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Hematuria

Hematuria. Katie Townes MD, PGY2. 8 year old male with episodic hematuria , initially thought to be due to trauma, but persisted for weeks and recurred with fevers. Also with severe anemia requiring multiple blood transfusions. Hematuria seemed to occur when he was febrile……. Case.

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Hematuria

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  1. Hematuria Katie Townes MD, PGY2

  2. 8 year old male with episodic hematuria, initially thought to be due to trauma, but persisted for weeks and recurred with fevers. Also with severe anemia requiring multiple blood transfusions. Hematuria seemed to occur when he was febrile…… Case

  3. >5 RBCs per high power field • Microscopic vs. gross hematuria • Multiple differentials of hematuria What is hematuria?

  4. RBCs in urine microscopy Library.med.utah.edu

  5. Foods or medicines that turn the urine red? • Urate crystals in diapers • Myoglobinuria? -positive heme on dipstick -no RBCs seen on microscopy -cause? -muscle breakdown from rhabdomyolysis (crush injury, burns, asphyxia) • Hemoglobinuria can be caused by hemolysis, but again, no RBCs seen on microscopy Things that are NOT Hematuria

  6. Urate Crystals in Diaper From newborns.stanford.edu

  7. Glomerular disease • Tubular disease • UTI • Schistosomiasis • Trauma • Tumors • Stones • Polycystic kidney disease Differentials

  8. History -coca-cola colored or smoky urine -edema -malaise • Physical -hypertension -edema • Labs -renal failure -microscopy RBC casts and dysmorphic RBCs Cyberrounds.com Glomerulonephritis

  9. -GBM is damaged -RBCs can get through GBM -Going through the tubule, the stick together, forming casts that appear in the urine Formation of RBC casts Library.med.utah.edu

  10. Casts and dysmorphic RBCs Library.med.utah.edu

  11. post-strep GN • membranoproliferative GN • RPGN • IgA nephropathy • SLE • Alport’s disease (not really GN…) Glomerulonephritis Causes

  12. Post-Strep GN usually self-resolves in kids • Kidney biopsy • RPGN, Membranoproliferative GN, IgA nephropathy, SLE- immunosuppressives (steroids, cyclophosphamide) • Supportive treatment: anti-HTN, fluid restriction, Lasix • Many will develop ESRD and need HD or transplant Glomerular Disease- Treatment

  13. ATN -anoxic injury -rhabdomyolysis -certain medications/toxins? -sometimes reversible with supportive care • Cortical necrosis -usually due to severe anoxia -often irreversible • AIN -urine eosinophils elevated -usually related to medications- sulfa, ibuprofen -reversible when stopped Tubular disease

  14. Causative organisms? • History -dysuria, frequency, urgency- lower UTI -Fever, back pain, vomiting- upper UTI • Physical -fever- upper -suprapubic pain -CVA tenderness- upper • Labs -CBC -U/A? -urine culture UTI Catsmeowvets.com

  15. WBC- see nuclei WBC cast in pyelonephritis UTI Library.med.utah.edu

  16. Cotrimoxazole 4mg TMP/20mg sulfa per kg PO BID x 5d if no signs of upper tract infection • Alternatives: Ampicillin, Amoxicillin, Cephalexin, Ciprofloxacin • If signs of pyelo or in young infants (<2 months), give parenteralAmpicillin and Gentamicin or cephalosporin x10-14 days • Consider sepsis or perinephric abscess if no resolution with antibiotics UTI Treatment (WHO book)

  17. Larval parasites penetrate cutaneously • Migrate hematogenously to portal system, where mating occurs over 1-3 months • S. hematobiumorganisms migrate to venous channels in bladder and lay eggs • Eggs breach vessel walls and enter the bladder, causing inflammatory response and urinary symptoms • Eggs are then passed back into the water by urination, completing the cycle Schistosomiasis-Pathophys

