Presentation on theme: "Hematuria For the boards... Gital Karamchandani-Patel, MD 4/11/2017"— Presentation transcript:
1 Hematuria For the boards... Gital Karamchandani-Patel, MD 4/11/2017 One of the most common reasons that kids are referred to a nephrologist by their pediatricianGital Karamchandani-Patel, MD
2 Definition Macroscopic (gross) Hematuria Microscopic Hematuria 4/11/2017DefinitionMacroscopic (gross) Hematuriaany discolored urine visible to the human eyeMicroscopic Hematuria>5 RBC/hpf seen under microscope50 RBC per microliter of unspun urine on a dipstick is also suggestive of hematuriaRBC seen on dipstick must be confirmed with an U/Amicroscopic urine is done on fresh centrifuged urine sample
3 Hematuria What is your first step? 4/11/2017HematuriaPatient comes to your office complaining that their urine is reddish in color...What is your first step?Good H+PHave to get a really good historyWhat kinds of questions are you going to ask?ask about foods, drugsask about recent illnessesask about menstrual cycleask about dysuria, feverask about visual changesask about family historyPerform a good physical examwhat to look for on PE:vitals (BP), edema, flank masses, bruising
4 Hematuria Is it really blood? Urine Dipstick Detects Hgb, myoglobin 4/11/2017HematuriaIs it really blood?Urine DipstickDetects Hgb, myoglobinDetects proteinIn your office, you will have dipsticks readily available to youHemoglobin and myoglobin will produce the same color changes on the dipstick as intact RBCs via a peroxidase reactionmyoglobinuria may occur secondary to rhabdomyolysis (viral disease, crush injury, DIC)false-positive test for blood can result from the presence of drugs such as ascorbic acid, sulfonamides, iron sorbitol, metronidazole, and nitrofurantoinBest thing is to send U/A to the lab for a urinalysisOn your dipstick, you can also see if you have proteinuria. Isolated hematuria is something a PCP should be able to manage…when you have hematuria with proteinuria, you should refer to a nephrologist.
5 4/11/2017HematuriaUrinalysisDefinitive for the presence of RBC
6 Hematuria Upper urinary tract Lower urinary tract calyx glomerulus 4/11/2017HematuriaUpper urinary tractglomeruluscollecting tubulesinterstitiumLower urinary tractcalyxpelvisureterbladderurethraOnce you have determined that it really is blood that you are dealing with, you need to try to figure out where it is coming from.Blood cells can come from anywhere in the urinary tract.The blood will look different depending on where it is coming from.
7 What PREP wants you to know... 4/11/2017What PREP wants you to know...Know the differential diagnosis of a child with gross hematuria
8 4/11/2017So to recap what our thinking process whenever we have someone present with gross hematuria to help us with our differentialget a good historymake sure it really is blood with a U/Aif it really is blood, do you have protein in your urine as well?If there are no RBC, is there something in the history that could cause discolored urine?-Myoglobin? PREP wants you to know that myoglobin can yield false + results for hematuria on urinalysis-Hemoglobin?-Diet/Drugs?-Porphyria?
9 Glomerular Hematuria brown, tea colored urine proteinuria 4/11/2017Glomerular Hematuriabrown, tea colored urineproteinuriadeformed urinary RBCsRBC castsProteinuriaRBC casts- RBC’s leak from the damaged glomerular wallsProteinuria occurs bc protein leaks thru glomerular basement membraneDeformed RBCs in the urine because they travel through the convoluted filtering system\Urinary casts are cylindrical aggregations of particulate matter that form in the distal nephron, dislodge, and eventually pass into the urine. They form via precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells, and sometimes also by albumin in conditions of proteinuria. Cast formation is pronounced in environments favoring protein denaturation and precipitation (low flow, concentrated salts, low pH).
