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When Should You Worry About Blood in Urine? · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Mike (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:07
  Mike, and with me is Dr.
• 0:09
  Judith Van Sickle, Medical Director of the Pediatric Kidney Transplant
• 0:15
  Program at Children's Mercy.
• 0:17
  Today, we're talking about proteinuria and hematuria in kids, and how
• 0:22
  to approach these findings in practice, when to worry, and what
• 0:27
  pediatricians really need to know.
• 0:31
  Dr.
• 0:31
  Van Sickle, welcome to the show.
• 0:33
  Great to have you on again.
• 0:35
  Judith VanSickle, MD: Thank you.
• 0:35
  Thank you again for inviting me to discuss that pretty important and I
• 0:40
  think frequently overlooked topics for blood in the urine, other way we
• 0:45
  call it hematuria, and protein in the urine, otherwise called it proteinuria
• 0:50
  Dr. Mike (Host):
• 0:50
  Well, let's, let's just start there.
• 0:51
  I, like I would love to know, and I know a lot of community pediatricians would love
• 0:56
  to know how you kind of approach these.
• 0:58
  So let's start with proteinuria, you know, protein in the, in the urine.
• 1:01
  How do you approach that
• 1:04
  Judith VanSickle, MD: So why do we have kidneys, We have kidneys because
• 1:07
  their job is to remove the toxins, the excess water, maintain the electrolyte
• 1:13
  and the pH, the acid-base homeostasis.
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  How do we do that is that there is an actually fence.
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  There is a filter inside of the kidney, okay?
• 1:23
  The job is to keep the cells, the protein, the nutrients in, and that
• 1:28
  complex filtration system basically gonna let the rest of them out.
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  That filtration comes with like cells and then like a molecular part together,
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  and they kind of attach like you would look like in, in a fence exactly.
• 1:42
  And so I think that's super important when we talk about proteinuria
• 1:46
  is that normally we should not have protein in the urine, okay?
• 1:50
  Except one really rare occasions, and we're gonna talk about it
• 1:54
  when we talk about with teenagers.
• 1:56
  So when we have protein in the urine, then we really have to think about
• 2:00
  it, that fence opened up enough to let that protein part, the molecular part
• 2:06
  out, but not too big that actually the cellular component could come out, okay?
• 2:12
  So having really protein in the urine is it usually related to some kind of illness
• 2:17
  that destroys that fencing barrier.
• 2:20
  Thing typically destroy the molecular charge of that barrier.
• 2:24
  And so with all that saying again, when we dip the urine and you see
• 2:29
  protein in the urine, one other thing that I want to remind a pediatrician
• 2:34
  is that you have to understand the dipstick limitations, 'cause that's
• 2:37
  like an enzymatic process, right?
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  Every test has a good part and bad part.
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  Good is that you can do it in your office right away.
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  Bad things that you have to understand is super sensitive,
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  so it picks up on everything, but it really, really not specific.
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  So bacteria and other stuff can also trigger it to be positive.
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  And so we always need to understand that if you see protein in
• 3:01
  the urine in a normal child, you should first quantify it.
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  So you should send it out for a further analysis
• 3:09
  Dr. Mike (Host):
• 3:09
  with that said about proteinuria so your approach to hematuria,
• 3:14
  how does that differ?
• 3:15
  Judith VanSickle, MD: Almost never, never normal to have blood in the urine.
• 3:18
  I think that's what's kind of like a key things with the,
• 3:22
  the compared to the two things.
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  And really, we're gonna talk about the presentation of the children, too.
• 3:26
  But with all of that saying, if you have red cells sneaking out, that
• 3:32
  means really that, that fenestration system is almost damaged or it's
• 3:38
  congenitally gone because you do have some other developmental problem with it.
• 3:42
  And typically, again, when you have blood coming through that filtration
• 3:46
  barrier, that is part of a systematic disease that is again, destroying
• 3:53
  the kidney, and it's losing the blood because you cannot filtrate it.
• 3:57
  Okay?
• 3:58
  But one other thing to remember that the kidneys has no innervation.
• 4:03
  There's no innervation with it.
