Lower urinary tract bleeds • Microscopic hematuria • Incidence: 0.5-2% in school age kids • Upper urinary tract bleeds • Prognosis based on diagnosis • Microscopic hematuria often resolves without any intervention and without any sequelae

  5. Diagnosis • Distinguish between upper vs lower bleeds

  6. Diagnosis • Urine Dipstick • Tetramethylbenzidine and H2O2 • Detects 1-5 RBC/hpf • Sensitivity: 100%, Specificity: 99% Dysmorphic RBCs RBC cast

  7. Common Confounders Table 1– Common Causes of “Dark Urine.” Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

  8. Hematuria Diagnosis Algorithms Figure 34.1. Liebelt, EL. “Chapter 34: Hematuria.” Textbook of Pediatric Emergency Medicine,4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000.

  9. Case 1: History 10 y/o boy presents with dark urine and altered mental status. He had been doing well until a couple of days ago when he started c/o headaches. Yesterday, his urine became a brownish color. Today, he has been lethargic. ROS: tactile fever, malaise, flank pain, decreased urine output, headaches PMH: none, IUTD PSH: hernia repair Meds: none NKDA SH: no ill contacts FH: none

  10. Case 1: Physical Exam T 37.2C HR 92 RR 38 BP 150/87 SaO2 98% RA GEN: lethargic, in mild distress HEENT: PERRL, OP clear, TM nl CV: tachycardic, nl S1S2, no m/r/g PULM: CTAB, no r/r/w ABD: diffuse abd discomfort to palp, no HSM, nl BS EXT: +2 pulses, CRT < 2 sec, +2 pitting edema to knees bilaterally NEURO: GCS 12 (E2, V4, M6), lethargic What would you like to order?

  11. Case 1: Labs 145 | 110 | 100 / 75 Ca 6.8 15 \ 9 / 160 8 | 15 | 2.5 \ Phos 8 / 28 \ U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 50-100, WBC 10-20, +RBC casts C3: 100 (low) C4: 22 (nl) ASLO: + WHAT’S YOUR DIAGNOSIS?

  12. Case 1: PSGN • Nephrotoxigenic strains of Group A Strep • Type 12: after strep throat • Type 49: after pyoderma • Prior treatment with antibiotics has no effect on incidence • Age: 5-12 y/o • Presentation: • Gross hematuria • Edema • Renal insufficiency with oliguria • Fever, malaise, lethargy, flank or abdominal pain

  13. Case 1: PSGN • Labs: • CBC: anemia • BMP or RFP: renal insufficiency or ARF • U/A: RBC, RBC casts, WBC (PMNs), proteinuria • Complement: C3 low, C4 slightly low or nl • RST or Strep culture • ASLO: positive in strep throat • Anti-DNAse B: positive in pyoderma • Streptozyme test: positive in both • U/S: enlarged kidneys • Biopsy: diffuse mesangial cell and matrix proliferation; “humps” on the epithelial side of GBM

  14. Case 1: PSGN • Complications • HTN (60%) • ARF • Encephalopathy (10%) • CHF Figure 511-2. Davis, ID and ED Avner. “Part XXII, Section 2: Conditions Particularly Associated with Hematuria.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2174.

  15. Case 1: Treatment & Prognosis • Supportive care • If no HTN or CHF: low Na diet and close follow up (48-72 hrs) • If still with strep infection: antibiotics (eg, PCN) • HTN: Ca channel blockers (eg, nifedipine), vasodilators (eg, hydralazine), ACE inhibitors • CHF: diuresis (eg, lasix), O2 • > 80% recover spontaneously • Acute phase, 6-8 wks • Proteinuria and HTN, up to 4-6 wks • Hematuria, up to 1-2 yrs

  16. Other Immune-mediated GN • Bacteria: Strep pneumoniae, Staph, Gram negatives, endocarditis • Viruses: Influenza, Hep B, Hep C • Fungus: Candida • Parasites: rickettsial (syphilis), Toxoplasma, malaria

  17. Case 2: History 5 y/o boy comes in with a history of fever and cold symptoms. He has been eating slightly less than usual, but has been urinating normally, except that the urine is reportedly darker than usual. ROS: fever, cough, rhinorrhea, anorexia PMH: h/o UTI PSH: none Meds: none NKDA SH: no ill contacts FH: kidney problems

  18. Case 2: Physical Exam T38.5C HR 100 RR 25 BP 130/82 SaO2 96% RA GEN: in NAD HEENT: PERRL, OP clear, TM nl CV: nl S1S2, no m/r/g PULM: CTAB, no r/r/w ABD: soft, NT/ND, no HSM, nl BS EXT: +2 pulses, CRT < 2 sec NEURO: grossly intact What would you like to do? 135 | 110 | 15 / 75 Ca 8.9 4.2 | 23 | 0.3 \ U/A: 1.025, + 2 protein, - LE, - nitrites, 10-20 RBC, 0 WBC

