Hematuria and Proteinuria in the Pediatric Patient Laurie Fouser, MD Pediatric Nephrology Swedish Pediatric Specialty Care Hematuria in the Child • Definition • ³ 1+ on dipstick on three urines 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 urine – 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 – Sickle Cell Disease – Hemolytic Uremic Syndrome Glomerular Causes of Hematuria • Chronic Glomerular Disease – IgA Nephropathy – Henoch-Schönlein Purpura or other Vasculitis – Alport Syndrome – SLE or other Collagen Vascular Disease – Proliferative Glomerulonephritis Non-Glomerular Hematuria • Extra-Renal • UTI • Benign urethralgia +/- meatal stenosis • Calculus • Vesicoureteral Reflux, Hydronephrosis • Foreign body • Rhabdomyosarcoma • AV M • Coagulation disorder Non-Glomerular Hematuria • Intra-Renal • Hypercalciuria • Polycystic Kidney Disease • Reflux Nephropathy with Renal Dysplasia • Sickle Cell Crisis • Renal Vein Thrombosis • Renal Hemangioma • Tumor or Leukemia • Nutcracker syndrome/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) – Edema (periorbital, pretibial, ascites) – Rash Urinalysis with Microscopy Evaluation - Phase I • Complete H&P • Urinalysis with microscopy • Urine culture • Urine calcium: urine creatinine ratio • CBC with platelets (+/-Sickle prep), BUN, Creatinine, albumin, C3 • Ultrasound of kidneys and bladder • Urine dipsticks on parents and siblings Evaluation - Phase II • C3, C4, ANA, Hepatitis B & C • Streptozyme • BUN, creatinine, electrolytes, albumin, calcium, phosphorus • Hearing evaluation • VCUG or CT Evaluation - Phase III • Other laboratory • Renal biopsy • Cystoscopy When to Refer • Family history of kidney disease • Gross hematuria or clots • RBC casts • Proteinuria ³ 1+ • Elevated creatinine or BUN • Hypertension • Imaging abnormalities • Parental anxiety Proteinuria in the Child Proteinuria • Definition – 1+ or more on dipstick – Urine protein: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 – Pregnancy – 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 • Nephrotic syndrome – Minimal change, FSGS, membranous • Glomerulonephritis – Henoch-Schonlein purpura, IgA nephropathy, Alport nephritis • Tubular Proteinuria – Dent’s disease, Fanconi syndrome When to Refer • Parental anxiety or confirmation of orthostatic proteinuria • Any pathologic proteinuria • ASAP for edema/anasarca, hypoalbuminemia, hypertension, associated hematuria, elevated creatinine .