THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS

1. THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA:CASE PRESENTATIONS Debbie Gipson, M.D., M.S. University of North Carolina-Chapel Hill

2. Case 1 • A healthy appearing 5 year old boy was noted to have asymptomatic hematuria at a school examination. Physical exam was normal. • Urinalysis had 1+ hemoglobin, no protein

3. Which of the following interpretations is correct? • 1. The child has blood in urine and requires further evaluation • 2. The test showed small amount of blood which is nothing to worry about • 3. The test showed small amount of blood which may be normal and repeat testing is indicated

4. Which of the following interpretations is correct? • 1. The child has blood in urine and requires further evaluation • 2. The test showed small amount of blood which is nothing to worry about • 3. The test showed small amount of blood which may be normal and repeat testing is indicated

5. How many children with microscopic hematuria do you see? • 1. One semiannually • 2. One a month • 3. One a year • 4. Never, the AAP recommends that we do not do urinary screening

6. You arrange dipstick screening to be done by school nurse on all 8th-graders. Abnormal results will be found in: • 1. 0.1% • 2. 1% • 3. 10% • 4. 20%

7. You arrange dipstick screening to be done by school nurse on all 8th-graders. Abnormal results will be found in: • 1. 0.1% • 2. 1% • 3. 10% • 4. 20%

8. AAP Urinary Screening Guidelines • 1. Infancy • 2. Early childhood • 3. Late childhood • 4. Adolescence AAP Policy: Recommendations for Preventative Care, 1993

9. Case 1 Continues • The healthy appearing 5 year old boy had persistent asymptomatic hematuria for six months. • There was no family history of renal disease; his father had urinary stones. His father also was found to have asymptomatic hematuria. • Physical exam was normal. • Urinalysis had 1+ hemoglobin, no protein

10. Urinalysis of 5 year old with 1+ blood

11. Which of the following tests would be expected to be diagnostic? • 1. Serum complement levels • 2. Urine culture • 3. Urine uric acid excretion • 4. Urine calcium excretion • 5. Serum IgA concentrations

12. Which of the following tests would be expected to be diagnostic? • 1. Serum complement levels • 2. Urine culture • 3. Urine uric acid excretion • 4. Urine calcium excretion • 5. Serum IgA concentrations

13. Normal calcium excretion in a 5 year old child is: • 1. < 2 mg/kg/day • 2. < 4 mg/kg/day • 3. Uca/creat < 0.6 • 4. Uca/creat < 0.2 birth - 16 years

14. Normal calcium excretion in a 5 year old child is: • 1. < 2 mg/kg/day • 2. < 4 mg/kg/day • 3. Uca/creat < 0.6 • 4. Uca/creat < 0.2 birth - 16 years

15. Do you have patients with hypercalciuria and hematuria in your practice? • 1. Yes • 2. No

16. Do you refer a child with persistent isolated microscopic hematuria and a normal renal ultrasound to a pediatric nephrologist? • 1. Yes • 2. No

17. Have you diagnosed hypercalciuria and hematuria in a child who later developed a urinary stone? • 1. Yes • 2. No

18. How do you treat a child with hypercalciuria? • 1. Dietary (fluids, low Na) alone • 2. Hydrochlorothiazide • 3. Citrate • 4. Lasix • 5. Decrease calcium intake • 6. Nothing

19. How do you treat a child with hypercalciuria? • 1. Dietary (fluids, low Na) alone • 2. Hydrochlorothiazide • 3. Citrate • 4. Lasix • 5. Decrease calcium intake • 6. Nothing

20. Which of the following tests is most frequently abnormal in the patient with persistent, asymptomatic, isolated microscopic hematuria? • 1. Renal/bladder ultrasound • 2. Urine culture • 3. BUN/creatinine • 4. Serum complement • 5. Urine calcium excretion

21. Which of the following tests is most frequently abnormal in the patient with persistent, asymptomatic, isolated microscopic hematuria? • 1. Renal/bladder ultrasound • 2. Urine culture • 3. BUN/creatinine • 4. Serum complement • 5. Urine calcium excretion

22. Results of Referral Evaluation Of 83 Consecutive Children in Memphis, Tenn(Stapleton, NEJM, 1984) • Unexplained 38 (46%) • Hypercalciuria 22 (27%) • Familial hematuria 7 (8%) • Post-inf GN 5 (6%) • IgA nephropathy 4 (5%) • Other 7 (8%)

23. 325 Consecutive Children with Isolated Microhematuria in Buffalo and Philadelphia • 1) Creatinine/BUN normal • 2) Ultrasounds normal • 3) Hypercalciuria (9%) • 4) Complement studies abnormal in 12%; none had GN

24. Cost of Evaluations in 325 Children with Microhematuria in Buffalo and Philadelphia • Total estimated cost $175,000 • Significant diagnoses: none

25. Case 2 • 9 year old male brought to physician because of bloody urine 2 days prior. Patient was asymptomatic during the event. The urine spontaneously cleared. • Examination: healthy appearance. BP 98/62 and urinalysis normal.