  19. Case 2: IgA Nephropathy • Most common chronic glomerular disease in world • Presents at all ages, male predominance • Usually noted with URI or GI infection • Can present with loin pain and HTN • NO other signs of systemic illness • Positive family history • Labs: • U/A: protein, RBC, RBC casts • BMP: may show renal insufficiency • Complement: nl C3 and C4 • Immunoglobulins: increased in 5% cases

  20. Case 2: Berger’s Disease • Diagnosis made by renal biopsy

  21. Case 2: Treatment & Prognosis • Treatment • BP control and proteinuria • Fish oil (omega-3 fatty acids) • Immunosuppression • Tonsillectomy • Hematuria will recur with other illnesses • Slow, progressive deterioration in renal function in 20-30% within 15-20 years of initial presentation • Poor prognostic factors: • Persistent HTN • Decreasing renal function • Heavy proteinuria

  22. Other GN with Crescent Formation • Systemic Lupus Erythematosis • Henoch-Schönlein Purpura • Rheumatoid Arthritis • Ankylosing Spondylitis • Inflammatory Bowel Disease • Celiac Disease • HIV

  23. Case 3: History 8 month old boy comes in with his father. He reports, after your having to repeat your questions a couple of times, that his son has blood in his urine. He loudly tells you there were URI symptoms with fever a couple of days ago but that they are getting better. He continues to feel warm and has started pulling at his right ear. ROS: fever, cough, rhinorrhea, otalgia, anorexia, hematuria PMH: none PSH: none Meds: none NKDA SH: no ill contacts FH: none reported

  24. Case 3: Physical Exam T37.8C ax HR 120 RR 32 BP 95/55 SaO2 98% RA GEN: playful, but in NAD HEENT: PERRL, OP clear, TM nl CV: nl S1S2, no m/r/g PULM: CTAB, no r/r/w ABD: soft, NT/ND, no HSM, nl BS GU: uncircumcised EXT: +2 pulses, CRT < 2 sec NEURO: grossly intact What would you like to do? 132 | 102 | 9 / 102 Ca 9.2 12 \ 10 / 180 4 | 27 | 0.3 \ / 30 \ U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 100-200, WBC 5-10

  25. Case 3: Alport Syndrome • Hereditary cause of hematuria • Defect in type IV collagen (in GBM): • COL4A5 • COL4A3 and A4 • Associated problems: • Sensorineural hearing loss • Eye abnormalities • Microscopic or gross hematuria about 1-2 days after a URI

  26. Case 3: Workup • U/A in relatives • Ophthalmologic exam • Audiogram • ± Renal biopsy

  27. Case 3: Treatment and Prognosis • Treatment • Supportive care for HTN, anemia, and electrolyte derangements • Cyclosporine • ACE inhibitors • Dialysis or transplant • Progresses to ESRD • Poor prognostic factors: • Gross hematuria • Nephrosis • Prominent GBM thickening

  28. Summary for GN Figure 1. Differential diagnosis of hematuria organized by location. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

  29. Summary for GN • Workup: • U/A with microscopy • CBC, BMP (or RFP) • C3 and C4 • Consider ASLO, anti-DNAse B, or streptozyme • Consider ANA Table IV: Distinguishing Features of Glmoerular and Non-Glomerular Hematruia. Indian Pediatric Nephrology Group, Indian Academy of Pediatrics. “Consensus Statement on Evaluation of Hematuria.” Indian Pediatrics. 2006 Nov, 43: 967

  30. Summary for GN Table 511-1. Davis, ID and ED Avner. “Part XXII, Section 2: Conditions Particularly Associated with Hematuria.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2174.

  31. Case 4: History 15 y/o young man comes in with abdominal pain. He has been having stabbing pain intermittently for the past 2-3 days, but now it’s getting worse and is constant. It is worse in his left abdomen with radiation into his groin. He does not report any fever, vomiting, diarrhea, dysuria, hematuria, or other symptoms. + anorexia and nausea. He has been taking Motrin 800 mg every 6 hours for the past 3 days. ROS: anorexia, nausea, abdominal pain PMH: h/o hematuria in past that resolved without intervention, IUTD PSH: none Meds: none NKDA SH: no ill contacts, not sexually active FH: kidney stones in MGM

  32. Case 4: Physical Exam T37.2C HR 110 RR 30 BP 130/82 SaO2 98% RA Wt 56 kg GEN: in moderate distress, constantly shifting position in stretcher HEENT: PERRL, OP clear, TM nl CV: nl S1S2, no m/r/g PULM: CTAB, no r/r/w ABD: difffuse abdominal pain, worse on mid L side and some in epigastric area, ND, nl BS GU: circumcised, bilateral testis descended (NT, no edema or erythema) EXT: +2 pulses, CRT < 2 sec NEURO: grossly intact What would you like to do?

  33. Case 4: Labs and Radiology 135 | 102 | 22 / 150 Ca 8.9 16 \ 13 / 220 4.3 | 22 | 0.8 \ / 40 \ U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 50-100, WBC 0-5, + crystals Figure 547-1. Elder, JS. “Part XXIII, Chapter 547: Urinary Lithiasis.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2268.

