Blood in urine is common in little kids, and routine screening can cause unnecessary anxiety. In this guide, pediatric nephrologist Elizabeth Black, MD, MAS, walks primary care providers through the process that starts with a positive dipstick. She describes types of hematuria, reviews the many causes, clarifies “persistent” hematuria, and covers workup options – ranging from assessing family history to testing renal function to imaging the kidneys.
mm hmm. And thank you so much for having me for this. Um and I will be talking to everyone about evaluation and differential diagnosis of Hugh materia and pediatric patients. Um, just to quickly introduce myself again, I am a pediatric nephrologist at UCSF. Um many of Children's hospital, but I'm primarily based in the Central Valley. Um, so I have clinics in Fresno and Modesto. So especially if you have patients who are local to the North Valley in the Modesto area, I'm very happy to see them in my clinic. Um but I'll go ahead and get started. Um, so I do have a few um sort of case things in my talk. I'd like you to kind of think about as I go through and think about what you would do and how you would approach this patient that we're going to talk about. Um so just to review the objectives quickly, I'm going to talk about indications for screening urine analysis will define him, materia will review the initial work up for Hugh material and pediatric patients and we'll also talk about common causes of both glamorous color and non glamorous materia. So we'll start with our case. This is Rebecca she is a four year old who you're seeing in your clinic for a well child. Check her family recently moved to into your area and this is her 1st 1st visit in your office. Her past medical history is remarkable for premature birth at 31 weeks And she had a five week nick. You stay. She also has moderate persistent asthma that's controlled on your destiny and seasonal allergies. Her vital signs including blood pressure are normal in your office and her parents report she had been doing she has been doing well and have no specific concerns. So in addition to sort of your routine well, child care, think about what other tests you would do on a patient like Rebecca with her history. Um so one of the things, so we'll talk about screening urine analysis. So as of 2007, the ap actually no longer recommends during screening your ins and healthy asymptomatic patients. And that's because there's quite a high incidence of transient transient you material and protein area and childhood. Um And there's a high rate of misinterpretation of tests. The lower and a lower rate of chronic kidney disease and bladder malignancy in this population. So your number needed to test actually um To find to find a patient with a significant kidney or bladder disease on screening urine analysis and the healthy population is about 8000. So that means for every 8000 patients you dip your ins on one of them. You might catch something. Um And we know that this unnecessary testing. You know, it can be it can be really anxiety provoking and families and there's also a medical cost to it But that doesn't mean that you shouldn't be getting routine urine on no patients. There are some where it is indicated. So like Rebecca was born at 31 weeks and we do recommend that you do a yearly urine dip in um Kidd with a history of less than 32 weeks prematurity. Um Or if they have very low birth weight, other neonatal complications that require in intensive care. And particularly if they have a history of umbilical arterial lines. And that's because we were concerned about the risk of clot formation on those umbilical lines and potential clotting of the kidneys that can be missed in the neonatal period. No. Also any patient with either with congenital heart disease whether that's prepared or unprepared. Anyone of course with recurrent Uti huma tree of Pretoria um known renal disease or your logic malformations patients with or any kind of organ transplant prolonged treatment with a toxic medications, anyone with a history of recurrent emphasis of history and also anyone with a history with the family history of inherited renal disease. Um so because Rebecca was born at 31 weeks at less than 32 weeks. Um You decided to perform a screening urine analysis and you perform a urine dipstick analysis and clinic. The results are shown on the right there. Um So what do you how do you think about what's the next step in your care of this patient and how would you discuss this result with Rebecca and her family. So you can see the other. Looks pretty good. But she does have one plus blend. So I would like to kind of start while you're pondering on that, I'll start by just defining human area. Um So microscopic topic he materia. That is the absence of a visible color change in the urine, but with the presence of at least five red blood cells per high powered field on microscopy. Mhm. On the other hand, microscopic or gross crematoria. That's blood you can see with your eyes. Um is is the presence of blood in sufficient quantity between visible with the naked eye. Um And that can be either bright red like Hawaiian punch or it can be dark and tea colored. Um And we know that it's very small amount of blood in the in the urine can cause a visible color change. So even just a drop of blood or a drop in a liter of liquid can cause a pink tinge. Um So when you see red urine in clinic, um the first thing we I would recommend that you do is do a dipstick analysis and look to see, do you have positive? Are you positive for red blood cells? Are you negative negative for blood? There are quite a few things that can cause red urine without Hugh materia. So that's pigments that are found in some in some foods like beets or rhubarb? Um Certain drugs toxins and metabolites. Um The classic is the brick dust urine that we see um in infants where they have uric acid are your uric acid crystal um