26. Case 2 continues... • The child was scheduled to return on 2 additional occasions for urinalysis. Although the history was consistent with transient recurrence of red urine, the urine samples were normal grossly, by dipstick and microscopic exam. • The child then brought in a urine that was red…. UA dipstick: Hg negative and Protein negative

27. All of the following are causes of heme negative, red urine except: • 1. Beets • 2. Senna • 3. Food coloring • 4. Metronidazole • 5. Red clover honey • 6. Iodine

28. All of the following are causes of heme negative, red urine except: • 1. Beets • 2. Senna • 3. Food coloring • 4. Metronidazole • 5. Red clover honey • 6. Iodine

29. Urinalysis: Dipstick Methodology • Blood Indicator • Peroxidase dependent oxidation of the • indicator dye • Hemoglobin + peroxidase • Other oxidants lead to false positive • Povidone-iodine • Hypochlorite • Bacterial peroxidase • Myoglobin

30. Case 3 • A 17 year old previously healthy African American female presents for a well child visit. • Dipstick evaluation reveals moderate blood and 3+ proteinuria. Microscopic examination of the urinary sediment reveals 10 RBC/hpf and no casts. • Physical examination is unremarkable

31. Your assessment and plan is: • 1. Microscopic hematuria. Repeat UA x 2 • 2. Asymptomatic proteinuria and hematuria. Requires no additional evaluation • 3. Proteinuria and hematuria. Additional evaluation indicated

32. Your assessment and plan is: • 1. Microscopic hematuria. Repeat UA x 2 • 2. Asymptomatic proteinuria and hematuria. Requires no additional evaluation • 3. Proteinuria and hematuria. Additional evaluation indicated

33. Appropriate tests include each of the following except: • 1. AM Urine for protein & creatinine • 2. Serum chemistries for creatinine, albumin, and cholesterol • 3. Urine for calcium excretion • 4. Serum complement • 5. Consider hepatitis and HIV serologies • 6. Renal ultrasound

34. Appropriate tests include each of the following except: • 1. 24 hour urine for protein and creatinine • 2. Serum chemistries for creatinine, albumin, and cholesterol • 3. Urine for calcium excretion • 4. Serum complement • 5. Consider hepatitis and HIV serologies • 6. Renal ultrasound

35. Hematuria + Proteinuria • Combination is an indicator of disease • Gross hematuria may have associated low grade proteinuria ( Up/c < 0.5)

36. CASE 4 • A six year old girl develops a puffy face and notices that her urine has turned brown. • No family history of renal disease. A sister complained of a sore throat one week before the onset of dark urine. • Physical exam shows generalized edema and a blood pressure of 135/ 83 mmHg. • Urinalysis contains: large hemoglobin, 2+ protein

38. The most likely diagnosis is? • 1. Hypercalciuria • 2. Acute Post Strept GN • 3. IgA nephropathy • 4. Membranoproliferative GN • 5. SLE

39. The most likely diagnosis is? • 1. Hypercalciuria • 2. Acute Post Strept GN • 3. IgA nephropathy • 4. Membranoproliferative GN • 5. SLE

40. Which of the following tests will be most helpful in determining the diagnosis? • 1. Serum BUN/creatinine • 2. Serum complement & streptozyme • 3. Serum IgA • 4. Renal ultrasound • 5. Serum albumin

41. Which of the following tests will be most helpful in determining the diagnosis? • 1. Serum BUN/creatinine • 2. Serum complement & streptozyme • 3. Serum IgA • 4. Renal ultrasound • 5. Serum albumin

42. The streptozyme titer is elevated and the serum complement (C3) is decreased

43. Which one of the following is not associated with depressed serum complement values? • 1. Acute post strept GN • 2. Membranoproliferative GN • 3. IgA nephropathy • 4. SLE

44. Which one of the following is not associated with depressed serum complement values? • 1. Acute post strept GN • 2. Membranoproliferative GN • 3. IgA nephropathy • 4. SLE

45. POST-STREPTOCOCCAL GN • Most common type of acute GN • May present with minimal symptoms • Complications often due to fluid overload • Complement levels may be depressed longer than previously recognized • Persistent microscopic hematuria up to one year is common • Prognosis is excellent

46. Do you hospitalize most children with acute post streptococcal glomerulonephritis? • 1. Yes • 2. No

47. CASE 5 • A 12 year old girl has a sore throat and that same day notices that her urine turns brown. • She generally feels well and without specific symptoms. • She has not had previous urinalyses. There is no family history of renal disease. • Her examination is normal. • The urinalysis contains large hemoglobin and 1+ protein.

49. What does this patient have? • 1. Glomerular hematuria • 2. Non-glomerular hematuria

50. What does this patient have? • 1. Glomerular hematuria • 2. Non-glomerular hematuria