when it looks like kool-aid: a brief look at hematuria

When It Looks Like Kool-Aid: a brief look at hematuria

John Cheng, MD

PEM Fellows’ Conference

Emory University School of Medicine

April 8, 2010

2

Objectives

Define hematuria

Discuss workup and management hematuria

Discuss some common diagnoses presenting with hematuria

3

Definitions

The presence of blood in urine• Gross: visible with the naked eye• Microscopic: visible on urinalysis (≥ 5 RBC/hpf)

Renal anatomy Bowman’s CapsuleFigures 508-1 and 508-4. Davis, ID and ED Avner. “Part XXII, Section 1: Glomerular Disease.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. pp2164-65.

4

Epidemiology

Gross hematuria• Incidence: 0.13%• Lower urinary tract bleeds

Microscopic hematuria• Incidence: 0.5-2% in school age kids• Upper urinary tract bleeds

Prognosis based on diagnosis• Microscopic hematuria often resolves without any

intervention and without any sequelae

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Diagnosis

Distinguish between upper vs lower bleeds

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Diagnosis

Urine Dipstick• Tetramethylbenzidine and H2O2

• Detects 1-5 RBC/hpf Sensitivity: 100%, Specificity: 99%

RBC cast Dysmorphic RBCs

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Common Confounders

Drugs Pigments

Rifampin Hemoglobin (hemolysis)

Phenazopyridine Myoglobin

Pyridium Bilirubin

Furazolidone Beets

Sulfa Blackberries

Nitrofurantoin Urates

Methyldopa Serratia marcescens

Levodopa Porphyrinuira

Metronidazole Alkaptonuria

Dexferroximine Homgentisic acid

Diphenylhydantoin Tyrosinosis

Iron sorbitol* Methemoglobinuria

Hypochlorite and iodine* Melanin

Table 1– Common Causes of “Dark Urine.” Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

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Hematuria Diagnosis Algorithms

Figure 34.1. Liebelt, EL. “Chapter 34: Hematuria.” Textbook of Pediatric Emergency Medicine, 4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000.

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Case 1: History

10 y/o boy presents with dark urine and altered mental status. He had been doing well until a couple of days ago when he started c/o headaches. Yesterday, his urine became a brownish color. Today, he has been lethargic.

ROS: tactile fever, malaise, flank pain, decreased urine output, headaches

PMH: none, IUTDPSH: hernia repairMeds: noneNKDASH: no ill contactsFH: none

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Case 1: Physical Exam

T 37.2C HR 92 RR 38 BP 150/87 SaO2 98% RA

GEN: lethargic, in mild distressHEENT: PERRL, OP clear, TM nlCV: tachycardic, nl S1S2, no m/r/gPULM: CTAB, no r/r/wABD: diffuse abd discomfort to palp, no HSM, nl BSEXT: +2 pulses, CRT < 2 sec, +2 pitting edema to knees bilaterallyNEURO: GCS 12 (E2, V4, M6), lethargic

WHAT WOULD YOU LIKE TO ORDER?

11

Case 1: Labs

145 | 110 | 100 / 75 Ca 6.8 15 \ 9 / 160 8 | 15 | 2.5 \ Phos 8 / 28 \

U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 50-100, WBC 10-20, +RBC casts

C3: 100 (low) C4: 22 (nl) ASLO: +

WHAT’S YOUR DIAGNOSIS?

12

Case 1: PSGN

Nephrotoxigenic strains of Group A Strep• Type 12: after strep throat• Type 49: after pyoderma

Prior treatment with antibiotics has no effect on incidence

Age: 5-12 y/o Presentation:

• Gross hematuria• Edema• Renal insufficiency with oliguria• Fever, malaise, lethargy, flank or abdominal pain

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Case 1: PSGN

Labs:• CBC: anemia

• BMP or RFP: renal insufficiency or ARF

• U/A: RBC, RBC casts, WBC (PMNs), proteinuria

• Complement: C3 low, C4 slightly low or nl

• RST or Strep culture

• ASLO: positive in strep throat

• Anti-DNAse B: positive in pyoderma

• Streptozyme test: positive in both

U/S: enlarged kidneys

Biopsy: diffuse mesangial cell and matrix proliferation; “humps” on the epithelial side of GBM

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Case 1: PSGN

Complications• HTN (60%)• ARF• Encephalopathy (10%)• CHF

Figure 511-2. Davis, ID and ED Avner. “Part XXII, Section 2: Conditions Particularly Associated with Hematuria.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2174.

