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D Spencer Mangum, PGY3

8/7/13

Morning Report

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Patient

17 yo healthy male referred to pediatric nephrologyfor asymptomatic microscopic hematuria:

Hematuria found incidentally from a scoutphysical 3 months prior, no other symptoms (No

urgency, frequency, hesitancy, dysuria, abd pain,or prior trauma). U/A: SG 1.025, 2+ protein, 3+ blood

PCP further work up:

Repeat U/As 1.5 months later: SG 1.005, no protein, + blood (? amount)

2 months later: SG 1.025, 1+ protein, 3+ blood

Documented normal BPs at all visits

Obtained serum labs: CMP and CBC wnl (BUN 20,

Cr 1)

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Patient

PMHx: Generally healthy (mild asthma whenyounger). No surgeries / hospitalizations. No

medications. NKDA. Imm: UTD

Family Hx: Mother with kidney stones. No chronic

kidney disease, Maternal grandmother with

migraine headaches and diabetes.

Social Hx: Lives in Utah with parents and older

sibling. Parents married. He will be in the 11th

grade. Active soccer player. No alcohol, smoking,

drugs, or sexual activity.

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PatientVS: wnl (BP 123/85, repeat manual 110/72, BMI: 23.4)

Physical Exam: wnl

GEN: Alert, NADHEENT: NC/AT, PERRL. EOMI. Conjunctiva clear w/out pallor.MMM, no oral lesions. Neck is supple. No LAD.CV: RRR, normal S1 and S2, no murmur or gallop. Peripheralpulses normal, CR 2 seconds.PULM: CTAB, symmetric air movement b/l, no increased work ofbreathing, or retractions. No wheezes / crackles

ABD: Soft, NT/ND, BS normal, no hepatosplenomegaly.

EXT: Warm and well perfused. Joints with full range of motion. Noperipheral edema.LYMPH: No peripheral adenopathy noted.NEURO: Cranial nerves II through XII are grossly intact withoutfocal deficits. Strength and gait appear normal.SKIN: No significant rashes or other lesions.

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Differential Diagnosis Urinary tract:

Nephrolithiasis / Hypercalciuria Meatal / Urethral Irritation UTI

Renal / Glomerular

Alport Thin Basement Membrane

Disease PSGN IgA nephropathy MPGN FSGS

Exercise

Trauma

Left renal vein compression

Rheum: SLE Goodpastures Wegners HSP Nephritis

Heme-Onc: Wilms' tumor Transitional cell carcinoma of the

bladder Sickle cell disease/trait Coagulopathy Renal Vein Thrombosis

Interstitial nephritis (associatedwith analgesic or antibiotic use)

Schistosomiasis

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Patient continued course:Further work up: PCP had also obtained a renal U/S: Normal

U/A in clinic: SG 1.010, large blood, trace protein. Micro with numerousRBCs with normal morphology.

Urine calcium/creatinine ratio less than 0.05

Initial Diagnosis: Most likely elevated urinary calcium with renal / tubularmicrotrauma

Persistent, asymptomatic, microscopic hematuria is a relatively commonfinding in adolescence without any cause found in up to 80% of patients.This patients presentation is reassuring that he has normal kidneyfunction, BPs and renal U/S without significant proteinuria.

The most common identified cause of microscopic hematuria is anelevated urinary calcium. Even though the recommended screening test forelevated urine calcium is a spot calcium/creatinine ratio, the variability ofurine calcium throughout a 24-hour period is high, therefore a teenagermay have hypercalciuria even with a normal screening test. Hypercalciuriais important because it is a risk factor for kidney stones.

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Patient continued course: Recommended increased hydration with return renal clinic

appointment in 6 months. If hematuria still persisting afterimproved hydration, will obtain 24 hour urine collection toassess for kidney stone risk factors

At 6 month visit, patient and mother remembered that hisurine turns brown whenever he gets sick for the past year. U/Aat that time w/ dysmorphic RBCs and casts with 2+ proteinuriaconsistent with glomerulonephritis

Continued monitoring over the next year by nephrology,

ultimately biopsy was obtained that revealed IgA nephropathy Prognosis: 20-40% of patients develop kidney failure within 20

years of diagnosis of IgA nephropathy. This pt has a relativelyfavorable outlook given his normal kidney function, normalblood pressure and that the protein/creatinine ratio is < 2.