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  Okay?
• 4:05
  So when you see a kid who present with dark-colored urine, brown urine, you
• 4:11
  should be really much more worried than compared to the kid, and I know it's
• 4:15
  doesn't make really any sense everybody.
• 4:17
  But when you have a patient who is coming with pain for hematuria, that's
• 4:21
  never gonna come from the kidney.
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  That's really come from the lower urinary part, right, the tube, the bladder
• 4:27
  Dr. Mike (Host):
• 4:27
  Right.
• 4:28
  So what findings should prompt a referral to a specialist like you then?
• 4:35
  Judith VanSickle, MD: So if you have pa-patients come with your
• 4:37
  clinic reporting blood in the urine, your first question should
• 4:41
  be, "Is it painful or painless?"
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  There was confirmed that this is a painless hematuria.
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  Please visibly look at the urine.
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  So take your time, and you really actually see that while it does look
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  discolored, you do the dipstick test, then do go out and send it out because
• 4:58
  like we talk about it, the dipstick can be pretty positive for other reason too.
• 5:03
  And then if for sure, if you do see that there is more than five to 10 red cells
• 5:09
  under the microscope on three different occasions, or that patients also present
• 5:13
  with other concerning symptoms, right?
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  Swelling, rash, joint pain, high blood pressure, those patients should be
• 5:20
  definitely worked up and, call us right away because that's why we are here.
• 5:24
  That's our typical bread-and-butter nephrology, right?
• 5:27
  That's what we like to talk about a lot
• 5:30
  Dr. Mike (Host):
• 5:30
  Okay.
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  I, I'm gonna back up just for a sec for the community pediatrician here.
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  and I wanna talk about some initial lab tests that maybe they
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  can run before referral to you.
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  So they, they do the urinalysis, they do the dipstick, they're gonna send that off.
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  if there's blood or protein possibly in that sample, what other tests
• 5:51
  should they be ordering right now to help you complete the picture?
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  Judith VanSickle, MD: And I think that's really good because, Mike, to be honest,
• 5:59
  many times we have these quest- questions, "What other things you want me to do it?"
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  And to be honest, our main thing is give us a good explanation, give us a good
• 6:08
  history, give us a good physical exam.
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  If you really want to do laboratory testing, that's perfectly fine just
• 6:15
  to check what's the kidney function.
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  So just do a basic blood work for a basic metabolic panel, and then maybe a
• 6:22
  liver function to check on serum albumin.
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  Again, you're looking for evidence of kidney dysfunction and
• 6:27
  evidence of losing protein, right?
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  So your albumin level should be low.
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  And again, many times many pediatrician wants to do the
• 6:34
  immunological workup, the lupus workup.
• 6:38
  Don't waste your time because those tests typically expensive, come back late.
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  We can deal with that, and those information is really
• 6:46
  just going to be the next step.
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  I think that's really the key thing is dipstick confirm with
• 6:52
  a microscopic exam and do a good physical exam and a good history
• 6:56
  Dr. Mike (Host):
• 6:56
  Dr.
• 6:57
  Van Sickle, at that point, you're not looking for even some imaging,
• 7:00
  an ultrasound of the urinary system or that's, that's something you're
• 7:03
  gonna take care of probably down the
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  Judith VanSickle, MD: and that's another really good question because
• 7:07
  really, again, if you are talking about the true nephrology etiology
• 7:11
  of blood in the urine, right?
• 7:12
  Something that coming from the other part of the kidney, you're not really gonna
• 7:15
  see a too lot of things on the ultrasound.
• 7:17
  It's fine to do one to making sure that you have two kidneys.
• 7:20
  They're gonna show that the kidneys are inflamed.
• 7:23
  If that patient comes in with a painful urination, right?
• 7:27
  So that's when we talk about a painful hematuria, then you should do an imaging
• 7:31
  because that's when you're looking for, right, why you have that painful hematuria
• 7:36
  is because that inner liner of the urinary collecting system got damaged,
• 7:40
  and that's where the blood coming from.
• 7:42
  And yes, those patients you will do an imaging.