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Case 1: Treatment & Prognosis

Supportive care• If no HTN or CHF: low Na diet and close follow up (48-72 hrs)• If still with strep infection: antibiotics (eg, PCN)• HTN: Ca channel blockers (eg, nifedipine), vasodilators (eg,

hydralazine), ACE inhibitors

• CHF: diuresis (eg, lasix), O2

> 80% recover spontaneously Acute phase, 6-8 wks Proteinuria and HTN, up to 4-6 wks Hematuria, up to 1-2 yrs

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Other Immune-mediated GN

Bacteria: Strep pneumoniae, Staph, Gram negatives, endocarditis

Viruses: Influenza, Hep B, Hep C

Fungus: Candida

Parasites: rickettsial (syphilis), Toxoplasma, malaria

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Case 2: History

5 y/o boy comes in with a history of fever and cold symptoms. He has been eating slightly less than usual, but has been urinating normally, except that the urine is reportedly darker than usual.

ROS: fever, cough, rhinorrhea, anorexia

PMH: h/o UTIPSH: noneMeds: noneNKDASH: no ill contactsFH: kidney problems

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T38.5C HR 100 RR 25 BP 130/82 SaO2 96% RA

GEN: in NADHEENT: PERRL, OP clear, TM nlCV: nl S1S2, no m/r/gPULM: CTAB, no r/r/wABD: soft, NT/ND, no HSM, nl BSEXT: +2 pulses, CRT < 2 secNEURO: grossly intact

WHAT WOULD YOU LIKE TO DO?

135 | 110 | 15 / 75 Ca 8.9

4.2 | 23 | 0.3 \

U/A: 1.025, + 2 protein, - LE, - nitrites, 10-20 RBC, 0 WBC

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Case 2: IgA Nephropathy

Most common chronic glomerular disease in world Presents at all ages, male predominance Usually noted with URI or GI infection Can present with loin pain and HTN NO other signs of systemic illness Positive family history

Labs: • U/A: protein, RBC, RBC casts• BMP: may show renal insufficiency• Complement: nl C3 and C4• Immunoglobulins: increased in 5% cases

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Case 2: Berger’s Disease

Diagnosis made by renal biopsy

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Case 2: Treatment & Prognosis

Treatment• BP control and proteinuria• Fish oil (omega-3 fatty acids)• Immunosuppression• Tonsillectomy

Hematuria will recur with other illnesses Slow, progressive deterioration in renal function in

20-30% within 15-20 years of initial presentation Poor prognostic factors:

• Persistent HTN• Decreasing renal function• Heavy proteinuria

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Other GN with Crescent Formation

Systemic Lupus Erythematosis Henoch-Schönlein Purpura Rheumatoid Arthritis Ankylosing Spondylitis Inflammatory Bowel Disease Celiac Disease HIV

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Case 3: History

8 month old boy comes in with his father. He reports, after your having to repeat your questions a couple of times, that his son has blood in his urine. He loudly tells you there were URI symptoms with fever a couple of days ago but that they are getting better. He continues to feel warm and has started pulling at his right ear.