deposition on the top of the diaper and that can be quite quite remarkable and can really scare parents. Um If they do, if you are positive for blood on the dipstick then that's when we look at it under the microscope. Um And seeing positive red blood cells on microscopy will confirm you materia negative RbC's on microscopy. Then you have to start thinking about some other things and we'll go into those a little bit more. Um So urine dipstick versus microscopic your analysis. I think everyone should be familiar familiar with this. Right? So the dipstick, we just have the stick, you dip it. There's a chemical reaction that causes a color change on each of those little boxes um versus actually spinning the air and in a centrifuge and examining it with the microscope. So when you have a urine dipstick that is positive for blood um What does that actually mean? And what is this what are these dip sticks actually measuring? Um So what the urine dipstick is actually testing for is the peroxide its activity of hemoglobin or myoglobin. Um So a dipstick that's positive for blood isn't positive for our BCS. It's actually positive for him pigment pigment. So that may reflect true Hugh materia or it may be hemoglobin area or myoglobin area. Like you would see in a patient with rhabdomyolysis or a patient who has um like rbc breakdown. Um The other thing though is that the urine district is super sensitive for blood. So as few as 2 to 3 high power are Vcs for high powered field can actually make that urine dip positive when normal would be less than five. So it's you may just have a normal number of red blood cells but still have a positive urine dipstick. And so for that reason it's really important to remember that just the dipstick on its own is not adequate to diagnose microscopic hair material. What you really do need to do if you are, you know, you get an abnormal dipstick is send that you're in for microscopic your analysis. And this is what we're looking for on microscopy right? That it gives us a lot more information. We can see if there are crystals in the urine. And we can also look and see what is the morphology if there are blood cells. What's the morphology of those are VCS and what do they look like? Um So and that gives us clues about the where the bleeding is coming from. Whether it's from a regular higher at the upper urinary tract or if it's more distal in the urinary urinary tract. Um So we generally see if it's um lower urinary tract bleeding as you see. Mono more fick um Or you more fake red blood cells. They look like little um little saucers or Frisbees in the urine or I'm so sorry. Um But they they may also have this kind of like spiky appearance um that's called they and that's if the if the urine is hyper tonic um You have movement of the water from inside of the R. B. C. S. To the outside. So they kind of looked like you've crumpled them up and then that's normal. Or at least that would still be considered a you more fake red blood cell. On the other hand you have these dysmorphic red blood cells. And that implies that they pass through the through the glomeruli basement membrane and they get these kind of funky funky looks to them. Um Classically we think about campus sites which is the mickey mouse kind of look with the two blobs but you can get all kinds of weird um weird morphology um in glamorous color bleeding. Um So the ap has this really wonderful review article about partnering and Hugh materia. And they have this great um flu chart that I think can be really useful for general pediatricians. Um So that kind of walks you through what should you do once you have a urine dipstick that is positive for him and I'll go through each of these steps individually. So the initial evaluation, right? So you have a patient to for your worried about something or they have a history where it's indicated for you to do your urine analysis and you choose to do urine dipstick in your office. Um And they come up positive for him. So of course the most important thing and this is what I'm gonna where if you only take one thing away from this talk this is what I want you to take away is if you have an abnormal dipstick or a dipstick that's positive for him. Please please please do send it for do send urine for microscopic urine analysis. Um The next step after you have um hey materia. So if you confirm that microscopic crematoria on A. U. A. The next is to confirm persistent he materia. Um And that's with by repeating the your analysis at least twice. And I do recommend you know once you have um a positive way that shows our vcs at least five per high powered field on those repeat us your analyses. I would recommend microscopic rather than repeating dip sticks in the office. Um So and then you should be thinking about sort of what's on your differential for patients who present to you with the material right? There are many causes that are transient or persistent and it may be different and the the your differential should be a little bit different. Um If it is gross versus microscopic. So some really common. Transit humanitarian is really common in pediatric patients. It can occur in the setting of urinary tract infection, exercise, trauma or fever and your arthritis. If there's just irritation of the of the urethra. Um You can also see transient gross Hugh material and patients again after U. T. I. If there's any trauma and instrumentation. Um Stone disease can cause transient gross Hugh materia schistosomiasis. If there's a patient with a history of travel to endemic countries, fortunately we don't really have justice. Soma in the US or hemorrhagic cyst status. Um So you had thinking back to Rebecca, you did her urine dip in your office and she had one plus blood. So you sent her urine sample from microscopic urine analysis. Um The results are abnormal. So you repeat the test one week later and the results are shown. And what is your diagnosis? What