10 Glomerular Hematuria RENAL MULTI-SYSTEM IgA nephropathy 4/11/2017Glomerular HematuriaRENALIgA nephropathyAlport syndromeThin glomerular BM diseasePost infectiousMPGNMULTI-SYSTEMSLE nephritisHSP nephritisWegener syndromeGoodpasture syndromeHUSSickle cell DiseaseThese will all be associated with proteinuriawill have brown/tea colored urine
11 W/u for Glomerular Hematuria 4/11/2017W/u for Glomerular HematuriaCBCC3, C4antistreptolysin-O titer, streptozyme titerserum electrolytes, BUN, serum Cr, serum albumintest for lupusHep Bantinuclear cytoplasmic antibody titerHep B because that can cause membranous nephropathyANCA for Wegeners
12 Extraglomerular Hematuria 4/11/2017Extraglomerular HematuriaHematuria from lower urinary tractterminal hematuriablood clotsnl urinary RBCsminimal proteinuriaTerminal hematuria is when the onset of gross hematuria occurs at the end of the urine stream
14 W/u for Extraglomerular Hematuria 4/11/2017W/u for Extraglomerular Hematuriaserum creatinineurine culturesickle cell preparation in AAurinary Ca/Cr ratioC3,C4U/S of kidneys/bladder to R/O polycystic kidney disease, tumor, ureteropelvic junction obstruction, and stonesBased on your history and physical you will determine what tests you want to order
16 Proteinuria Occurs in 10% of kids 8-15 yrs differentiate between 4/11/2017ProteinuriaOccurs in 10% of kids 8-15 yrsdifferentiate betweenrenal diseasetransientbenign
17 Proteinuria Dipstick detects mostly ALBUMIN negative (0 mg/dL) 4/11/2017ProteinuriaDipstick detects mostly ALBUMINnegative (0 mg/dL)trace (10-20 mg/dL)1+ (30 mg/dL)2+ (100 mg/dL)3+ (300 mg/dL)4+ ( mg/dL)False negatives may also occur if the protein in the urine is composed mainly globulins or Bence-Jones Proteins because the reagent on the test strips, Bromphenol blue, is highly specific for albumin
18 4/11/2017Orthostatic proteinuriaTransient proteinuriacaused be temp >101oFexcersisedehydrationcold exposureCHFseizurestressGlomerular proteinuria is usually due to loss of albumintubular proteinuria is usually due to loss of other proteins
19 Proteinuria What is your next step? 4/11/2017ProteinuriaA child comes into your office for a routine visitScreening urine dipstick reveals 1+ proteinWhat is your next step?
20 Proteinuria R/O benign conditions sg >1.020 pH >7.5 mucoproteins 4/11/2017ProteinuriaR/O benign conditionssg >1.020pH >7.5mucoproteinsacute illnessAcute illnesses, excersiseOnce you have determined that none of these are what caused the + dipstick, you can move on to further evaluation.
21 Proteinuria Next step is to determine if this is transient or fixed 4/11/2017ProteinuriaNext step is to determine if this is transient or fixedR/O orthostatic proteinuriafirst am U/AW/u for persistent fixed proteinuriaalb, C3, 24 hr urine proteinPr/Cr ratioW/u for glomerular hematuria if + RBCs
22 Let’s see who has been paying attention... 4/11/2017Quiz TimeLet’s see who has been paying attention...
23 4/11/2017Quiz time #110 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?What is the diagnosis.You have something familial going on…Lets think about our differential for familial causes of hematuria
24 Quiz time #1 Familial Causes of Hematuria Polycystic kidney disease 4/11/2017Quiz time #1Familial Causes of HematuriaPolycystic kidney diseaseThin basement membrane diseaseAlport syndrome (hereditary nephritis with deafness)Hypercalciuria with family history of nephrolithiasisSickle CellA family history of autosomal dominant polycystic kidney disease demands that this disease be ruled out by renal U/S.A family history of hematuria without renal failure may be seen with thin basement membrane disease.A family history of hematuria, chronic renal failure, dialysis, or renal transplantation with bilateral deafness at an early age and ocular abnormalities strongly suggests Alport syndrome. An audiogram is indicated for children suspected of having Alport syndrome because high-tone hearing loss may not be apparent on the initial examination.A family history of nephrolithiasis raises the diagnostic possibility of nephrolithiasis or hypercalciuria.Sickle cell disease or sickle cell trait in the patient's family may suggest this diagnosisa screening urinalysis in available first-degree relatives is an important test
25 Quiz time #2 Gross hematuria following a URI C3 is wnl 4/11/2017Quiz time #2Gross hematuria following a URIC3 is wnlWhat is your diagnosis?What two things could it be?Post strepIgA nephropathyhow can you tell the difference?