ROS: fever, cough, rhinorrhea, otalgia, anorexia, hematuria

PMH: nonePSH: noneMeds: noneNKDASH: no ill contactsFH: none reported

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T37.8C ax HR 120 RR 32 BP 95/55 SaO2 98% RA

GEN: playful, but in NADHEENT: PERRL, OP clear, TM nlCV: nl S1S2, no m/r/gPULM: CTAB, no r/r/wABD: soft, NT/ND, no HSM, nl BSGU: uncircumcised EXT: +2 pulses, CRT < 2 secNEURO: grossly intact


132 | 102 | 9 / 102 Ca 9.2 12 \ 10 / 180 4 | 27 | 0.3 \ / 30 \

U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 100-200, WBC 5-10

25

Case 3: Alport Syndrome

Hereditary cause of hematuria Defect in type IV collagen (in GBM):

• COL4A5• COL4A3 and A4

Associated problems:• Sensorineural hearing loss• Eye abnormalities

Microscopic or gross hematuria about 1-2 days after a URI

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Case 3: Workup

U/A in relatives Ophthalmologic exam Audiogram ± Renal biopsy

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Case 3: Treatment and Prognosis

Treatment• Supportive care for HTN, anemia, and electrolyte

derangements• Cyclosporine• ACE inhibitors• Dialysis or transplant

Progresses to ESRD Poor prognostic factors:

• Gross hematuria• Nephrosis• Prominent GBM thickening

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Summary for GN

Figure 1. Differential diagnosis of hematuria organized by location. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

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Summary for GN

Workup: U/A with microscopy CBC, BMP (or RFP) C3 and C4 Consider ASLO, anti-DNAse B, or streptozyme Consider ANA

Table IV: Distinguishing Features of Glmoerular and

Non-Glomerular Hematruia. Indian Pediatric Nephrology

Group, Indian Academy of Pediatrics. “Consensus

Statement on Evaluation of Hematuria.” Indian Pediatrics.

2006 Nov, 43: 967

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Summary for GN

Table 511-1. Davis, ID and ED Avner. “Part XXII, Section 2: Conditions Particularly Associated with Hematuria.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2174.

31

Case 4: History

15 y/o young man comes in with abdominal pain. He has been having stabbing pain intermittently for the past 2-3 days, but now it’s getting worse and is constant. It is worse in his left abdomen with radiation into his groin. He does not report any fever, vomiting, diarrhea, dysuria, hematuria, or other symptoms. + anorexia and nausea. He has been taking Motrin 800 mg every 6 hours for the past 3 days.

ROS: anorexia, nausea, abdominal pain

PMH: h/o hematuria in past that resolved without intervention, IUTDPSH: noneMeds: noneNKDASH: no ill contacts, not sexually activeFH: kidney stones in MGM

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T37.2C HR 110 RR 30 BP 130/82 SaO2 98% RA Wt 56 kg

GEN: in moderate distress, constantly shifting position in stretcherHEENT: PERRL, OP clear, TM nlCV: nl S1S2, no m/r/gPULM: CTAB, no r/r/wABD: difffuse abdominal pain, worse on mid L side and some in

epigastric area, ND, nl BSGU: circumcised, bilateral testis descended (NT, no edema or erythema)EXT: +2 pulses, CRT < 2 secNEURO: grossly intact


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Case 4: Labs and Radiology

135 | 102 | 22 / 150 Ca 8.9 16 \ 13 / 220 4.3 | 22 | 0.8 \ / 40 \

U/A: >1.030, +2 protein, + Hgb, -LE, -nitrite, RBC 50-100, WBC 0-5, + crystals

Figure 547-1. Elder, JS. “Part XXIII, Chapter 547: Urinary Lithiasis.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2268.

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Case 4: Nephro- and Urolithiasis

Prevalence: 1-5%, high recurrence rate (6.5-44%) School age children, usually Caucasian Male ≥ Female Epidemiology changes with geographic area Usually underlying metabolic disorder

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Case 4: Nephro- and Urolithiasis

Mechanisms:• Changes in solubility factors

Increased solubility product (ie, more ions) Decreased concentration of inhibitors

Risk factors:• Urinary stasis• Damage to uroepithelium or foreign body• Dehydration

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Case 4: Causes of stones

~50% positive family history ~ 90% radio-opaque

• Uric acid and drug stones are NOT radio-opaque

Table 547-1. Elder, JS. “Part XXIII, Chapter 547: Urinary Lithiasis.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007. p 2267.

“The stone is not the disease itself; it is only one serious sign!” (Hoppe and Kemper, “Diagnostic examination of the child with urolithiasis or nephrocalcinosis.” Pediatr Nephrol (2010) 25: 403-413.)

