THE OFFICE EVALUATION OF
HEMATURIA AND PROTEINURIA:
CASE PRESENTATIONS
Debbie Gipson, M.D., M.S.
University of North Carolina-Chapel Hill
Case 1
A healthy appearing 5 year old boy was noted to
have asymptomatic hematuria at a school
examination. Physical exam was normal.
Urinalysis had 1+ hemoglobin, no protein
Which of the following interpretations
is correct?
1. The child has blood in urine and requires further
evaluation
2. The test showed small amount of blood which is
nothing to worry about
3. The test showed small amount of blood which may
be normal and repeat testing is indicated
Which of the following interpretations
is correct?
1. The child has blood in urine and requires further
evaluation
2. The test showed small amount of blood which is
nothing to worry about
3. The test showed small amount of blood which may
be normal and repeat testing is indicated
How many children with microscopic
hematuria do you see?
1. One semiannually
2. One a month
3. One a year
4. Never, the AAP recommends that we
do not do urinary screening
You arrange dipstick screening to be
done by school nurse on all 8th-graders.
Abnormal results will be found in:
1. 0.1%
2. 1%
3. 10%
4. 20%
You arrange dipstick screening to be done by
school nurse on all 8th-graders. Abnormal
results will be found in:
1. 0.1%
2. 1%
3. 10%
4. 20%
AAP Urinary Screening Guidelines
1. Infancy
2. Early childhood
3. Late childhood
4. Adolescence
AAP Policy: Recommendations for Preventative Care, 1993
Case 1 Continues
The healthy appearing 5 year old boy had
persistent asymptomatic hematuria for six
months.
There was no family history of renal disease; his
father had urinary stones. His father also was
found to have asymptomatic hematuria.
Physical exam was normal.
Urinalysis had 1+ hemoglobin, no protein
Urinalysis of 5 year old with 1+ blood
Which of the following tests would be
expected to be diagnostic?
1. Serum complement levels
2. Urine culture
3. Urine uric acid excretion
4. Urine calcium excretion
5. Serum IgA concentrations
Which of the following tests would be
expected to be diagnostic?
1. Serum complement levels
2. Urine culture
3. Urine uric acid excretion
4. Urine calcium excretion
5. Serum IgA concentrations
Normal calcium excretion in a 5
year old child is:
1. < 2 mg/kg/day
2. < 4 mg/kg/day
3. Uca/creat < 0.6
4. Uca/creat < 0.2 birth - 16 years
Normal calcium excretion in a 5
year old child is:
1. < 2 mg/kg/day
2. < 4 mg/kg/day
3. Uca/creat < 0.6
4. Uca/creat < 0.2 birth - 16 years
Do you have patients with
hypercalciuria and hematuria in
your practice?
1. Yes
2. No
Do you refer a child with persistent
isolated microscopic hematuria and
a normal renal ultrasound to a
pediatric nephrologist?
1. Yes
2. No
Have you diagnosed hypercalciuria
and hematuria in a child who later
developed a urinary stone?
1. Yes
2. No
How do you treat a child with
hypercalciuria?
1.
2.
3.
4.
5.
6.
Dietary (fluids, low Na) alone
Hydrochlorothiazide
Citrate
Lasix
Decrease calcium intake
Nothing
How do you treat a child with
hypercalciuria?
1. Dietary (fluids, low Na) alone
2. Hydrochlorothiazide
3. Citrate
4. Lasix
5. Decrease calcium intake
6. Nothing
Which of the following tests is most
frequently abnormal in the patient with
persistent, asymptomatic, isolated
microscopic hematuria?
1.
2.
3.
4.
5.
Renal/bladder ultrasound
Urine culture
BUN/creatinine
Serum complement
Urine calcium excretion
Which of the following tests is most
frequently abnormal in the patient with
persistent, asymptomatic, isolated
microscopic hematuria?
1.
2.
3.
4.
5.