do you tell the family about the significance of these findings? So um looking at the your analysis there on the right one plus blood and this time you do see 5 to 10 red blood cells. So less than five is normal. More than five is abnormal. So you would say that this patient has microscopic a material. Um and given that she's otherwise well her vital signs were normal. Um She had no specific complaints. You would call this asymptomatic, isolated microscopic humanitarian. Um so that is defined as microscopic he materia that's not associated with clinical symptoms like pain, disc area urinary frequency urgency hypertension, any systemic symptoms like drink pain and rush. Um And it's a really common finding in pediatric patients with an incidence of up to 4% in childhood and it's probably actually higher than that. It's just that, you know, if we were checking everybody's here and all the time you would probably have an even higher incidence of asymptomatic microscopic hay materia and kids. Um It's usually transient and not associated with significant clinical disease but we do consider it persistent if it's present on three specimens. So um thinking back to Rebecca, if she comes into your office you do that screening urine analysis. You're a dipstick center from you a um and that shows the 5 to 10 R. B. C. S. Bring her back a week or so later send another year analysis for um for microscopy and that one is normal. You say it's transient microscopic you materia commenting. Kids nothing to worry about. Um We'll repeat in a year since she does have an indication to check. Um So but we'll go with a different scenario. So you repeat here that you a third time and the third one is abnormal. So now you've concerned confirmed persistent asymptomatic microscopic material and that does rather other than transient. That requires um a little you know more digging to look for causes. Um So you obtain a further information including a thorough family history. Rebecca's mother reports that she has been told that there was blood in her urine in the past but has never had grocery material. She also reports that multiple family members on her side have osteoporosis. Her father reports that he does not know if he has ever had blood in his urine but that many of his family members have hypertension. There is no known family history of chronic kidney disease or kidney failure. But further work up. Would you order for Rebecca and what is in your differential diagnosis now? So now we have some family history. Um So we definitely and we have persistent microscopic in victoria. So we definitely do need to do further evaluation for Rebecca. So in a patient like Rebecca um and oftentimes you know, they come to me at this point, but these are some things that you can even do in your own office and that's totally reasonable. Um The most important thing I think is getting a really, really good history and particularly family history because what you want to scream for is any inherited renal disease. These patients should have been no function testing um a urine culture to rule out infection. Even if the urine is otherwise bland. And if that in culture does come up positive, we recommend antibiotic therapy um that maybe um bacterial, you know, asymptomatic bacteria and bacterial colonization of the bladder. Um but it could still there maybe there's a little bit of irritation that's causing the material. We would I would ask you to get a calcium to creatinine ratio to look for hyper calc area. Um That is best done fasting if possible. Um imaging, including a renal ultrasound with Doppler is where I would start. Um And then other causes of microscopic unitary include things like coagulation disorders and sickle cell anemia or sickle cell trade. So um you can think about in these patients getting hemoglobin, electrophoresis or coagulation studies based on their history. So if there's a history of abnormal bleeding or bruising, getting cold bags would be a good place to start. Or family history of sickle cell disease. You probably want to do that hemoglobin, electric phrases. Um So going through, I talked a little bit about infection but other things that we're looking for on those tests is um like for the calcium to creatinine. What I'm thinking about and those patients is hey brit calc area. So hyper calcium area is associated with asymptomatic microscopic bacteria. It's probably from you know microscopic trauma from those calcium crystals. Um It's totally reasonable to start with a spot calcium to creatinine ratio rather than doing a full 24 hour urine collection, especially in younger kids, the 24 hour urine collection is um is pretty onerous. Um So for pc PS I recommend um just starting with a spot ratio if that's abnormal you can send them to nephrology and what we can do the 24 hour times collection From normal spot values do vary by age. So you have more higher calcium excretion the younger you are but by the time you're over a year you should your calcium to creatinine creatinine ratio should be less than .2. Now this is um diet dependent. Um So I do again recommend if possible doing that calcium to creatinine ratio fasting. Um And then if it's elevated repeating it um And if it remains elevated then we become concerned for hyper calc area. There's many causes of hyper calc area including all different kinds of um uh you know anomalies and the in bone mineral metabolism and the calcium handling. Um patients who are you know bedridden have higher may have increased calcium reservation from bone and then increased calcium excretion in urine. But the most common cause of hyper calc area is actually idiopathic hyper calc area. This is very common. Seems to be autism will dominant and inheritance um and runs in families and that's hyper calc area with normal calcium intake with normal serum calcium parathyroid hormone phosphorus and vitamin D. Including activated vitamin D. Um These