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Case 4: Common stones

calcium oxalate uric acid

triple phosphate cystine

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“Pediatric Urolithiasis: Experience at a Tertiary Care Pediatric Hospital” (Kit LC, et al. CUAJ 2008; 2(4): 381-6)

Population:• 72 pts with diagnosis of urolithiais or nephrolithiasis

• 1/99-7/04 at Children’s Hospital of Eastern Ontario

Presentation:• 63% c/o abd or flank pain, 49% c/o N/V

Workup:• U/A: 17% neg, 82% + RBC, 40% c/w UTI

• 74% dx by U/S, 56% by KUB, only 7% by CT

Results:• mean stone size 5mm (1-22mm)

• 41% had metabolic abnormality usually hypercalciuria or hyperoxaluria

• 14% had GU abnormality (usually at UPJ)

• 47% passed stone spontaneously (mean size 4 mm, range 1-11mm)

• 93% stones were calcium oxalate or phosphate

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Case 4: Presentation and Workup

Presentation:• Abdominal or flank pain ± radiation to scrotum or labia• Nausea and vomiting• Difficulty voiding• Urinary symptoms (if not obstructed):

dysuria, urgency, frequency, gross hematuria

Labs:• Blood: RFP, Alk Phos, Uric Acid• Urine studies:

U/A with microscopy 24 hour urine Ca Spot Urine Ca:Creatinine ratio

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Case 4: Radiology

Abdominal Xray• ~90% stones radio-opaque

Ultrasound

Noncontrast helical CT

Pyelogram

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Case 4: Treatment and Prognosis

Treat underlying cause Analgesia Hydrate with twice MIVF (if no renal insufficiency)

Consult GU if obstructed• <5 mm usually pass spontaneously• Surgical

High chance of recurrence, particularly in underlying metabolic disease

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Renal Trauma

47% GU trauma involves the kidneys • Usually blunt trauma (90%)• Associated with intraperitoneal injuries

More common in kids for anatomic/developmental reasons

American Association for the Surgery of Trauma grading system• Treatment based on grade

43

Renal Trauma Classification

Figure 109.2. G

arcia, CT

. “Chapter 109: G

enitourinary Traum

a.” Textbook of P

ediatric E

mergency M

edicine, 4th ed. G

R F

leisher and S Ludw

ig, eds. Philadelphia, Lippincott

William

s & W

ilkins, 2000. p 1373.

44

Renal Trauma Presentation & Workup

Presentation:• Abdominal or flank pain• Localizing signs• Shock

Workup:• U/A with microscopy• Abdominal Xray• IVP with delayed images• Abdomen/pelvis CT with IV contrast• Other tests:

Ultrasound, Nuclear med scan, Angiography

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Renal Trauma Treatment & Prognosis

TREATMENT If < 20 RBC/hpf on U/A

• repeat U/A and possible

radiologic test as outpatient

Grade 1-3• Strict bedrest, analgesia,

antibiotics

Grade 4-5• Close observation, serial

Hct, antibiotics

If devascularized, needs to be

revascularized < 12 hrs from

injury to be successful.

COMPLICATIONS• Bleeding (delayed,

persistent, recurrent)• Urine extravasation or

urinoma• Infection• Infarction• Hydronephrosis• AV fistula• Renal-intestitnal fistula• Stones• HTN

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Renal Trauma Treatment Algorithm

Figure 109.1. Garcia, CT. “Chapter 109: Genitourinary Trauma.” Textbook of Pediatric Emergency Medicine, 4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000. p 1372.

47

Hematuria Workup Algorithms

Figure 2. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6): 1519-1537.

48



49



50

Summary

Defintion: blood in the urine, ≥ 5 RBC/hpf

Distinguish between glomerular vs lower urinary tract bleeds.

Higher index of suspicion of severe disease when there are signs of systemic disease, eg– HTN, edema, abdominal pain.

Use labs to determine etiology of bleeding and need for further follow up.

Regardless of diagnosis, follow up with the PCP for a repeat urinalysis should be done.

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And now it’s time for roulette!

