Microscopic Hematuria in Children- Evaluating

Question 1

What method is the gold standard for detecting microscopic hematuria

Answer 1

Examination of the sample under 40 times magnification with a microscope

Question 2

How is a diagnosis of microscopic hematuria determined from a micro urinalysis?

Answer 2

There must be at least 5 RBCs per high-powered field

Question 3

How is persistent hematuria defined?

Answer 3

By having a positive repeat test 6 months apart

Question 4

What are the 3 most common underlying causes of persistent hematuria in children?

Answer 4

Glomerulopathies, hypercalciuria, and nutcracker syndrome

Question 5

What are the the 4 most common glomerulopathies causing persistent hematuria?

Answer 5

1. IgA nephropathy
2. Alport syndrome
3. Thin basement membrane disease (AKA benign familial hematuria)
4. Poststreptococcal glomerulonephritis.

Question 6

How can IgA nephropathy present?

Answer 6

It may present as a persistent microscopic hematuria with episodes of gross hematuria, usually after a URI or GI related illness.

Question 7

How is IgA glomerulonephropathy diagnosed and what is usually found on that test?

Answer 7

It is usually diagnosed by renal biopsy which will reveal mesangial IgA deposits under and immunofluorescence study

Question 8

What is the generic inheritance for Alport syndrome, and thus who would be most affected?

Answer 8

X-linked recessive and predominantly males, it is associated with hereditary nephritis and hematuria.

Question 9

With Alport syndrome what are the comorbidities and in whom would you see them?

Answer 9

Affected males can have sensorineural hearing loss, anterior limb to conus of the eyes and finally progressive renal failure

Question 10

How can heterozygous female manifest Alport’s.

Answer 10

They may have hematuria which does not usually progressed to renal failure

Question 11

How is Alport syndrome diagnosed and what of the findings.

Answer 11

Alport’s may be diagnosed with renal biopsy showing a thin glomerular basement membrane under EM, and
Genetic testing to identify mutation in the collagen genes.

Question 12

What is the inheritance pattern for thin basement membrane disease or also known as benign familial hematuria

Answer 12

Autosomal dominant

Question 13

How do patients generally present with benign familial hematuria?

Answer 13

They may have microscopic hematuria with a family history that significant for hematuria without progression to renal disease.

Question 14

How is benign familial hematuria or thin basement membrane disease diagnosed and what are the findings.

Answer 14

A renal biopsy may be used for diagnosis which does show a thin glomerular basement membrane under electron microscopy

Question 15

What is the most common presentation for post streptococcus glomerular nephritis?

Answer 15

And asymptomatic microscopic hematuria

Question 16

How long may the hematuria with poststreptococcal glomerulonephritis last?

Answer 16

May resolve within 3 to 6 months

Question 17

What other type of renal disease can occur following a skin or throat infection with group A strep?

Answer 17

Can present as an acute nephritic syndrome.

Question 18

In children 6 years of age and older how is hypercalciuria diagnosed?

Answer 18

A urine calcium to creatinine ratio greater than 0.2.

Question 19

When should a calcium to creatinine ratio will be examined on a urinalysis?

Answer 19

In patients with an asymptomatic microscopic hematuria

Question 20

What are the 2 ways that patients with nephrolithiasis and nephrocalcinosis can present and which is the most common?

Answer 20

They can present with gross hematuria and abdominal pain (more likely) but may present with microscopic hematuria without abdominal pain

Question 21

What may be a presenting symptom for nutcracker syndrome in children

Answer 21

Generally it is asymptomatic but may present with left flank pain

Question 22

How is nutcracker syndrome diagnosed?

Answer 22

Is diagnosed with either Doppler ultrasound or CT scan

Question 23

What are the general findings or pathophysiology causing the nutcracker syndrome?

Answer 23

The left renal vein is compressed between the proximal superior mesenteric artery and the aorta

Question 24

What are common etiologies for transient hematuria?

Answer 24

UTIs, fever, exercise and trauma

Question 25

What determines transient microscopic hematuria in children?

Answer 25

If microscopic hematuria is detected then repeat a urinalysis 2-week later if still persisting and decreasing, may repeat in an additional 2 weeks after that

Question 26

In a child with microscopic hematuria what is the most common reason for the finding?

Answer 26

The most common presentation is due to an isolated, asymptomatic and transient microscopic hematuria.

Question 27

What is the most reasonable evaluation and treatment approach for a child with isolated, asymptomatic microscopic hematuria?

Answer 27

Generally, simply observing the patient and repeating the urinalysis.

Question 28

What other measures should be done in the patient with microscopic hematuria and how often should they be evaluated.

Answer 28

In addition to the urinalysis a blood pressure should be obtained and should be repeated weekly for 2 weeks. (Exercise can cause hematuria so advised patient not to exercise prior to the urinalysis)

Question 29

For patient with microscopic hematuria what constitutes becoming symptomatic?

Answer 29

During the 2-week's at any time if the patient has gross hematuria, hypertension, proteinuria, etc.

Question 30

When should a urine culture be obtained in a patient with asymptomatic persistent hematuria?

Answer 30

After 2 weeks a urine culture should be obtained.

Question 31

If a urine culture is negative for a child with isolated asymptomatic microscopic hematuria what is the next step?

Answer 31

The neck step would be to observe the patient over the next 3 to 6 months at which time repeat urinalysis and blood pressure.

Question 32

For an isolated asymptomatic microscopic hematuria persisting for 1 year what are the etiologies to be ruled out?

Answer 32

Hypercalciuria should be checked with a urine to creatinine ratio Genetic causes such as Alport syndrome or Thin basement membrane disease may be detected by testing first-degree relatives for microscopic hematuria or Sickle cell trait by performing hemoglobin analysis and Looking for nutcracker syndrome with a Doppler ultrasound

Question 33

Describe what needs to be done for patient who also has proteinuria with their asymptomatic microscopic hematuria?

Answer 33

Urinalysis with micro should be obtained and measurement of the protein content with either quantifying the proteinuria with a 24-hour urine collection or first morning sample and a urine protein to creatinine ratio

Question 34

What proteinuria finding is positive for a urine protein to creatinine ratio or a 24-hour urine collection sample?

Answer 34

A urine protein to urine creatinine ratio of 0.2 is positive or a 24-hour urine protein excretion of 4 mg per metered square per hour.

Question 35

What should be done if there is still proteinuria or hematuria that is less than the diagnostic values?

Answer 35

Clinical observation and repeat labs and urinalysis in 2 to 3 weeks. (If the proteinuria persist in the patient should be referred).

Question 36

For patient with symptomatic microscopic hematuria how should the patient be worked up?

Answer 36

Obtaining a thorough history and do a thorough physical exam

Question 37

What questions should be asked in the history part of an evaluation for patient with symptomatic microscopic hematuria?

Answer 37

Ask about trauma, symptoms suggestive of UTI including incontinence, dysuria, urgency and frequency, unilateral flank pain, does the pain radiate, ask about concurrent illnesses including pharyngitis or impetigo, URI symptoms, ask about history of sickle cell disease or trait, history of hemophilia, deafness, family history of hematuria or renal disease, or of kidney stones, also review the medications for possible interstitial nephritis, and on physical exam looking for findings of elevated blood pressure, edema, weight gain, purpura, and abdominal discomfort or masses for Wilms tumor,