THE OFFICE EVALUATION OF HEMATURIA AND PROTEINURIA: CASE PRESENTATIONS

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THE OFFICE EVALUATION OF HEMATURIA AND
PROTEINURIACASE PRESENTATIONS

• Debbie Gipson, M.D., M.S.
• University of North Carolina-Chapel Hill

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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

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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
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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

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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

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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
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AAP Urinary Screening Guidelines

• 1. Infancy
• 2. Early childhood
• 3. Late childhood
• 4. Adolescence

AAP Policy Recommendations for Preventative
Care, 1993
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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

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Urinalysis of 5 year old with 1 blood
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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

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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

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Normal calcium excretion in a 5 year old child is

• 1. lt 2 mg/kg/day
• 2. lt 4 mg/kg/day
• 3. Uca/creat lt 0.6
• 4. Uca/creat lt 0.2 birth - 16 years

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Normal calcium excretion in a 5 year old child is

• 1. lt 2 mg/kg/day
• 2. lt 4 mg/kg/day
• 3. Uca/creat lt 0.6
• 4. Uca/creat lt 0.2 birth - 16 years

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Do you have patients with hypercalciuria and
hematuria in your practice?

• 1. Yes
• 2. No

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Do you refer a child with persistent isolated
microscopic hematuria and a normal renal
ultrasound to a pediatric nephrologist?

• 1. Yes
• 2. No

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Have you diagnosed hypercalciuria and hematuria
in a child who later developed a urinary stone?

• 1. Yes
• 2. No

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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

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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

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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

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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

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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)

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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

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Cost of Evaluations in 325 Children with
Microhematuria in Buffalo and Philadelphia

• Total estimated cost 175,000
• Significant diagnoses none

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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.

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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

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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

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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
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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

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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

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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

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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
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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

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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

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Hematuria Proteinuria

• Combination is an indicator of disease
• Gross hematuria may have associated low grade
  proteinuria ( Up/c lt 0.5)

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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

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The most likely diagnosis is?

• 1. Hypercalciuria
• 2. Acute Post Strept GN
• 3. IgA nephropathy
• 4. Membranoproliferative GN
• 5. SLE

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The most likely diagnosis is?

• 1. Hypercalciuria
• 2. Acute Post Strept GN
• 3. IgA nephropathy
• 4. Membranoproliferative GN
• 5. SLE

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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

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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

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

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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

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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

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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

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Do you hospitalize most children with acute post
streptococcal glomerulonephritis?

• 1. Yes
• 2. No

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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.

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What does this patient have?

• 1. Glomerular hematuria
• 2. Non-glomerular hematuria

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What does this patient have?

• 1. Glomerular hematuria
• 2. Non-glomerular hematuria

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The most likely diagnosis is?

• 1. Acute Post Strept GN
• 2. Hypercalciuria
• 3. Alports Syndrome
• 4. IgA nephropathy
• 5. Hemolytic Uremic Syndrome

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The most likely diagnosis is?

• 1. Acute Post Strept GN
• 2. Hypercalciuria
• 3. Alports Syndrome
• 4. IgA nephropathy
• 5. Hemolytic Uremic Syndrome

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DIAGNOSIS OF 56 BIOPSIES IN TEENAGERS WITH GROSS
HEMATURIA

• IgA glomerulonephropathy 28 (50)
• Minimal lesion 10 (16)
• Diffuse mesangial prolif. 6 (7)
• Proliferative nephritis 4 (6)
• MPGN 3 (5)
• Focal sclerosis 3 (5)
• Crescentic GN 2 (4)

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Do you have patients with IgA nephropathy?

• 1. Yes
• 2. No

55
Current treatments for IgA nephropathy

• 1. Prednisone
• 2. Fish oil
• 3. Vitamin E
• 4. ACE inhibitors
• 5. Nothing

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Which of the following suggests a serious
prognosis?

• 1. Family history
• 2. Proteinuria
• 3. Elevated serum IgA values
• 4. Low serum complement values
• 5. Abdominal pain

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Which of the following suggests a serious
prognosis?

• 1. Family history
• 2. Proteinuria
• 3. Elevated serum IgA values
• 4. Low serum complement values
• 5. Abdominal pain

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CASE 6

• 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, and no RBC casts.

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Appropriate tests include each of the following
except

• 1. Urine culture
• 2. Renal ultrasound
• 3. Urine for calcium excretion
• 4. Serum complement
• 5. Test for sickle cell trait

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Appropriate tests include each of the following
except

• 1. Urine culture
• 2. Renal ultrasound
• 3. Urine for calcium excretion
• 4. Serum complement
• 5. Test for sickle cell trait

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Evaluation of Isolated Macroscopic Hematuria
(without Casts)

• Urine culture
• Renal ultrasound
• Urine calcium excretion
• Family urinalyses
• Sickle cell status
• Cystoscopy (occasional)
• Angiogram

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Evaluation of Hematuria with Proteinuria

• Serum creatinine, albumin
• Urine protein excretion
• Streptococcal antibody screen
• Serum complement
• Family urinalyses
• ANA, hepatitis studies (selected)

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Evaluation of Non-orthostatic Proteinuria is
Similar to that of Hematuria With
Proteinuria(Exception vesicoureteral
reflux-induced nephropathy)