52

Roulette

HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 102 | 12 / 152

4.2 | 25 | 0.3 \ 8.9

7.6\ 11 / 200 / 34 \

U/A: + 1 protein, WBC 20, RBC 50

Pyelonephritis

HSP5 y/o girl with a rash.

53

Roulette

IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

130 | 103 | 61 / 99 Ca 7.3

4.9 | 21 | 3.7 \

AST 293 AP 175 TP 5.1ALT 201 TB 1.7 Alb 2.5

15.5 \ 9.3 / 46 + microcytes

/ 24 \ + schistocytes

U/A: + 1 protein,WBC 0, RBC 5-10

Pyelonephritis HSP HUS

2 y/o girl “not urinating.”

54

Roulette

SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

133 | 99 | 20 / 152 C3 nl

5.6 | 16 | 1.0 \ C4 low

17 \ 11 / 420 / 35 \

U/A: + 2 protein, WBC 10-15, RBC 100-150, RBC casts

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease

13 y/o girl with hemoptysis.

55

Roulette

Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

152 | 95 | 40 / 52

3.2 | 8 | 0.8 \

19 \ 14 / 85 / 40 \

U/A: grossly bloody, + 2 protein, WBC 5-10, RBC TNTC

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis

4 months old with persistent vomiting and diarrhea x 3 days, one wet diaper in 24 hours

56

Roulette

HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 102 | 12 / 152 Ca 8.9

4.2 | 25 | 0.3 \

18 \ 12 / 420 / 38 \

U/A: + LE, + nitrites, WBC 50-75, RBC 20-25

Pyelonephritis10 y/o girl with high fevers and vomiting.

57

Roulette

Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 102 | 25 / 152 C3 nl

4.2 | 25 | 0.6 \ C4 nl

12 \ 13 / 420 / 40 \

U/A: + 2 protein, WBC 0, RBC 10-15, RBC casts

Pyelonephritis HSP HUS IgA nephropathy

7 y/o boy with URI and blood in urine.

58

Roulette

Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 102 | 9 / 152 C3 nl

4.2 | 25 | 0.3 \ C4 nl

12 \ 13 / 420 / 40 \


Pyelonephritis HSP HUS IgA nephropathy Alport syndrome

2 y/o boy with blood in urine 1-2 days after a URI

59

Roulette

Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 102 | 27 / 152 Ca 8.9

4.2 | 25 | 1 \ CPK nl

10 \ 12 / 220 / 38 \

U/A: dk red, + hgb, - LE & nitritesWBC 0-5, RBC clots

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise

17 y/o boy with severe muscle pain during football training season

60

Roulette

132 | 103 | 15 / 270 Ca 8.8

3 | 17 | 0.6 \

17 \ 8 / 510 / 23 \

U/A: + hgb, +2 protein, WBC 10-15, RBC TNTC

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

10 y/o boy run over by car. On exam, has perineal edema and ecchymosis, along with unstable pelvis.

61

Roulette

UPJ disruption Urethral trauma

138 | 100 | 15 / 175 Ca 8.7

4.1 | 22 | 0.7 \

16 \ 12 / 390 / 38 \

U/A: + hgb, +1 protein, - LE & nitrites, WBC 0-5, RBC 25-30

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia

Nephrolithiasis

10 y/o girl with nausea; recurrent abdominal pain, now constant; unable to get comfortable on stretcher.

62

Roulette

Nephrolithiasis UPJ disruption Urethral trauma

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise

Pigmenturia

3 month old comes in for blood in urine. No fever. Has been doing well.