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Differential in depth: Transient hematuria -

UTI

Trauma: Can originate from kidneys to all along urinary tract.

Exercise: Originates from glomerular bleeding, resolves with rest. Benigncondition.

Hypercalciuria - Associated with asymptomatic microscopic hematuria.Defined in kids >6 as urine calcium/creatinine ratio >0.2 (mg/mg).Prevalence of 11-35%. An elevated Specific Gravity (ie concentratedurine) can be suggestive of this. Encourage hydration and re-test.

Alport syndrome - Initially present with asymptomatic persistentmicroscopic hematuria in childhood. Is an inherited disorder of type IVcollagen. Classically is an X-linked recessive disorder, although femalecarriers can have hematuria. Accompanied by high-frequencysensorineural hearing loss and ocular abnormalities. Developprogressive renal failure over time.

Thin basement membrane disease / AKA benign familial hematuriaClassically is persistent or intermittent asymptomatic microscopichematuria. Autosomal dominant inheritance. Does not lead to renalfailure.

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Differential in depth: Poststreptococcal / postinfectious glomerulonephritis - Typically

starts with pharyngitis or skin infection with development ofedema, gross hematuria (coke colored urine), and HTN 1-3weeks after. (Can be subclinical with just microscopichematuria.) Caused by binding of IgG antibodies to C3 thatdeposit in renal glomeruli. Hematuria generally resolves withinthree to six months after the presentation. C3 is initially low, thennormalizes after. Recurrence is rare.

Membranoproliferative Glomelularnephritis (MPGN) Variablepresentation, but initial symptoms can include either microscopicor gross hematuria. Is mediated by deposition of immunecomplexes or complement in renal glomeruli. Can mimic PSGNin presentation, but pt will have either initially normal C3

(immune complex) or persistently low C3 (complementmediated).

IgA nephropathy - Recurrent episodic gross hematuria with orshortly after infection (URI - synpharyngitic or Gastro usually).IgA antibodies bind complement and are deposited in renalglomeruli. Can lead to renal failure. Normal C3 throughout

illness.

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Differential in depth: Focal Segmental Glomerulosclerosis: Can be

primary or secondary. More classically results innephrotic syndrome, but hematuria is notuncommon.

Wegener's: More common in older adults but canaffect all ages. Classically have sinus, pulmonary,and renal disease. Can present withasymptomatic hematuria, which may remit andrelapse. pANCA positive.

Goodpastures: Affects older children and adults.Both lung and renal involvement. Typicallypresents with relatively acute renal failure withproteinuria and nephritic sediment characterized

by dysmorphic red cells / red cell casts.

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Microscopic Hematuria Approach

Is it actually hematuria? Urine dipsticks test for Hemoglobin / Myoglobin. Hematuria

require RBCs as established by U/A.

Rhabdomyolysis -> Myoglobin

Hemolysis -> Hemoglobin Beets -> pigmented urine that tests positive

Are there symptoms suggestive of a specific etiology?

Dysuria, frequency, fever or abnormal U/A suggestive of UTI

TraumaAssociated with exercise

Associated with infection: URI, Gastroenteritis, or Skin

infection (PSGN / PIGN)

Is it a menstruating female?

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Microscopic Hematuria ApproachAre there red flags that would prompt more immediate

testing (RFP / CBC) and / or referral to Nephrology? Hypertension

Edema

Oliguria Signs of glomerulonephritis:

Red cell casts (pathognomonic)

Proteinuria (more than 2+)

Dysmorphic RBCs

Gross Hematuria If occurs with proteinuria / RBC casts is concerning for

glomerulonephritis as above

If without, is concerning for malignancy, cystic renal disease , astructural urogenital abnormality, or an obstructing calculus

Consider renal and bladder U/S and / or referral to Urology

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Microscopic Hematuria Approach

If hematuria is confirmed by U/A, asymptomatic, and withoutred flags:

Establish that the Hematuria is persistent Repeat the U/A x2 over coming weeks to months

Encourage hydration prior to repeat testing, particularly if SpecificGravity is elevated on initial U/A

Refer to Nephrology for persistent hematuria Among patients with persistent hematuria, family history of chronic

kidney disease (CKD), hearing loss, or kidney stones is also more

worrisome. Prior to referral, if any concerns for kidney function, an

RFP is easy test to establish function (BUN/Cr) and arenal U/S is also an easy noninvasive test that can bepursued.