patients may have a family history of known family history of hyper cal syria, microscopic key materia but they shouldn't have a family you know a concerning family history for progressive renal disease. Um And these patients may also have a family history of osteoporosis. So patients with idiopathic hyper calc area do have an increased risk of hyper osteoporosis later in life. So something to keep in mind. Um for our kids what we do for this is you know absolutely we don't want to restrict their calcium intake. They need that for healthy bones. But we do want to reduce their calcium excretion. So that's through um low sodium diet actually reduces urinary calcium excretion, sodium excretion in the urine drives calcium excretion reducing animal protein. There's data that shows that high animal protein intake increases urinary calcium excretion through mechanisms that are still controversial. Um And then these are patients who we want to drink. You know, really good water intake. So we recommend 1 to 1 to 1.5 times maintenance fluid intake for these patients because you really want that you're into keep flowing. Um And the reason for that is we don't want them to get nephrology biases. So patients with hyper calc area right? They do have a risk of having kidney stones. Um Although there are other causes of kidney stones and kidney stones can cause um microscopic or macroscopic or microscopic crematoria. They may actually have microscopic heat the material and be otherwise asymptomatic. If those stones are you know just sitting in the in the renal callouses and not moving too much. Um Or they may present with quite dramatic symptoms, right, severe flink or grain pains, vomiting grossi materia. Um For these patients right when I see a patient with stones we do pain control um and urgent neurologic consultation if obstructed. Um And then we increase their fluid intake during their while they're passing a stone. Um chronically the management of kidney stones is really dependent on risk factors. We assess those through 24 hour urine collection family history. Sometimes genetic testing. Um But all stone formers. We do recommend high fluid intake and low salt, low salt diet and low animal protein. So just like the hyper calc area patients that some of the general management, in addition to addressing specific risk factors are the same of other common causes of Hugh material. Whether transient or gross nutcracker syndrome, sometimes known as March crematoria is a surprisingly common thing that we see. Um That's an interesting kind of anatomical defect where there's entrapment of the distal end of the left renal vein between the aorta and the S. M. A. And what happens is it causes general, these patients have left flank pain and microscopic or gross c materia and that's usually exacerbated by exercise. So uh kind of a classic presentation is a patient who has done um You know I had a vigorous vigorous activity. Maybe a teenager, a teenager who has run you know a half marathon, develops left sided um flank pain and then grocery material. It's much more common in girls than boys. Um And boys may actually have very castle on that same side on the left side from distention of the ganado vein. Um We also sometimes see this um Similar to like superior military artery syndrome that causes abdominal pain. Um We you can also see nutcracker syndrome after weight loss. Um And we diagnosed it um With renal ultrasound with Doppler. So that's why part of our initial work up for a patient with persistent he material. Is that renal ultrasound with the Doppler um C. T. Or M. R. Angiography is reserved for cases where the Doppler is equivocal. Um We don't really want to expose patients to radiation or to um or to contrast if we don't have to. Um And particularly a nutcracker syndrome. The management is usually conservative. Um Sometimes vascular surgery gets involved but only if there's persistent symptoms for at least two years and usually only if those symptoms are pretty severe. Um This is just a few uh images from a ct venogram showing nutcracker phenomenon on the left side. You can see that, I don't know if you can see my mouse or not. But the left renal vein is here and it's here's the aorta and the superior measurement eric artery is up here this right here. So you can see how the left renal vein is compressed and distended between these two. And then here is the Benadryl order genital vein. Um That is very very distended. And so this is a patient where I would expect to also see a very conceal generally. Um Like I said March or March Cemetery or nutcracker syndrome. We don't really do too much about it unless that's um persistent for two years. And then those symptoms are really troublesome um continuing in the vein of boys and particularly teenage boys. Um idiopathic your interrogation. Um It is also known as idiopathic hemorrhagic. Your arthritis of childhood. It's a very common cause of gross human materia. Um in Children generally adolescents. And it's much much more common in boys than girls. I've never seen it in a girl. Um It's recurrent. It's characterized by recurrent episodes of painless gross human materia. Um And that's um Hugh material that occurs at the end of victory shin. They have no systemic symptoms. The real function is normal. The kidneys are normal. Um Some patients may have diphtheria avoiding dysfunction um in really severe cases urethral stenosis can develop. That's very very rare. This is generally self limiting. Um These are patients which should tip you off if you have a again particularly a teenage boy who is complaining of blood in his pee. Um asking if there is blood spotting in the underwear is a sign that that blood is coming from the urethra and you should be thinking about um hemorrhagic your arthritis, childhood or idiopathic ratio. I've heard it described as sort of like a nosebleed from your urethra. Um It usually goes away on its own. It's