Hematuria
For the boards...
Gital Karamchandani-Patel, MD
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Definition

Macroscopic (gross) Hematuria
 any
discolored urine visible to the
human eye

Microscopic Hematuria
 >5
RBC/hpf seen under
microscope
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Hematuria

Patient comes to your office
complaining that their urine is
reddish in color...
What
is your
first step?
– Good H+P
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Hematuria
Is it really blood?
 Urine
Dipstick
 Detects
Hgb, myoglobin
 Detects protein
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Hematuria
 Urinalysis
 Definitive
for the presence of RBC
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Hematuria

Upper urinary
tract



glomerulus
collecting tubules
interstitium

Lower urinary
tract





calyx
pelvis
ureter
bladder
urethra
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What PREP wants you to
know...

Know the differential diagnosis of a
child with gross hematuria
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Differential Diagnosis
Macroscopic Hematuria
obtain U/A
+ RBCs
- RBCs
with
proteinuria
without
proteinuria
heme +
heme -
glomerular*
extraglomerular
Hgb
myoglobin
drugs
dyes
prompt eval for kidney dz
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Glomerular Hematuria
 brown,
tea colored urine
 proteinuria
 deformed urinary RBCs
 RBC casts
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Glomerular Hematuria
RENAL
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IgA nephropathy
Alport syndrome
Thin glomerular BM
disease
Post infectious
MPGN
MULTI-SYSTEM
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SLE nephritis
HSP nephritis
Wegener syndrome
Goodpasture syndrome
HUS
Sickle cell Disease
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W/u for Glomerular
Hematuria

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CBC
C3, C4
antistreptolysin-O titer, streptozyme titer
serum electrolytes, BUN, serum Cr,
serum albumin
test for lupus
Hep B
antinuclear cytoplasmic antibody titer
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Extraglomerular
Hematuria

Hematuria from lower urinary tract
 terminal
hematuria
 blood clots
 nl urinary RBCs
 minimal proteinuria
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Extraglomerular Hematuria
UPPER URINARY
TRACT
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pyelonephritis
ATN
papillary necrosis
nephrocalcinosis
thrombosis
malformation
SCD
tumor
PCKD
LOWER URINARY
TRACT
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cystitis
urethritis
urolithiasis
trauma
coagulopathy
heavy excersise
UPJ obstruction
ureterocele
Munchausen, MBP
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W/u for Extraglomerular
Hematuria
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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
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Proteinuria
For the boards...
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Proteinuria

Occurs in 10% of kids 8-15 yrs
 differentiate
between
 renal
disease
 transient
 benign
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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)
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Differential Diagnosis
Proteinuria
benign
orthostatic
transient
fixed
glomerular
tubular
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Proteinuria


A child comes into your office for a
routine visit
Screening urine dipstick reveals 1+
protein
What
is your next step?
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Proteinuria

R/O benign conditions
 sg
>1.020
 pH >7.5
 mucoproteins
 acute illness
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Proteinuria

Next step is to determine if this is
transient or fixed
 R/O
orthostatic proteinuria
 first
 W/u
am U/A
for persistent fixed proteinuria
 alb,
C3, 24 hr urine protein
 Pr/Cr ratio
 W/u
for glomerular hematuria if +
RBCs
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Quiz Time
Let’s see who has been paying
attention...
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Quiz time #1
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

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?
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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
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Quiz time #2
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Gross hematuria following a URI
C3 is wnl
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What is your diagnosis?
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IgA Nephropathy
(Berger’s Disease)
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IgA deposits seen on renal biopsy
nl C3
elevated IgA in 15%
often hypertensive
need long-term f/u
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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?
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Acute Post-Infectious
Glomerulonephritis

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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
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Quiz time #4
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
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3 yr old F with diarrhea
6 days later develops a rash,
abdominal pain
on PE, you note pallor and purpura
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Quiz time #4

What is your diagnosis?
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Hemolytic-Uremic
Syndrome

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MCC of ARF in children
Caused by shiga toxin producing
E.coli O157:H7
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Quiz time #5
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Infant comes in with hematuria
h/o constipation
h/o TEF repair

What is your diagnosis?
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VATER association
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V vertebral anomalies
A anal atresia
T TEF
E
R radial limb anomalies
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Quiz time #6
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14yo female with hematuria
More “tired” lately
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Quiz time #6
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What is your diagnosis?
What labs will you order?
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SLE nephritis
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C3 and C4 will be LOW
Sometimes will only manifest as
kidney disease
WHO staging of nephritis
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Quiz time #7
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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?
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Membranoproliferative
Glomerulonephritis


MPGN is the MCC of chronic
glomerulonephritis in children
renal biopsy confirms dx
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Confused about
complement?

What three conditions cause
hypocomplementemia?
P
post infectious GN
M
membrano proliferative GN
S
SLE
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Quiz time #8

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.
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Quiz time #8
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
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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?
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Quiz time #8

Answer: Urine Ca/Cr ratio!!
 urinary
calcium:urinary creatinine
ratio of > 0.21
 24-hour urinary calcium excretion
of >4 mg/kg
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Hypercalciuria

Idiopathic 30%
 15%
go on to have renal stones
 Immobilization
 Hyperparathyroidism
 Furosemide
 Vit
D intoxication
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Thank you for your
attention!
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PREP specs

Plan the evaluation of hematuria in
a child with sickle cell disease.
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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.
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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
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PREP 2005 #70
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Correct Answer: C
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