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
2
Definitions
 The presence of blood in urine
• Gross: visible with the naked eye
• Microscopic: visible on urinalysis (≥ 5 RBC/hpf)
Renal anatomy
3
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.
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
4
Diagnosis
 Distinguish between upper vs lower bleeds
5
Diagnosis
 Urine Dipstick
• Tetramethylbenzidine and H2O2
• Detects 1-5 RBC/hpf
 Sensitivity: 100%, Specificity: 99%
RBC cast
6
Dysmorphic RBCs
Common Confounders
Drugs
Pigments
Rifampin
Hemoglobin (hemolysis)
Phenazopyridine
Myoglobin
Pyridium
Bilirubin
Furazolidone
Beets
Sulfa
Blackberries
Nitrofurantoin
Urates
Methyldopa
Serratia marcescens
Levodopa
Porphyrinuira
Metronidazole
Alkaptonuria
Dexferroximine
Homgentisic acid
Diphenylhydantoin
Tyrosinosis
Iron sorbitol*
Methemoglobinuria
Hypochlorite and iodine*
Melanin
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.
7
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.
8
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
9
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?
10
Case 1: Labs
145 | 110 | 100 / 75
8 | 15 | 2.5 \
Ca 6.8
Phos 8
15 \ 9 / 160
/ 28 \
U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 50-100, WBC 10-20,
+RBC casts
C3: 100 (low)
ASLO: +
C4: 22 (nl)
WHAT’S YOUR DIAGNOSIS?
11
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:
•
•
•
•
12
Gross hematuria
Edema
Renal insufficiency with oliguria
Fever, malaise, lethargy, flank or abdominal pain
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
13
 Biopsy: diffuse mesangial cell and matrix
proliferation; “humps” on the epithelial side of GBM
Case 1: PSGN
 Complications
•
•
•
•
14
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.
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
15
Other Immune-mediated GN
 Bacteria: Strep pneumoniae, Staph, Gram
negatives, endocarditis
 Viruses: Influenza, Hep B, Hep C
 Fungus: Candida
 Parasites: rickettsial (syphilis), Toxoplasma, malaria
16
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
17
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
4.2 | 23 | 0.3 \
18
Ca 8.9
U/A: 1.025, + 2 protein, - LE, - nitrites, 10-20 RBC, 0 WBC
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:
•
•
•
•
19
U/A: protein, RBC, RBC casts
BMP: may show renal insufficiency
Complement: nl C3 and C4
Immunoglobulins: increased in 5% cases
Case 2: Berger’s Disease
 Diagnosis made by renal biopsy
20
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:
21
• Persistent HTN
• Decreasing renal function
• Heavy proteinuria
Other GN with Crescent Formation
 Systemic Lupus Erythematosis
 Henoch-Schönlein Purpura
 Rheumatoid Arthritis
 Ankylosing Spondylitis
 Inflammatory Bowel Disease
 Celiac Disease
 HIV
22
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
23
Case 3: Physical Exam
T37.8C ax
HR 120
RR 32
BP 95/55
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
4 | 27 | 0.3 \
24
Ca 9.2
12 \ 10 / 180
/ 30 \
U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite,
RBC 100-200, WBC 5-10
SaO2 98% RA
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
25
Case 3: Workup
 U/A in relatives
 Ophthalmologic exam
 Audiogram
 ± Renal biopsy
26
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
27
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.
28
Summary for GN
 Workup:
 U/A with microscopy
 CBC, BMP (or RFP)
 C3 and C4
 Consider ASLO, anti-DNAse B, or streptozyme
 Consider ANA
29
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
Summary for GN
30
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.
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
31
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?
32
Case 4: Labs and Radiology
135 | 102 | 22 / 150
4.3 | 22 | 0.8 \
Ca 8.9
16 \ 13 / 220
/ 40 \
U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 50-100, WBC 0-5,
+ crystals
33
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.
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
34
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
35
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
36
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.
examination of the child with urolithiasis or
nephrocalcinosis.” Pediatr Nephrol (2010) 25: 403413.)
Case 4: Common stones
37
calcium oxalate
uric acid
triple phosphate
cystine
“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
38
• 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
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
39
Case 4: Radiology
 Abdominal Xray
• ~90% stones radio-opaque
 Ultrasound
 Noncontrast helical CT
 Pyelogram
40
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
41
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
42
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.
43
Table 1. Lee, YJ et al. “Renal Trauma.” Radiologic Clinics of North America. 2007, 45: 583
Renal Trauma Classification
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
44
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.
45
COMPLICATIONS
• Bleeding (delayed,
persistent, recurrent)
• Urine extravasation or
urinoma
• Infection
• Infarction
• Hydronephrosis
• AV fistula
• Renal-intestitnal fistula
• Stones
• HTN
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.
46
Hematuria Workup Algorithms
47
Figure 2. Patel, HP and JJ Bissler.
“Hematuria in Children.” Pediatric
Clinics of North America. 2001, 48(6):
1519-1537.
Hematuria Workup Algorithms
48
Figure 3. Patel, HP and JJ Bissler.
“Hematuria in Children.” Pediatric
Clinics of North America. 2001, 48(6):
1519-1537.
Hematuria Workup Algorithms
49
Figure 4. Patel, HP and JJ
Bissler. “Hematuria in Children.”
Pediatric Clinics of North America.
2001, 48(6): 1519-1537.
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.
50
And now it’s time for roulette!
51
Roulette
5 y/o girl with a rash.
7.6\ 11 / 200
/ 34 \
140 | 102 | 12 / 152
4.2 | 25 | 0.3 \ 8.9
U/A: + 1 protein, WBC 20, RBC 50
52
 Pyelonephritis
 HSP













HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
2 y/o girl “not urinating.”
130 | 103 | 61 / 99
4.9 | 21 | 3.7 \
AST 293
ALT 201
AP 175
TB 1.7
15.5 \ 9.3 / 46
/ 24 \
TP 5.1
Alb 2.5
+ microcytes
+ schistocytes
U/A: + 1 protein,
WBC 0, RBC 5-10
53
Ca 7.3















Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
13 y/o girl with hemoptysis.
133 | 99 | 20 / 152
5.6 | 16 | 1.0 \
C3 nl
C4 low
17 \ 11 / 420
/ 35 \
U/A: + 2 protein, WBC 10-15,
RBC 100-150, RBC casts
54





Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome










Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
4 months old with persistent vomiting
and diarrhea x 3 days, one wet diaper
in 24 hours
152 | 95 | 40 / 52
3.2 | 8 | 0.8 \
19 \ 14 / 85
/ 40 \
U/A: grossly bloody, + 2 protein,
WBC 5-10, RBC TNTC
55















Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
 Pyelonephritis
10 y/o girl with high fevers and
vomiting.
140 | 102 | 12 / 152
4.2 | 25 | 0.3 \
18 \ 12 / 420
/ 38 \
U/A: + LE, + nitrites,
WBC 50-75, RBC 20-25
56
Ca 8.9














HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
7 y/o boy with URI and blood in
urine.
140 | 102 | 25 / 152
4.2 | 25 | 0.6 \
C3 nl
C4 nl
12 \ 13 / 420
/ 40 \
U/A: + 2 protein,
WBC 0, RBC 10-15, RBC casts
57




Pyelonephritis
HSP
HUS
IgA nephropathy











Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
2 y/o boy with blood in urine 1-2
days after a URI
140 | 102 | 9 / 152
4.2 | 25 | 0.3 \
C3 nl
C4 nl
12 \ 13 / 420
/ 40 \
U/A: + 2 protein, WBC 5-10,
RBC 150-200, RBC casts
58




Pyelonephritis
HSP
HUS
IgA nephropathy
 Alport syndrome










Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
17 y/o boy with severe muscle pain
during football training season
140 | 102 | 27 / 152
4.2 | 25 | 1 \
Ca 8.9
CPK nl
10 \ 12 / 220
/ 38 \
U/A: dk red, + hgb, - LE & nitrites
WBC 0-5, RBC clots
59










Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy





Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
10 y/o boy run over by car. On exam,
has perineal edema and ecchymosis,
along with unstable pelvis.
132 | 103 | 15 / 270
3 | 17 | 0.6 \
Ca 8.8
17 \ 8 / 510
/ 23 \
U/A: + hgb, +2 protein,
WBC 10-15, RBC TNTC














Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
 Urethral trauma
60
Roulette
10 y/o girl with nausea; recurrent
abdominal pain, now constant;
unable to get comfortable on
stretcher.
138 | 100 | 15 / 175
4.1 | 22 | 0.7 \
Ca 8.7
16 \ 12 / 390
/ 38 \
U/A: + hgb, +1 protein, - LE &
nitrites, WBC 0-5, RBC 25-30
61












Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
 Nephrolithiasis
 UPJ disruption
 Urethral trauma
Roulette
3 month old comes in for blood in
urine. No fever. Has been doing
well.











Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
 Pigmenturia
 Nephrolithiasis
 UPJ disruption
 Urethral trauma
62
Roulette
12 y/o girl with fever, joint pains,
rash
138 | 103 | 25 / 83
4.7 | 20 | 1.3 \
C3 low
C4 low






Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
 SLE nephritis
19 \ 9 / 390
/ 29 \
U/A: + 2 protein, WBC 5-10,
RBC 50-75, RBC casts
63








Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
6 month old presents with finger
swelling, crying, and fever
140 | 110 | 8 / 150
4 | 17 | 0.2 \
20 \ 8 / 405
/ 24 \
U/A: grossly bloody, + 2 protein,
WBC 0-5, RBC 25-50
64









Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
 Sickle cell nephropathy





Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Roulette
4 y/o boy with fever and grossly
bloody urine.
140 | 102 | 12 / 152
4.2 | 25 | 0.3 \
Ca 8.9
10 \ 12 / 220
/ 38 \
U/A: + LE, + nitrites,
WBC 10-20, RBC TNTC
Ucx: NGTD
65















Pyelonephritis
HSP
HUS
IgA nephropathy
Alport syndrome
Goodpasture disease
SLE nephritis
Hemorrhagic cystitis
Renal vein thrombosis
Sickle cell nephropathy
Heavy exercise
Pigmenturia
Nephrolithiasis
UPJ disruption
Urethral trauma
Questions?
66
References
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67
Beck, LH and DJ Salant. “Glomerular and Tubolointerstitial Diseases.” Primary Care: Clinics in Office
Practice. 2008, 35: 265-296.
Butani L and A Kalia. “Idiopathic hypercalciuria in children – how valid are the existing diagnostic
criteria.” Pediatric Nephrology. 2004, 19:577-582.
Cronan, K and ME Norman. “Chapter 86: Renal and Electrolyte Emergencies.” Textbook of Pediatric
Emergency Medicine, 4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams &
Wilkins, 2000.
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.
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.
Elder, JS. “Part XXIII, Chapter 538: Urinary Tract Infections.” Nelson Textbook of Pediatrics, 18th ed.
RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.
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18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.
Elder, JS. “Part XXIII, Chapter 547: Urinary Lithiasis.” Nelson Textbook of Pediatrics, 18th ed. RM
Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.
Garcia, CT. “Chapter 109: Genitourinary Trauma.” Textbook of Pediatric Emergency Medicine, 4th ed.
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Gordon, C and FB Stapleton. “Hematuria in adolescents.” Adolescent Medicine Clinics. 2005, 16: 229239.
Hoppe, B and MJ Kemper. “Diagnostic examination of the child with urolithiasis or nephrocalcinosis.”
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Indian Pediatric Nephrology Group, Indian Academy of Pediatrics. “Consensus Statement on Evaluation
of Hematuria.” Indian Pediatrics. 2006 Nov, 43: 965-973.
Kasthan, CE. “Familial Hematuria.” Pediatric Nephrology. 2009, 24: 1951-1958.
Kit, LC et al. “Pediatric urolithiasis: experience at a tertiary care pediatric hospital.” CUAJ. 2008, Aug,
2(4): 381-386.
Lau, KK and RJ Wyatt. “Glomerulonephritis.” Adolescent Medicine Clinics. 2005, 16: 67-85.
Lee, YJ et al. “Renal Trauma.” Radiologic Clinics of North America. 2007, 45: 581-592.
Leslie, JA and MP Cain. “Pediatric Urologic Emergencies and Urgencies.” Pediatric Clinics of North
America. 2006, 53: 513-527.
Liebelt, EL. “Chapter 34: Hematuria.” Textbook of Pediatric Emergency Medicine, 4th ed. GR Fleisher
and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000Noe, HN and DP Jones. “Chapter
111– Renal Diseases in Childhood.” Wein: Campbell-Walsh Urology, 9th ed. Wein, ed. Philadelphia:
Elsevier, 2007.
Pan, CG. “Evaluation of Gross Hematuria.” Pediatric Clinics of North America. 2006, 53: 401-412.
Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6):
1519-1537.
Quigley, R. “Evaluation of hematuria and proteinuria: how should a pediatrician proceed?” Current
Opinion in Pediatrics. 2008, 20:140-144.