• 7:45
  And so that's-- I think it's a really easy way to sort of sort it out in your mind.
• 7:49
  Painless hematuria, I should really work it up as a possible renal etiology.
• 7:54
  Painful hematuria, there's probably some kind of urological
• 7:57
  Dr. Mike (Host):
• 7:57
  Yeah.
• 7:58
  Well, Dr.
• 7:58
  Van Sickle, you know I'm a radiologist, so I want to take
• 8:00
  pictures of everything all the time.
• 8:02
  Anyways, moving on.
• 8:04
  Um
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  Judith VanSickle, MD: If I, if I would have ultrasound in
• 8:06
  my office, I would probably…
• 8:08
  You know, again, we just don't have it, but I think it's, it's definitely
• 8:11
  you got a good point with it.
• 8:12
  Sure.
• 8:13
  Dr. Mike (Host):
• 8:13
  So let's-- Okay so we're talking about, I mean, we're talking
• 8:17
  about pediatrics here, right?
• 8:18
  I mean, the age ranges are huge.
• 8:21
  When we look at protein or blood in the urine, how does your approach change
• 8:27
  from, infants to adolescents to preteens?
• 8:31
  Like, can you walk us through that a little bit?
• 8:33
  Judith VanSickle, MD: I'm so glad you brought it up, 'cause actually
• 8:35
  that was my very first article.
• 8:37
  That's my very first publication what I did when I started as a nephrology fellow.
• 8:41
  So having a teenager, and even a younger teenager, so like a teen who is
• 8:48
  really tall and skinny, they're gonna be protein in the urine during the
• 8:53
  daytime because there's something called orthostasis, You know, you're standing,
• 8:58
  and the hydrostatic pressure, there's no really fat tissue around the kidneys.
• 9:02
  And so because of that hydrostatic overflow, there can be some
• 9:06
  protein overfiltration, okay?
• 9:08
  So teenager, think orthostatic first for proteinuria.
• 9:12
  And that's for a reason.
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  You should never check
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  or if you have a daytime, during the midday sample, you should have
• 9:20
  that standard first morning sample, which is again, before you go to
• 9:24
  sleep, urinate, wake up, and right away that first sample, that's what
• 9:29
  you want
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  Dr. Mike (Host):
• 9:30
  right, That, first void is the key one, right?
• 9:32
  Okay.
• 9:33
  Yeah.
• 9:33
  Judith VanSickle, MD: Yep.
• 9:33
  And the key thing is to empty your bladder before you go to sleep, because
• 9:36
  again, remember, bacteria in the bladder can produce protein, right?
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  They can produce all sorts of bad things, right?
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  Now, for the baby, that's a little bit difficult, right?
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  How do I check a urine if, especially if you are just want to do a random thing?
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  And so a bagged specimen for that, again, cleaning the skin, putting the plastic
• 9:54
  bag on, keeping them for no longer than one hour, can give you enough sample to
• 9:59
  just do that regular p- you know, testing, random testing for protein or blood in it.
• 10:05
  And so again, remember with the, especially with the baby, if you
• 10:09
  do see protein but you don't have any other symptoms, otherwise the
• 10:13
  baby looks good, then the number one thing that I would first really
• 10:17
  worry about it that, well, my, my collection way was not clean, right?
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  There is bacteria or something that triggering the dipstick.
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  So use your lab.
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  And the lab persons are really helpful, even locally.
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  You can send out that collected specimen for a random testing, or you call
• 10:33
  us, but you let us know that I send that s- specimen out, and that kind
• 10:37
  of is really helpful to interpreting that protein in that random sample.
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  Because, of course, we're not gonna do a 24-hour collection in a baby,
• 10:45
  but that will be really helping you out in that period of time.
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  And as you're getting younger and younger, having blood and protein
• 10:52
  in the urine, again, should be even more and more concerning.
• 10:56
  Dr. Mike (Host):
• 10:56
  But now, I mean, obviously tw- so 24-hour collection is not really for the infant.
• 10:59
  But when you're moving into adolescence and if you're thinking hormonal issues,
• 11:03
  maybe there's growth, stunted growth, what have you, is a 24-hour collection
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  of hormones and stuff at that point good?