  34. Case 4: Nephro- and Urolithiasis • Prevalence: 1-5%, high recurrence rate (6.5-44%) • School age children, usually Caucasian • Male ≥ Female • Epidemiology changes with geographic area • Usually underlying metabolic disorder

  35. Case 4: Nephro- and Urolithiasis • Mechanisms: • Changes in solubility factors • Increased solubility product (ie, more ions) • Decreased concentration of inhibitors • Risk factors: • Urinary stasis • Damage to uroepithelium or foreign body • Dehydration

  36. Case 4: Causes of stones • ~50% positive family history • ~ 90% radio-opaque • Uric acid and drug stones are NOT radio-opaque “The stone is not the disease itself; it is only one serious sign!” (Hoppe and Kemper, “Diagnostic examination of the child with urolithiasis or nephrocalcinosis.” Pediatr Nephrol (2010) 25: 403-413.) Table 547-1. Elder, JS. “Part XXIII, Chapter 547: Urinary Lithiasis.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2267.

  37. Case 4: Common stones calcium oxalate uric acid triple phosphate cystine

  38. “Pediatric Urolithiasis: Experience at a Tertiary Care Pediatric Hospital” (Kit LC, et al. CUAJ 2008; 2(4): 381-6) • Population: • 72 pts with diagnosis of urolithiais or nephrolithiasis • 1/99-7/04 at Children’s Hospital of Eastern Ontario • Presentation: • 63% c/o abd or flank pain, 49% c/o N/V • Workup: • U/A: 17% neg, 82% + RBC, 40% c/w UTI • 74% dx by U/S, 56% by KUB, only 7% by CT • Results: • mean stone size 5mm (1-22mm) • 41% had metabolic abnormality • usually hypercalciuria or hyperoxaluria • 14% had GU abnormality (usually at UPJ) • 47% passed stone spontaneously (mean size 4 mm, range 1-11mm) • 93% stones were calcium oxalate or phosphate

  39. Case 4: Presentation and Workup • Presentation: • Abdominal or flank pain ± radiation to scrotum or labia • Nausea and vomiting • Difficulty voiding • Urinary symptoms (if not obstructed): • dysuria, urgency, frequency, gross hematuria • Labs: • Blood: RFP, Alk Phos, Uric Acid • Urine studies: • U/A with microscopy • 24 hour urine Ca • Spot Urine Ca:Creatinine ratio

  40. Case 4: Radiology • Abdominal Xray • ~90% stones radio-opaque • Ultrasound • Noncontrast helical CT • Pyelogram

  41. Case 4: Treatment and Prognosis • Treat underlying cause • Analgesia • Hydrate with twice MIVF (if no renal insufficiency) • Consult GU if obstructed • <5 mm usually pass spontaneously • Surgical • High chance of recurrence, particularly in underlying metabolic disease

  42. Renal Trauma • 47% GU trauma involves the kidneys • Usually blunt trauma (90%) • Associated with intraperitoneal injuries • More common in kids for anatomic/developmental reasons • American Association for the Surgery of Trauma grading system • Treatment based on grade

  43. Renal Trauma Classification Table 1. Lee, YJ et al. “Renal Trauma.” Radiologic Clinics of North America. 2007, 45: 583 Figure 109.2. Garcia, CT. “Chapter 109: Genitourinary Trauma.” Textbook of Pediatric Emergency Medicine,4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000. p 1373.

  44. Renal Trauma Presentation & Workup • Presentation: • Abdominal or flank pain • Localizing signs • Shock • Workup: • U/A with microscopy • Abdominal Xray • IVP with delayed images • Abdomen/pelvis CT with IV contrast • Other tests: • Ultrasound, Nuclear med scan, Angiography

  45. Renal Trauma Treatment & Prognosis TREATMENT • If < 20 RBC/hpf on U/A • repeat U/A and possible radiologic test as outpatient • Grade 1-3 • Strict bedrest, analgesia, antibiotics • Grade 4-5 • Close observation, serial Hct, antibiotics If devascularized, needs to be revascularized < 12 hrs from injury to be successful. Complications • Bleeding (delayed, persistent, recurrent) • Urine extravasation or urinoma • Infection • Infarction • Hydronephrosis • AV fistula • Renal-intestitnal fistula • Stones • HTN

  46. Renal Trauma Treatment Algorithm Figure 109.1. Garcia, CT. “Chapter 109: Genitourinary Trauma.” Textbook of Pediatric Emergency Medicine,4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000. p 1372.

  47. Hematuria Workup Algorithms Figure 2. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

  48. Hematuria Workup Algorithms Figure 3. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

  49. Hematuria Workup Algorithms Figure 4. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

  50. Summary • Defintion: blood in the urine, ≥ 5 RBC/hpf • Distinguish between glomerular vs lower urinary tract bleeds. • Higher index of suspicion of severe disease when there are signs of systemic disease, eg– HTN, edema, abdominal pain. • Use labs to determine etiology of bleeding and need for further follow up. • Regardless of diagnosis, follow up with the PCP for a repeat urinalysis should be done.

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