26 IgA Nephropathy (Berger’s Disease) 4/11/2017IgA Nephropathy (Berger’s Disease)IgA deposits seen on renal biopsynl C3elevated IgA in 15%often hypertensiveneed long-term f/uAssoc with viral URI or AGE20-30% of children who have this will have progressive disease years down the road
27 4/11/2017Quiz time #3This kid was in your office 2 weeks ago. Mom is calling and saying his urine looks like coca-cola.What is your diagnosis?This boy came into your office two weeks ago. His mom is calling the office saying is urine is tea colored.What is this boy’s diagnosis? impetigoWhat is it caused by? nephritogenic strain of GASHow do you diagnose it? Streptozyme (for skin), (ASO for throat)could this have been prevented with appropriate abx? NOWhat do you treat it with?What would you expect his C3 levels to be? LOWwhat happens to C3 level after 2 months? Returns to nl
28 Acute Post-Infectious Glomerulonephritis 4/11/2017Acute Post-Infectious GlomerulonephritisCaused by nephritogenic GAS infections of the pharynx or skinMost children recover complete renal functionC3 levels LOW initially, then return to NL after 6-8 wksmay have BP, proteinuria, hematuria for up to 3 mos after initial presentation
29 Quiz time #4 3 yr old F with diarrhea 4/11/2017Quiz time #43 yr old F with diarrhea6 days later develops a rash, abdominal painon PE, you note pallor and purpura
30 Quiz time #4 What is your diagnosis? 4/11/2017 You get a CBC and peripheral smear reveals fragmented RBCs
31 Hemolytic-Uremic Syndrome 4/11/2017Hemolytic-Uremic SyndromeMCC of ARF in childrenCaused by shiga toxin producing E.coli O157:H7HUS is most common in kids less than 4yrspreceded by AGE with fever, vomiting, bloody diarrheaE.coli transmitted by undercooked meat, unpasteurized milkthis organism has a verotoxin which is absorbed by the intestine and initiate endothelial cell injurymicroangiopathic hemolytic anemia
32 Quiz time #5 Infant comes in with hematuria h/o constipation 4/11/2017Quiz time #5Infant comes in with hematuriah/o constipationh/o TEF repairWhat is your diagnosis?What is your diagnosis?VATER associationV vertebral anomaliesA anal atresiaTE TEFR radial limb anomaliesWhat is your next study?Chromosomes for genetic syndrome should be ruled out
33 VATER association V vertebral anomalies A anal atresia T E 4/11/2017VATER associationV vertebral anomaliesA anal atresiaTER radial limb anomaliesTEF
34 4/11/2017Quiz time #614yo female with hematuriaMore “tired” lately
35 Quiz time #6 What is your diagnosis? What labs will you order? 4/11/2017Quiz time #6What is your diagnosis?What labs will you order?
36 SLE nephritis C3 and C4 will be LOW 4/11/2017SLE nephritisC3 and C4 will be LOWSometimes will only manifest as kidney diseaseWHO staging of nephritisClass IV is the most common and most severe form of nephritis
37 Quiz time #7 11 yr old boy with gross hematuria, edema. 4/11/2017Quiz time #711 yr old boy with gross hematuria, edema.Initial labs reveal LOW C3 and C4What is your diagnosis?How do you make definitive dx?You know it is something glomerular because of hematuria and proteinuria. Lab work helps you.
38 Membranoproliferative Glomerulonephritis 4/11/2017Membranoproliferative GlomerulonephritisMPGN is the MCC of chronic glomerulonephritis in childrenrenal biopsy confirms dx
39 Confused about complement? What three conditions cause hypocomplementemia?P post infectious GNM membrano proliferative GNS SLE
40 4/11/2017Quiz time #8last one!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.
41 Quiz time #8You 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?
42 Quiz time #8 Answer: Urine Ca/Cr ratio!! urinary calcium:urinary creatinine ratio of > 0.2124-hour urinary calcium excretion of >4 mg/kg
43 Hypercalciuria Idiopathic 30% Immobilization Hyperparathyroidism 4/11/2017HypercalciuriaIdiopathic 30%15% go on to have renal stonesImmobilizationHyperparathyroidismFurosemideVit D intoxicationRenal ultrasonography and plain abdominal radiography are helpful in ruling out the presence of nephrocalcinosis or nephrolithiasis.The finding of hypercalciuria in a child who has hematuria should not exclude consideration of other etiologies of hematuria
46 4/11/2017PREP specsPlan the evaluation of hematuria in a child with sickle cell disease.
47 4/11/2017PREP 2005 #70A 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.
48 4/11/2017PREP 2005 #70You suspect that this boy has sickle cell trait and papillary necrosis.Of the following, the BEST test to confirm the diagnosis is:A. abdominal xrayB. CTC. intravenous pyelographyD. renal scintigraphyE. renal U/SAb x-ray will not help you look for papillary necrosisCT may show papillary necrosisIVPrenal scintigraphy is done when obstruction is present, show tracer uptake of functioning kidneyrenal U/S will show vague changes in the medulla but not specific for papillary necrosis
49 PREP 2005 #70 Correct Answer: C 4/11/2017 Hematuria results from microthrombosis secondary to sicklingthey want you to know that IVP is the best test to look for papillary necrosisthe difference is hematuria and PAIN