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Hematuria

Hematuria. For the boards. Gital Karamchandani-Patel, MD. Definition. Macroscopic (gross) Hematuria any discolored urine visible to the human eye Microscopic Hematuria >5 RBC/hpf seen under microscope. Hematuria.

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Hematuria

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  1. Hematuria For the boards... Gital Karamchandani-Patel, MD

  2. Definition • Macroscopic (gross) Hematuria • any discolored urine visible to the human eye • Microscopic Hematuria • >5 RBC/hpf seen under microscope

  3. Hematuria • Patient comes to your office complaining that their urine is reddish in color... • What is your first step? • Good H+P

  4. Hematuria Is it really blood? • Urine Dipstick • Detects Hgb, myoglobin • Detects protein

  5. Hematuria • Urinalysis • Definitive for the presence of RBC

  6. Upper urinary tract glomerulus collecting tubules interstitium Lower urinary tract calyx pelvis ureter bladder urethra Hematuria

  7. What PREP wants you to know... • Know the differential diagnosis of a child with gross hematuria

  8. Glomerular Hematuria • brown, tea colored urine • proteinuria • deformed urinary RBCs • RBC casts

  9. 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 Glomerular Hematuria

  10. 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

  11. Extraglomerular Hematuria • Hematuria from lower urinary tract • terminal hematuria • blood clots • nl urinary RBCs • minimal proteinuria

  12. 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 Extraglomerular Hematuria

  13. 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

  14. Proteinuria For the boards...

  15. Proteinuria • Occurs in 10% of kids 8-15 yrs • differentiate between • renal disease • transient • benign

  16. 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)

  17. Proteinuria • A child comes into your office for a routine visit • Screening urine dipstick reveals 1+ protein • What is your next step?

  18. Proteinuria • R/O benign conditions • sg >1.020 • pH >7.5 • mucoproteins • acute illness

  19. 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

  20. Quiz Time Let’s see who has been paying attention...

  21. 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?

  22. 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

  23. Quiz time #2 • Gross hematuria following a URI • C3 is wnl • What is your diagnosis?

  24. IgA Nephropathy (Berger’s Disease) • IgA deposits seen on renal biopsy • nl C3 • elevated IgA in 15% • often hypertensive • need long-term f/u

  25. 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?

  26. 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

  27. Quiz time #4 • 3 yr old F with diarrhea • 6 days later develops a rash, abdominal pain • on PE, you note pallor and purpura

  28. Quiz time #4 • What is your diagnosis?

  29. Hemolytic-Uremic Syndrome • MCC of ARF in children • Caused by shiga toxin producing E.coli O157:H7

  30. Quiz time #5 • Infant comes in with hematuria • h/o constipation • h/o TEF repair • What is your diagnosis?

  31. VATER association • V vertebral anomalies • A anal atresia • T • E • R radial limb anomalies TEF

  32. Quiz time #6 • 14yo female with hematuria • More “tired” lately

  33. Quiz time #6 • What is your diagnosis? • What labs will you order?

  34. SLE nephritis • C3 and C4 will be LOW • Sometimes will only manifest as kidney disease • WHO staging of nephritis

  35. 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?

  36. Membranoproliferative Glomerulonephritis • MPGN is the MCC of chronic glomerulonephritis in children • renal biopsy confirms dx

  37. Confused about complement? • What three conditions cause hypocomplementemia? • Ppost infectious GN • Mmembrano proliferative GN • SSLE

  38. Quiz time #8 last one! • 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.

  39. 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?

  40. Quiz time #8 • Answer: Urine Ca/Cr ratio!! • urinary calcium:urinary creatinineratio of > 0.21 • 24-hour urinary calcium excretion of>4 mg/kg

  41. Hypercalciuria • Idiopathic 30% • 15% go on to have renal stones • Immobilization • Hyperparathyroidism • Furosemide • Vit D intoxication

  42. Thank you for your attention!

  43. PREP specs • Plan the evaluation of hematuria in a child with sickle cell disease.

  44. 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.

  45. 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

  46. PREP 2005 #70 • Correct Answer: C

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