Presentation on theme: "Jump to first page Hematuria For the boards... Gital Karamchandani-Patel, MD."— Presentation transcript:
Jump to first page Hematuria For the boards... Gital Karamchandani-Patel, MD
Jump to first page Definition n Macroscopic (gross) Hematuria u any discolored urine visible to the human eye n Microscopic Hematuria u >5 RBC/hpf seen under microscope
Jump to first page Hematuria n Patient comes to your office complaining that their urine is reddish in color... F What is your first step? –Good H+P
Jump to first page Hematuria Is it really blood? u Urine Dipstick F Detects Hgb, myoglobin F Detects protein
Jump to first page Hematuria u Urinalysis F Definitive for the presence of RBC
Jump to first page Hematuria n Upper urinary tract F glomerulus F collecting tubules F interstitium u Lower urinary tract F calyx F pelvis F ureter F bladder F urethra
Jump to first page What PREP wants you to know... n Know the differential diagnosis of a child with gross hematuria
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Glomerular Hematuria u brown, tea colored urine u proteinuria u deformed urinary RBCs u RBC casts
Jump to first page Glomerular Hematuria RENAL n IgA nephropathy n Alport syndrome n Thin glomerular BM disease n Post infectious n MPGN MULTI-SYSTEM n SLE nephritis n HSP nephritis n Wegener syndrome n Goodpasture syndrome n HUS n Sickle cell Disease
Jump to first page W/u for Glomerular Hematuria n CBC n C3, C4 n antistreptolysin-O titer, streptozyme titer n serum electrolytes, BUN, serum Cr, serum albumin n test for lupus n Hep B n antinuclear cytoplasmic antibody titer
Jump to first page Extraglomerular Hematuria n Hematuria from lower urinary tract u terminal hematuria u blood clots u nl urinary RBCs u minimal proteinuria
Jump to first page Extraglomerular Hematuria UPPER URINARY TRACT n pyelonephritis n ATN n papillary necrosis n nephrocalcinosis n thrombosis n malformation n SCD n tumor n PCKD LOWER URINARY TRACT n cystitis n urethritis n urolithiasis n trauma n coagulopathy n heavy excersise n UPJ obstruction n ureterocele n Munchausen, MBP
Jump to first page W/u for Extraglomerular Hematuria n serum creatinine n urine culture n sickle cell preparation in AA n urinary Ca/Cr ratio n C3,C4 n U/S of kidneys/bladder to R/O polycystic kidney disease, tumor, ureteropelvic junction obstruction, and stones
Jump to first page Proteinuria For the boards...
Jump to first page Proteinuria n Occurs in 10% of kids 8-15 yrs u differentiate between F renal disease F transient F benign
Jump to first page Proteinuria n Dipstick detects mostly ALBUMIN u negative (0 mg/dL) u trace (10-20 mg/dL) u 1+ (30 mg/dL) u 2+ (100 mg/dL) u 3+ (300 mg/dL) u 4+ ( mg/dL)
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Proteinuria n A child comes into your office for a routine visit n Screening urine dipstick reveals 1+ protein u What is your next step?
Jump to first page Proteinuria n R/O benign conditions u sg >1.020 u pH >7.5 u mucoproteins u acute illness
Jump to first page Proteinuria n Next step is to determine if this is transient or fixed u R/O orthostatic proteinuria F first am U/A u W/u for persistent fixed proteinuria F alb, C3, 24 hr urine protein F Pr/Cr ratio u W/u for glomerular hematuria if + RBCs
Jump to first page Quiz Time Let’s see who has been paying attention...
Jump to first page Quiz time #1 n 10 yr old boy coming in for school physical. Found to have 30 RBC/hpf on microscopic analysis. n Fam Hx reveals uncle used to have “blood in his urine” n What is your diagnosis?
Jump to first page Quiz time #1 n 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
Jump to first page Quiz time #2 n Gross hematuria following a URI n C3 is wnl n What is your diagnosis?
Jump to first page IgA Nephropathy (Berger’s Disease) n IgA deposits seen on renal biopsy n nl C3 n elevated IgA in 15% n often hypertensive n need long-term f/u
Jump to first page 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?
Jump to first page Acute Post-Infectious Glomerulonephritis n Caused by nephritogenic GAS infections of the pharynx or skin n Most children recover complete renal function n C3 levels LOW initially, then return to NL after 6-8 wks n may have BP, proteinuria, hematuria for up to 3 mos after initial presentation
Jump to first page Quiz time #4 n 3 yr old F with diarrhea n 6 days later develops a rash, abdominal pain n on PE, you note pallor and purpura
Jump to first page Quiz time #4 n What is your diagnosis?
Jump to first page Hemolytic-Uremic Syndrome n MCC of ARF in children n Caused by shiga toxin producing E.coli O157:H7
Jump to first page Quiz time #5 n Infant comes in with hematuria n h/o constipation n h/o TEF repair n What is your diagnosis?
Jump to first page VATER association n V vertebral anomalies n A anal atresia n T n E n R radial limb anomalies TEF
Jump to first page Quiz time #6 n 14yo female with hematuria n More “tired” lately
Jump to first page Quiz time #6 n What is your diagnosis? n What labs will you order?
Jump to first page SLE nephritis n C3 and C4 will be LOW n Sometimes will only manifest as kidney disease n WHO staging of nephritis
Jump to first page Quiz time #7 n 11 yr old boy with gross hematuria, edema. n Initial labs reveal LOW C3 and C4 n What is your diagnosis? n How do you make definitive dx?
Jump to first page Membranoproliferative Glomerulonephritis n MPGN is the MCC of chronic glomerulonephritis in children n renal biopsy confirms dx
Jump to first page Confused about complement? n What three conditions cause hypocomplementemia? u P post infectious GN u M membrano proliferative GN u S SLE
Jump to first page Quiz time #8 n It is 10pm. You are the intern on call for purple. A 5 th floor nurse pages you to tell you that ortho has just consulted you on one of their patients for hematuria.
Jump to first page Quiz time #8 n You look through the chart and the all you can decipher is that she was in a car crash 2 weeks ago. n You go to examine her and note she is in a full body cast, o/w NAD and afebrile. n What is the one test you will order before you go back to your call room?
Jump to first page Quiz time #8 n Answer: Urine Ca/Cr ratio!! F urinary calcium:urinary creatinine ratio of > 0.21 F 24-hour urinary calcium excretion of >4 mg/kg
Jump to first page Hypercalciuria n Idiopathic 30% F 15% go on to have renal stones u Immobilization u Hyperparathyroidism u Furosemide u Vit D intoxication
Jump to first page Thank you for your attention!
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PREP specs n Plan the evaluation of hematuria in a child with sickle cell disease.
Jump to first page PREP 2005 #70 n 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.
Jump to first page PREP 2005 #70 n You suspect that this boy has sickle cell trait and papillary necrosis. n Of the following, the BEST test to confirm the diagnosis is: u A. abdominal xray u B. CT u C. intravenous pyelography u D. renal scintigraphy u E. renal U/S
Jump to first page PREP 2005 #70 n Correct Answer: C