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  Judith VanSickle, MD: for us, 24 hours would be your standard.
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  So for sure, we would love to have a 24-hour urine collection.
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  Teenagers also not really like to do that.
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  Like, who wants to walk around with, with a can, right?
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  But they would do it for us if we really, really want it.
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  So having a random specimen for the first start, that's perfectly fine.
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  Many of these patients, when they actually ending up for the whole workup,
• 11:32
  for example, for a stone, we will make them to do a 24-hour urine collection.
• 11:36
  But again, for a PCP office, a random specimen, again, understand when you
• 11:41
  collect it in a teenager, do it at the first morning, making sure that you send
• 11:46
  it out right away, call us, and then we will help you how to interpret it
• 11:51
  Dr. Mike (Host):
• 11:51
  So Dr.
• 11:52
  Van Sickle, you've been doing this for a long time.
• 11:54
  You're the expert.
• 11:55
  you must know some common mistakes or misconceptions that come across, your
• 12:01
  desk when evaluating these patients.
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  What-- Can you share some of that with us?
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  Judith VanSickle, MD: I think not confirming the
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  dipstick under the microscope.
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  That's number one thing, right?
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  This is again-- And it just can cause so much alarm for the parents, too.
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  Like, there's a dipstick positive, there's a trace positive, but I can see nothing.
• 12:20
  The kid maybe just have bedwetting or urinary infections.
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  Again, confirm it.
• 12:27
  Dr. Mike (Host):
• 12:27
  how often are you seeing dipsticks not confirmed under their microscope?
• 12:31
  Judith VanSickle, MD: Very often.
• 12:32
  Very often.
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  Yes.
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  Yes, very often.
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  So I think that's, that's number one thing that really we want--
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  going to emphasize with it.
• 12:39
  Two, having a painless brown discolored urine is hematuria.
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  And especially if you have a patient who has other symptoms,
• 12:48
  rash, swelling, take it seriously.
• 12:51
  I think that's other, the second thing that we see it, that because those kids
• 12:54
  are not typically symptomatic, right?
• 12:57
  Typically get later diagnosed.
• 12:59
  I think that's another thing.
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  And then again, the third one, if you have a child with the painful hematuria,
• 13:04
  and they have blood in the urine, and they have protein in the urine too, Mike,
• 13:08
  that's the kid that you should have a radiology when you-- imaging, right?
• 13:11
  That's a kid that you might have UTI, you might have stones, you
• 13:15
  might have voiding dysfunction.
• 13:16
  So imaging actually can help even to make a diagnosis for a
• 13:20
  Dr. Mike (Host):
• 13:20
  Yeah.
• 13:20
  I, you know, I would assume overt blood in, in the urine is one thing,
• 13:23
  but you probably, you know, community pediatricians probably see more of
• 13:28
  the brown color, the-- and they're not sure what that really means, and they
• 13:32
  should just think blood right there.
• 13:34
  Is that the point?
• 13:35
  Judith VanSickle, MD: Yes, it's a dark tea-colored urine.
• 13:38
  I really want the pediatrician to check it.
• 13:40
  But okay, you know, especially if you have a high blood pressure,
• 13:44
  you have other symptoms, headaches, dizziness, blurred vision, just that's
• 13:49
  the kid that we probably call us.
• 13:51
  Send the urine for the exam.
• 13:53
  Do-- If you really wanna do a blood work, just do that.
• 13:56
  Because those are the kids that if you're delaying the diagnosis, right,
• 13:59
  you're decreasing your chances of the treatable condition or actually think
• 14:03
  about the fence is going away, right?
• 14:05
  You wanna make sure that the fence will be retaining so we can actually treat
• 14:09
  that inflammatory process on time.
• 14:11
  Don't let it to go for scar formation
• 14:15
  Dr. Mike (Host):
• 14:15
  So, protein in the urine, blood in the urine, we know
• 14:17
  overall it, it's not uncommon.
• 14:20
  but how is the patient normally presenting?