  18. Acute sx -fevers -pruritic rash (swimmer’s itch) -LAN -abdominal pain • Chronic sx -terminal hematuria -dysuria -obstructive uropathy -Chronic inflammation can cause malnutrition, poor growth • Diagnosis: urine microscopy to look for eggs (only in chronic stage) • Treatment- Praziquantel, education (avoid fresh water!) Schisto- Clinical

  19. commons.wikimedia.org Schistosomiasis

  20. History -trauma to the back -flank pain • Physical -evidence of trauma -flank bruising • Labs: hematuria without casts Trauma

  21. Wilms tumor (nephroblastoma) • Most common pediatric renal malignancy • Median age 3-3.5 years, M=F • History: hematuria, abdominal mass, fever, abd pain • Physical: palpable abdominal massTreatment: surgery +/- chemoradiation • Rhabdomyosarcoma Tumors?

  22. Wilms Tumor www.szote.u-szeged.hu/radio/retr/ret4c.gif

  23. Uncommon in children • History: flank pain, gross hematuria • Physical: writhing in pain, flank pain, abdominal pain, can’t get comfortable • Labs: Urinalysis with positive heme and positive RBCs (no casts) • Treatment: pain control, fluids. Stones can usually pass on their own if not too big • Complications: obstruction causing UTI, abscess, sepsis if stone doesn’t pass Stones

  24. Most common places to obstruct: Renal pelvis Crossing the pelvic brim Entering the bladder Stones Calcium oxalate Staghorn calculus All images from google images

  25. Autosomal dominant PKD doesn’t affect children (renal failure usually 4th-5th decade) • Autosomal recessive PKD affects children, can be variable (infants-adolescent presentation). • Depending on category, liver disease also part of the syndrome • Clinical- renal failure, palpable flank masses, cystic kidneys on ultrasound • Treatment- ARPKD eventually progresses to ESRD, needing HD or transplant Polycystic kidney disease

  26. nature.com PKD-Images Healthjockey.com

  27. Due to hemolysis (sickle cell, G6PD def, malaria, TTP, DIC, HUS) • U/A shows positive heme, but no RBCs • Hemoglobin is toxic to kidneys, causes ATN Hemoglobinuria

  28. Rare, autosomal dominant mutation of RBC membrane protein (GPI-anchor), leads to complement deposition and intravascular hemolysis • Clinical triad of intravascular hemolytic anemia, venous thrombosis, and pancytopenia • Median age 46, but children can be affected • Children tend to have aplastic anemia • Hematuria most noticeable in AM when urine is concentrated, but can occur anytime Paroxysmal Nocturnal Hematuria

  29. History -Fatigue and jaundice (hemolytic anemia) -coca cola colored urine -abdominal pain, headache, SOB (clots) -bleeding, infections, fatigue (BM failure) • Physical -signs of hemolytic anemia (pallor, tachy, jaundice) -usually no spleen, because intravascular hemolysis -abdominal pain may suggest hepatic or portal vein thrombosis -petechiae or fevers to suggest pancytopenia Paroxysmal Nocturnal Hematuria

  30. Treatment -medial survival is 10 years, death usually due to thrombosis -immunosuppression with steroids can help with hemolytic anemia -Folic Acid for all children with hemolytic anemia. Why? -beware infection risk…. Paroxysmal Nocturnal Hematuria

  31. So what diagnosis makes the most sense? -UTI? -Trauma? -Glomerulonephritis? -Myoglobinuria? -Paroxysmal nocturnal hemoglobinuria? -Sickle cell anemia? Back to the case:

  32. Besa, Emmanuel. “Paroxysmal Nocturnal Hematuria.” emedicine.com. March 2009 • library.med.utah.edu/WebPath/TUTORIAL/URINE/URINE.html#2 • Nelson’s Essentials of Pediatrics. 5th Edition. Chapter 163, page 757-759. • Young, B. Y. et al. Autosomal Recessive Polycystic Kidney Disease. Emedicine.com. April 28, 2010. • www.szote.u-szeged.hu/radio /retr/ret4c.gif References

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