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Home , Hematuria, Kidney disease, Proteinuria

10/16/2014

BASIC INFORMATION

 Gross hematuria (GH): 10-20% of pediatric referrals  Microscopic hematuria (MH): 80-90%

 Measured as : ratio > 0.2 (mg/mg) PEDIATRIC  OR :creatinine ratio > 30 (mg/g)  OR > 4 mg/m2/hr in time collection PROTEINURIA AND HEMATURIA Adam Goldstein Howard Trachtman, M.D.  A recent study puts the incidence of hematuria and proteinuria in children at over 6%

MECHANISM OF THOSE AT HIGHER RISK OF UA FINDINGS

Proteinuria Hematuria

• History of disease • History of

• • History of urinary stone disease

• Fever, exertion • Use of certain medications including and anticoagulants

• Those who perform strenuous activities

• Recent viral or bacterial disease

DIFFERENTIAL DIAGNOSIS: HEMATURIA

Signs and Symptoms •Resolving PSAGN Glomerular •IgA Nephropathy Hematuria Proteinuria •Hereditary

•Anatomic Abnormality Gross Microscopic Short duration Persistent Non- •Hypercalciuria

Possible pain as May be sign of •Kidney Stones Pink or red Nothing will be Glomerular a result of significant colored seen with the No symptoms obstructing clots, glomerular Declining GFR naked eye w/ or w/o clots free disease •UTI Underlying causes are the same in children with GH or MH. However, likelihood of establishing the diagnosis is greater with GH

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HEMATURIA AND PROTEINURIA: OVERALL CLINICAL APPROACH ASSESSMENT: HEMATURIA -OVERALL

 Microscopy: RBC morphology and casts Hematuria Proteinuria  Other Urinalysis Findings:  WBCs suggest UTI or renal parenchymal disease.  Concomitant proteinuria indicates higher likelihood Microscopic Gross Sub-nephrotic Range Nephrotic Range of significant kidney disease  Blood tests: Examine Urine: Consider Biopsy if Observe Glomerular vs. Non- Observe 6-12 months Up/c is rising or >2  Creatinine Glomerular  Albumin/ Cholesterol  C Assess according to 3 RBC morphology  (hardly ever indicated in children)  Kidney imaging test: Only for non- glomerular hematuria  Kidney biopsy

DYSMORPHIC CAST RBC ASSESSMENT: HEMATURIA-GLOM VS. NON GLOM

Glomerular: Casts/ Non- Glomerular: Dysmorphic RBC No Casts/ Eumorphic RBC

Careful Family History Urine calcium/creatinine

C3 Ultrasound if gross hematuria

Audiogram

? Creatinine

Kidney biopsy

TREATMENT: HEMATURIA ASSESSMENT (PROTEINURIA)

Always  Isolated MH usually resolves Check P/C in first morning urine because orthostatic  MH that persists but is not accompanied by any proteinuria is common in pediatric patients other evidence of renal disease can be followed  GH usually prompts immediate evaluation. If child is well and no other signs of renal disease then,  If a cause for GH is found, treat accordingly. Observe for 4-6 months  If no cause for GH is found:  Children with non- glomerular GH can be observed.  Those with glomerular GH usually require kidney biopsy. If persists or Up/c >2

C3 ANA Kidney biopsy

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TREATMENT: PROTEINURIA AREAS OF CONTROVERSY

 If proteinuria is sub-nephrotic: JAMA Hematuria Frequency of Proteinuria as a Prognosis Testing CV risk factor  Observation warranted if patient is well An Israeli study, AAP recommends no Studies in adults  If it is persistent, a biopsy may be done and with over 1.2 million routine UA in suggest a treatment will be guided by the diagnosis military recruits who healthy children at correlation between had a UA in their all visits because of proteinuria and  If proteinuria is in the nephrotic range: initial examination, frequent false developing a  Biopsy is usually performed and treatment is based demonstrated a positives, cardiovascular on histopathology findings hazard ration of 32 psychological effects, disease. for ESKD in those and cost of testing.  ACE inhibitors or angiotensin receptor blockers with persistent Implication: There can be used as sole treatment in patients with isolated MH. are no data about sub-nephrotic proteinuria or as ancillary therapy Implication: Some the long term CV Implication: Routine children with renal ramifications of in those with nephrotic range proteinuria UA may predict disease may detecting adverse renal experience a delay in proteinuria in prognosis. diagnosis. childhood.

WORKS CITED

USA. NIH. NIDDK. Hematuria. N.p.: n.p., 2008. Print.

USA. NIH. NIDDK. Proteinuria. N.p.: n.p., 2008. Print.

Trachtman, Howard. “Outpatient : Hematuria.” Nephrology Self Assessment Program 11 (2012) 10. Print.

Trachtman, Howard. “Outpatient Nephrology: Proteinuria.” Nephrology Self Assessment Program 11 (2012) 10-12. Print.

Culleton, BF, and Et Al. "Proteinuria as a Risk Factor for and Mortality in Older People." Am J Med 109.1 (2000): 1-8. Print.

Dodge, Warren, and Et Al. "Proteinuria and Hematuria in Schoolchildren: Epidemiology and Early Natural History." The Journal of Pediatrics 88.2 (1976): 327-47. Print.

"UNC Kidney Center." UNC Kidney Center. N.p., n.d. Web. .

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