Hematuria and in the Pediatric Patient

Laurie Fouser, MD Pediatric Swedish Pediatric Specialty Care in the Child

• Definition • ³ 1+ on dipstick on three over three weeks • 5 RBCs/hpf on three fresh urines over three weeks • Prevalence • 4-6% for microscopic hematuria on a single specimen in school age children • 0.3-0.5% on repeated specimens Sources of Hematuria

• Glomerular or “Upper Tract” – Dysmorphic RBCs and RBC casts – Tea or cola colored – Proteinuria, WBC casts, renal tubular cells • Non-Glomerular or “Lower Tract” – RBCs have normal morphology – Clots/ Bright red or pink urine The Glomerular Capillary Wall The Glomerular Capillary Wall Glomerular Causes of Hematuria

• Benign or self-limiting

– Benign Familial Hematuria – Exercise-Induced Hematuria – Fever-Induced Hematuria

Glomerular Causes of Hematuria

• Acute Glomerular Disease – Poststreptococcal/ Postinfectious – Henoch-Schönlein Purpura – – Hemolytic Uremic Syndrome Glomerular Causes of Hematuria

• Chronic Glomerular Disease – IgA Nephropathy – Henoch-Schönlein Purpura or other – – SLE or other Collagen – Proliferative

Non-Glomerular Hematuria

• Extra-Renal • UTI • Benign urethralgia +/- • Calculus • Vesicoureteral Reflux, • Foreign body • • AV M • Coagulation disorder

Non-Glomerular Hematuria

• Intra-Renal • Hypercalciuria • Polycystic Disease • with Renal Dysplasia • Sickle Cell Crisis • • Renal Hemangioma • Tumor or Leukemia • /Loin Pain Hematuria Evaluation – Phase I

• Complete History – Duration, color, discrete clots vs diffuse? – In males, change during stream? – Pain or painless (dysuria, abdominal, flank) – Recent or current infection? – Rashes, joint, or GI symptoms?

Evaluation – Phase I

• Complete Physical – Blood pressure – Volume status (“dry or wet”, rales, gallop) – (periorbital, pretibial, ) – Rash Urinalysis with Microscopy Evaluation - Phase I

• Complete H&P • Urinalysis with microscopy • Urine culture • Urine calcium: urine ratio • CBC with platelets (+/-Sickle prep), BUN, Creatinine, , C3 • Ultrasound of kidneys and bladder • Urine dipsticks on parents and siblings

Evaluation - Phase II

• C3, C4, ANA, B & C • Streptozyme • BUN, creatinine, electrolytes, albumin, calcium, phosphorus • Hearing evaluation • VCUG or CT Evaluation - Phase III

• Other laboratory

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• When to Refer • Family history of • Gross hematuria or clots • RBC casts • Proteinuria ³ 1+ • Elevated creatinine or BUN • • Imaging abnormalities • Parental anxiety

Proteinuria in the Child Proteinuria

• Definition – 1+ or more on dipstick – Urine :creatinine • >0.2 mg/mg if over 2 yrs • >0.6 mg/mg ages 6 months- 2yrs • Nephrotic range is >2 mg/mg – Timed urine protein excretion • >96 mg/m2/24 hrs • >150 mg/1.73m2/24hrs • Nephrotic range is >3 gm/1.73m2/24 hrs Causes of Proteinuria

• Physiologic or Intermittent • Postural or Orthostatic • Pathologic – Glomerular – Tubular Glomerular Permeability Barrier Physiologic or Intermittent Proteinuria • Mechanism is change • Causes in glomerular capillary – Acute elevations in BP wall permeability or intraglomerular – Increased luminal volume hydrostatic pressure – Catecholamines/stress – Increased blood – Metabolism flow Physiologic or Intermittent Proteinuria • Clinical Settings • Duration – Fever – Transient (hours- – Physical stress (march days) proteinuria) – Self-remitting – – No need for referral – Immediately post op unilateral nephrectomy – Acute hypertension or CHF Postural or Orthostatic Proteinuria • Two patterns – Fixed, reproducible (15-20%) – Transient (75-80%) • Accounts for 60% of children and 75% of adolescents with proteinuria • Incidence – 2-5% of adolescents • MUST DISTINGUISH FROM PATHOLOGIC PROTEINURIA WITH A POSTURAL COMPONENT Postural or Orthostatic Proteinuria

• Evaluation: – Blood pressure, edema should not be present, UA/UC – First am void for urine protein:creatinine (patient must be sure to go to bed with empty bladder) • If <0.2 mg/mg, likely orthostatic – Normal renal function panel and renal ultrasound

Postural or Orthostatic Proteinuria • Protein in 24 hr fractional urine collection – Supine: <50-75 mg for 8-12 hrs – Upright: 200-1000 mg • Etiology – Variant of normal permeability or renal vein kink/entrapment • Long term follow-up – 10-20 years: resolution or benign outcome Pathologic Proteinuria Pathologic Proteinuria

• Fixed proteinuria – PE (edema, rash, >150-300 mg/24hrs volume), Ht, Wt, BP – UA (?hematuria), 24 hr or urine protein • First am void has &creatinine urine – BUN, creatinine, albumin, lytes, protein:creatinine calcium, phosphorus, >0.2 or lipids, C3, C4 • Edema – CBC Causes of Pathologic Proteinuria

• – Minimal change, FSGS, membranous • Glomerulonephritis – Henoch-Schonlein purpura, IgA nephropathy, Alport • – Dent’s disease, When to Refer

• Parental anxiety or confirmation of orthostatic proteinuria • Any pathologic proteinuria • ASAP for edema/anasarca, , hypertension, associated hematuria, elevated creatinine