• 14:22
  Is asymptomatic kind of a very common way?
• 14:26
  You know, all of a sudden the doctor does a dipstick and sees
• 14:28
  some blood, but the patient has no complaints, family has no…
• 14:31
  Is that, is that the common scenario?
• 14:34
  Judith VanSickle, MD: I think now that we're going into the, the fall
• 14:36
  season and the winter season, that's going to be the most likely, right?
• 14:41
  Sore throat or respiratory infection.
• 14:44
  You saw the, the kid 10, 14 days later, parents call you
• 14:49
  that kind of not peeing same.
• 14:51
  I think it's dark.
• 14:53
  Look a little bit puffy.
• 14:55
  What is going on?"
• 14:56
  Right?
• 14:57
  And that would be, again, your, your bread and butter typical
• 15:00
  something called post-infectious or post-streptococcal, right?
• 15:04
  By, you know, inflammation in the kidney.
• 15:06
  And so I think that is one of those symptoms that just remember.
• 15:09
  And my other favorite one is unfortunately we live in an area, right, where E.
• 15:13
  coli is really often in a, in a summertime in the lake water.
• 15:18
  And so there's something called AGUS, right?
• 15:20
  When you can have hemolytic process breaking down the
• 15:22
  cells, you have diarrhea.
• 15:24
  You just saw that kid, and in about five to seven days, the parents
• 15:28
  call you that, "Hey, now the urine
• 15:30
  Dr. Mike (Host):
• 15:30
  Yeah, now the urine, the urine takes a little longer to kick in.
• 15:33
  Judith VanSickle, MD: Exactly
• 15:34
  right?
• 15:35
  because-- Exactly because those poor kidneys are just there.
• 15:39
  They're just filtering and filtering and filtering, and it's
• 15:41
  just like a wastebasket, right?
• 15:43
  And so I think that's what just you re- need to remember that,
• 15:46
  oh, that must be the kidney.
• 15:49
  Dr. Mike (Host):
• 15:49
  Dr.
• 15:49
  Francisco again, every time you come on the show, it's fantastic.
• 15:52
  Thank you so much.
• 15:53
  The, the amount of information you give is incredible.
• 15:56
  I-- So, but I always wanna get your take on, like, what, what's, what does
• 16:01
  the future look like when it comes to, the laboratory test, the clinical
• 16:05
  practice of proteinuria and hematuria?
• 16:09
  Judith VanSickle, MD: Well, we don't have an AI to replace the exam, that's
• 16:12
  for sure, and the history taking.
• 16:15
  So I think that's number one.
• 16:17
  When you see a patient like that, good history, good exam
• 16:20
  gonna save a lot with that too.
• 16:22
  Dipstick, great, use it in the office, understand how to interpret it,
• 16:27
  understand what's the limitation of that, and then have an established
• 16:30
  lab where you know h- how fast you can have that lab results back.
• 16:34
  And so I think that's really important with that.
• 16:37
  and then lastly, if you have any questions, just call us.
• 16:41
  We are here.
• 16:41
  We are available 24/7.
• 16:43
  We will provide you with guidelines, how to work it up.
• 16:47
  We do really like to talk to the pediatricians ahead of our time because
• 16:51
  it, it saves us lots of headaches and potentially can save kidney function
• 16:55
  Dr. Mike (Host):
• 16:55
  Dr.
• 16:56
  Pfanziegel, listen, I love having you on.
• 16:57
  You're awesome.
• 16:59
  Judith VanSickle, MD: Thank you so much for the time.
• 17:00
  This was awesome again.
• 17:01
  this is the view of a transplant nephrologist, right?
• 17:04
  Who kind of sees the things from the other end.
• 17:07
  But also like you said, kidney problem not always walks into that pediatric door.
• 17:12
  So when it walks in, just think really clearly, and then step by
• 17:16
  step we'll help you to, to work up
• 17:18
  that process
• 17:19
  Dr. Mike (Host):
• 17:19
  Great summary.
• 17:20
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• 17:25
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• 17:32
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  I'm Dr.
• 17:47
  Mike.
• 17:48
  Thanks for listening