Renal/bladder ultrasound
Urine culture
BUN/creatinine
Serum complement
Urine calcium excretion
Results of Referral Evaluation Of 83
Consecutive Children in Memphis, Tenn
(Stapleton, NEJM, 1984)
Unexplained
38
(46%)
Hypercalciuria
22
(27%)
Familial hematuria
7
(8%)
Post-inf GN
5
(6%)
IgA nephropathy
4
(5%)
Other
7
(8%)
325 Consecutive Children with Isolated
Microhematuria in Buffalo and
Philadelphia
1) Creatinine/BUN normal
2) Ultrasounds normal
3) Hypercalciuria (9%)
4) Complement studies abnormal in 12%; none
had GN
Cost of Evaluations in 325 Children
with Microhematuria in Buffalo and
Philadelphia
• Total estimated cost $175,000
• Significant diagnoses: none
Case 2
9 year old male brought to physician because
of bloody urine 2 days prior. Patient was
asymptomatic during the event. The urine
spontaneously cleared.
Examination: healthy appearance. BP 98/62
and urinalysis normal.
Case 2 continues...
The child was scheduled to return on 2
additional occasions for urinalysis. Although
the history was consistent with transient
recurrence of red urine, the urine samples
were normal grossly, by dipstick and
microscopic exam.
The child then brought in a urine that was red….
UA dipstick: Hg negative and Protein negative
All of the following are causes of heme
negative, red urine except:
1. Beets
2. Senna
3. Food coloring
4. Metronidazole
5. Red clover honey
6. Iodine
All of the following are causes of heme
negative, red urine except:
1. Beets
2. Senna
3. Food coloring
4. Metronidazole
5. Red clover honey
6. Iodine
Urinalysis: Dipstick Methodology
Blood Indicator
Peroxidase dependent oxidation of the
indicator dye
Hemoglobin + peroxidase
Other oxidants lead to false positive
Povidone-iodine
Hypochlorite
Bacterial peroxidase
Myoglobin
Case 3
A 17 year old previously healthy African
American female presents for a well child
visit.
Dipstick evaluation reveals moderate blood
and 3+ proteinuria. Microscopic
examination of the urinary sediment
reveals 10 RBC/hpf and no casts.
Physical examination is unremarkable
Your assessment and plan is:
1. Microscopic hematuria. Repeat UA x 2
2. Asymptomatic proteinuria and hematuria.
Requires no additional evaluation
3. Proteinuria and hematuria. Additional
evaluation indicated
Your assessment and plan is:
1. Microscopic hematuria. Repeat UA x 2
2. Asymptomatic proteinuria and hematuria.
Requires no additional evaluation
3. Proteinuria and hematuria. Additional
evaluation indicated
Appropriate tests include each of the
following except:
1. AM Urine for protein & creatinine
2. Serum chemistries for creatinine,
albumin, and cholesterol
3. Urine for calcium excretion
4. Serum complement
5. Consider hepatitis and HIV serologies
6. Renal ultrasound
Appropriate tests include each of the
following except:
1. 24 hour urine for protein and creatinine
2. Serum chemistries for creatinine,
albumin, and cholesterol
3. Urine for calcium excretion
4. Serum complement
5. Consider hepatitis and HIV serologies
6. Renal ultrasound
Hematuria + Proteinuria
Combination is an indicator of disease
Gross hematuria may have associated
low grade proteinuria ( Up/c < 0.5)
CASE 4
A six year old girl develops a puffy face and
notices that her urine has turned brown.
No family history of renal disease. A sister
complained of a sore throat one week
before the onset of dark urine.
Physical exam shows generalized edema and
a blood pressure of 135/ 83 mmHg.
Urinalysis contains: large hemoglobin, 2+
protein
The most likely diagnosis is?
1.
2.
3.
4.
5.
Hypercalciuria
Acute Post Strept GN
IgA nephropathy
Membranoproliferative GN
SLE
The most likely diagnosis is?
1.
2.
3.
4.
5.
Hypercalciuria
Acute Post Strept GN
IgA nephropathy
Membranoproliferative GN
SLE
Which of the following tests will be
most helpful in determining the
diagnosis?