63

Roulette

Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

138 | 103 | 25 / 83 C3 low

4.7 | 20 | 1.3 \ C4 low

19 \ 9 / 390 / 29 \


Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis

12 y/o girl with fever, joint pains, rash

64

Roulette

Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 110 | 8 / 150

4 | 17 | 0.2 \

20 \ 8 / 405 / 24 \

U/A: grossly bloody, + 2 protein, WBC 0-5, RBC 25-50

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis Renal vein thrombosis Sickle cell nephropathy

6 month old presents with finger swelling, crying, and fever

65

Roulette

Renal vein thrombosis Sickle cell nephropathy Heavy exercise Pigmenturia Nephrolithiasis UPJ disruption Urethral trauma

140 | 102 | 12 / 152 Ca 8.9

4.2 | 25 | 0.3 \

10 \ 12 / 220 / 38 \

U/A: + LE, + nitrites, WBC 10-20, RBC TNTC

Ucx: NGTD

Pyelonephritis HSP HUS IgA nephropathy Alport syndrome Goodpasture disease SLE nephritis Hemorrhagic cystitis

4 y/o boy with fever and grossly bloody urine.

66

Questions?

67

References

Beck, LH and DJ Salant. “Glomerular and Tubolointerstitial Diseases.” Primary Care: Clinics in Office Practice. 2008, 35: 265-296.

Butani L and A Kalia. “Idiopathic hypercalciuria in children – how valid are the existing diagnostic criteria.” Pediatric Nephrology. 2004, 19:577-582.

Cronan, K and ME Norman. “Chapter 86: Renal and Electrolyte Emergencies.” Textbook of Pediatric Emergency Medicine, 4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000.

Davis, ID and ED Avner. “Part XXII, Section 1: Glomerular Disease.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.

Davis, ID and ED Avner. “Part XXII, Section 2: Conditions Particularly Associated with Hematuria.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.

Elder, JS. “Part XXIII, Chapter 538: Urinary Tract Infections.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.

Elder, JS. “Part XXIII, Chapter 546: Trauma to the Genitourinary Tract.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.

Elder, JS. “Part XXIII, Chapter 547: Urinary Lithiasis.” Nelson Textbook of Pediatrics, 18th ed. RM Kliegman et al, eds. Philadelphia, Saunders Elsevier: 2007.

Garcia, CT. “Chapter 109: Genitourinary Trauma.” Textbook of Pediatric Emergency Medicine, 4th ed. GR Fleisher and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000.

Gordon, C and FB Stapleton. “Hematuria in adolescents.” Adolescent Medicine Clinics. 2005, 16: 229-239.

Hoppe, B and MJ Kemper. “Diagnostic examination of the child with urolithiasis or nephrocalcinosis.” Pediatric Nephrology. 2010, 25: 403-413.

68

References

Indian Pediatric Nephrology Group, Indian Academy of Pediatrics. “Consensus Statement on Evaluation of Hematuria.” Indian Pediatrics. 2006 Nov, 43: 965-973.

Kasthan, CE. “Familial Hematuria.” Pediatric Nephrology. 2009, 24: 1951-1958. Kit, LC et al. “Pediatric urolithiasis: experience at a tertiary care pediatric hospital.” CUAJ. 2008, Aug,

2(4): 381-386. Lau, KK and RJ Wyatt. “Glomerulonephritis.” Adolescent Medicine Clinics. 2005, 16: 67-85. Lee, YJ et al. “Renal Trauma.” Radiologic Clinics of North America. 2007, 45: 581-592. Leslie, JA and MP Cain. “Pediatric Urologic Emergencies and Urgencies.” Pediatric Clinics of North

America. 2006, 53: 513-527. Liebelt, EL. “Chapter 34: Hematuria.” Textbook of Pediatric Emergency Medicine, 4th ed. GR Fleisher

and S Ludwig, eds. Philadelphia, Lippincott Williams & Wilkins, 2000Noe, HN and DP Jones. “Chapter 111– Renal Diseases in Childhood.” Wein: Campbell-Walsh Urology, 9th ed. Wein, ed. Philadelphia: Elsevier, 2007.

Pan, CG. “Evaluation of Gross Hematuria.” Pediatric Clinics of North America. 2006, 53: 401-412. Patel, HP and JJ Bissler. “Hematuria in Children.” Pediatric Clinics of North America. 2001, 48(6):

1519-1537. Quigley, R. “Evaluation of hematuria and proteinuria: how should a pediatrician proceed?” Current

Opinion in Pediatrics. 2008, 20:140-144.

when it looks like kool-aid: a brief look at hematuria

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