Hematuria

1. Hematuria

2. Objectives • Plan the appropriate management of a child with microscopic hematuria • Recognize the differential diagnosis and prognosis of patients with persistent microscopic hematuria with and without proteinuria • Plan the evaluation of a child with persistent microscopic hematuria

3. Definition • 5 to 10 RBC’s per high power microscopic field • Should be obtained from a midstream voided urine sample

4. Beware False Positives on Urine Dip • Myoglobin produces the same color change on the dipstick • Drugs: ascorbic acid, sulfonamides, iron sorbitol, metronidazole, and nitrofurantoin • Take home: Verify test results with microscopy!

5. History and Differential DiagnosisPursue a diagnosis if > 1 month

6. History and Differential Diagnosis

7. History and Differential Diagnosis

8. Family History • Hematuria without renal failure • thin basement membrane disease • Hematuria, renal failure, dialysis, or transplant with hearing loss • Alport syndrome (high tone hearing loss) • Nephrolithiasis or hypercalciuria • ADPKD – must be ruled out radiologically • Sickle cell or trait

9. Examination • Urine microscopy • RBCs from all areas other than glomeruli will be normal in size or slightly small and eumorphic • Nonglomerular bleeding usually with normal protein and no RBC casts

10. Urine Culture Sickle cell prep – if African American Urinary calcium Urinary creatinine ratio Serum creatinine C3 Streptozyme titer Ultrasound – to rule out polycystic kidney disease, tumor, ureteropelvic junction obstruction, and stones Urinary protein excretion when protein elevated for 12-24 hour period OR Spot urine protein:urine creatine ratio Testing

11. Testing for Proteinuria • Protein excretion of less than 4 mg/m2 per hour is normal • Protein excretion of more than 40 mg/m2 per hour is considered in the nephrotic • Urine protein: urine creatinine ratio > 0.2 abnormal, > 1.0 nephrotic

12. CBC C3, C4 ASLO Streptozyme titer Chem 7 (BUN.Cre) Albumin Testing for lupus Hepatitis B Screening RENAL BIOPSY WHEN TESTING NONDIAGNOSTIC Further Testing if Glomerulonephritis Likely

13. Hematuria & Hypercalciuria • Idiopathic hypercalciuria • Urinary calcium: urinary creatinine ratio > 0.21 • 24 hour urinary calcium excretion of > 4 mg/kg • Hypercalciuria in a child with hematuria should not exclude the consideration of other etiologies • Hyperparathyroidism • Immobilization • Vitamin D intoxication • Furosemide use

15. UTI most common Perineal irritation Meatal stenosis with ulceration Trauma Recent surgery Clotting Abnormalities Nephrolithiasis Glomerulonephritis Etiology of Gross Hematuria 1/1000 visits to pediatric ER

16. Gross Hematuria • Of 58 adolescents who had a biopsy in one study, 52% had IgA nephropathy, most others had other mesangial lesions • Approximately 15% of children who have isolated persistent hematuria for more than 12 months will have IgA nephropathy

17. Renal Structural Abnormalities Associated with Hematuria • Polycystic kidney disease • Uteropelvic junction obstruction • Vesicoureteral reflux • Renal or bladder stones, diverticulae or tumors • Renal arteriovenous fistula • Foreign bodies

18. Follow-Up:After Pathologic Causes Ruled Out • Patients should be followed at 6-12 month intervals • Assess linear growth, blood pressure, and UA • 10-50% of children with persistent hematuria may develop progressive renal disease

19. When to Refer • Red blood cell casts on microscopic urine exam • Significant proteinuria • Hypertension; edema • Abnormal renal function; decreased C3 • Persistent hematuria for more than 1 year • Hypercalciuria • Renal structure abnormality • Family history of hereditary nephritis or polycystic renal disease