1.
2.
3.
4.
5.
Serum BUN/creatinine
Serum complement & streptozyme
Serum IgA
Renal ultrasound
Serum albumin
Which of the following tests will be
most helpful in determining the
diagnosis?
1.
2.
3.
4.
5.
Serum BUN/creatinine
Serum complement & streptozyme
Serum IgA
Renal ultrasound
Serum albumin
The streptozyme titer is elevated
and the serum complement (C3)
is decreased
Which one of the following is not
associated with depressed serum
complement values?
1.
2.
3.
4.
Acute post strept GN
Membranoproliferative GN
IgA nephropathy
SLE
Which one of the following is not
associated with depressed serum
complement values?
1.
2.
3.
4.
Acute post strept GN
Membranoproliferative GN
IgA nephropathy
SLE
POST-STREPTOCOCCAL GN
•
•
•
•
Most common type of acute GN
May present with minimal symptoms
Complications often due to fluid overload
Complement levels may be depressed
longer than previously recognized
• Persistent microscopic hematuria up to
one year is common
• Prognosis is excellent
Do you hospitalize most children
with acute post streptococcal
glomerulonephritis?
1. Yes
2. No
CASE 5
A 12 year old girl has a sore throat and that
same day notices that her urine turns brown.
She generally feels well and without specific
symptoms.
She has not had previous urinalyses. There is
no family history of renal disease.
Her examination is normal.
The urinalysis contains large hemoglobin and
1+ protein.
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
What does this patient have?
1. Glomerular hematuria
2. Non-glomerular hematuria
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
The most likely diagnosis is?
1. Acute Post Strept GN
2. Hypercalciuria
3. Alport’s Syndrome
4. IgA nephropathy
5. Hemolytic Uremic Syndrome
DIAGNOSIS OF 56 BIOPSIES IN
TEENAGERS WITH GROSS HEMATURIA
IgA glomerulonephropathy
Minimal lesion
Diffuse mesangial prolif.
Proliferative nephritis
MPGN
Focal sclerosis
Crescentic GN
28 (50%)
10 (16%)
6 (7%)
4 (6%)
3 (5%)
3 (5%)
2 (4%)
Do you have patients with
IgA nephropathy?
1. Yes
2. No
Current treatments for
IgA nephropathy
1.
2.
3.
4.
5.
Prednisone
Fish oil
Vitamin E
ACE inhibitors
Nothing
Which of the following
suggests a serious prognosis?
1. Family history
2. Proteinuria
3. Elevated serum IgA values
4. Low serum complement values
5. Abdominal pain
Which of the following
suggests a serious prognosis?
1. Family history
2. Proteinuria
3. Elevated serum IgA values
4. Low serum complement values
5. Abdominal pain
CASE 6
A 12 year old girl has a sore throat and that
same day notices that her urine turns brown.
She generally feels well and without specific
symptoms.
She has not had previous urinalyses. There is
no family history of renal disease.
Her examination is normal.
The urinalysis contains large hemoglobin and
1+ protein, and no RBC casts.
Appropriate tests include each of the
following except:
1. Urine culture
2. Renal ultrasound
3. Urine for calcium excretion
4. Serum complement
5. Test for sickle cell trait
Appropriate tests include each of the
following except:
1. Urine culture
2. Renal ultrasound
3. Urine for calcium excretion
4. Serum complement
5. Test for sickle cell trait
Evaluation of Isolated Macroscopic
Hematuria (without Casts)
Urine culture
Renal ultrasound
Urine calcium excretion
Family urinalyses
Sickle cell status
Cystoscopy (occasional)
Angiogram
Evaluation of Hematuria with
Proteinuria
Serum creatinine, albumin
Urine protein excretion
Streptococcal antibody screen
Serum complement
Family urinalyses
ANA, hepatitis studies (selected)
Evaluation of Non-orthostatic
Proteinuria is Similar to that of
Hematuria With Proteinuria*
(*Exception: vesicoureteral refluxinduced nephropathy)