not something this is a case for you know reassurance. Um is appropriate. Reassurance and just monitoring to make sure that it resolves again more common than teenage boys. So um asking them not to manipulate that area. Too much may also be helpful. Um Now kind of moving on to some familiar things into some areas where we start to get more concerned. Um I'm gonna talk briefly about thin basement membrane defraud apathy. Um so thin basement membrane disease um presents is asymptomatic, persistent hey materia usually microscopic though sometimes patients can have episodes of microscopic or gross cemetery mia materia. Um It is generally uh an autism more dominant and inheritance. Um It used to be called benign, familiar with the material, but benign is in quotes, big quotes um Because 30% of these patients will develop chronic kidney disease and hypertension. Yeah. And generally there is a positive family history of human material but there may be a family history of kidney failure or chronic kidney disease as well. Um uh The most common cause of this is a hetero cycles defect in the college in four a three or four a four um gene that's those genes contribute to the collagen formation that's present in the memory of her basement membrane. Um and that's what causes that thinning. So on the left side there, on the figure on the, on the right, you can see a normal glomeruli basement membrane. Um on the right is a thin one, this is a diagnosis that used to be only possible through um uh renal biopsy. But now these are patients where we would do genetic testing and oftentimes if I have a patient who has persistent microscopic he materia. Um and you know, no clear cause that I can find. I will often and particularly if there's family history, I will offer these patients genetic testing to look for something like the basement membrane. Therefore apathy kind of in the same vein, there's also hereditary nephritis and that's commonly known as output syndrome that we're moving away from Eminem's. Um that is also caused by mutations and type for college and most commonly college and for A five. Um but you can also have mutations in college and for a three year college in four A four and those are the same mutations that are seen in a large number of patients within basement membrane. Therefore apathy. No, this presents um initially with asymptomatic microscopic crematoria. Um But patient affected patients progress to hypertension protein area and chronic kidney disease. Um And all affected males with excellent her hereditary nephritis will invariably progressive. End stage renal disease. Um Other extra renal manifestations that should tip you off to hereditary in arthritis or hearing loss. Um And then anterior linda cohn is that's where there's protrusion of the central lens surface um into the capsule, into the up to interior capsule of the eye. Um That is pathan demonic for excellent hereditary nephritis. Um So thin basement member enough empathy and hereditary nephritis really exists on a spectrum of disease. So you can have with this even though the biopsy findings are a little bit different. You actually an hereditary in the friends. You actually see this kind of thin and split and large in the basement membrane because that collagen is just not functional. Um But it's important to sort of know that these things are they're not really separate diseases so much that kind of exist on a spectrum. And in fact patients with thin basement remembering the fear apathy right If with others the more dominant inheritance if they have a child with somebody with the same mutation or you know a mutation in the same in college and for um and they pass on to abnormal copies of that gene. Then that patient may develop hereditary nephritis and may have a more more severe kidney disease later in life. So it's really important not to just say, you know there's Hugh material and the family nobody's had kidney disease. It's nothing to worry about. Um Because thin basement membrane naturopathic can cause significant chronic kidney disease and can have um implicates significant implications for reproduction and for offspring. Um Another common cause of human urea would be something like A G A. N. F. Apathy. And here again I'm sort of transitioning into the gloom, irregular kind of human area from apathy. Um is a relatively common um because of episodic heat, grocery material and patients um and this often occurs after you are I no some patients may also present with microscopic you materia and protein area. Um And in rare cases patients with jennifer apathy can have rapidly progressive gram really nephritis and renal failure. Um importantly. Um this is normal complement to mix. So it is due to antibody complex formation or immune complex formation that you complement levels tend to be normal in these patients and we diagnose them by biopsy. This is another one that has a tendency we see it in families. Um There is some genetic predisposition but it's not such a clear you know medallion pattern of inheritance like hereditary nephritis. Um So thinking about patients with I. G. And empathy potentially with hereditary nephritis right? Those patients may present to you with symptomatic Hugh materia. Um Or or they may have extra renal symptoms. So what we want you to look for in any patient who comes in complaining of either growth of grocery materia or where you find Hugh materia on the on the dipstick. Is do they have hypertension? Do they have protein area? Is there decreased renal function and the electrolyte abnormalities? And then um extra renal symptoms like fever, rash, joint pain, hearing loss, vision issues. A Dema especially. But these are patients that you should refer to us pretty quickly and you really want to be careful with these kids. They may need emergent evaluation particularly if they have a Dema you know evidence of fluid overload or if they have hypertension. Um Or if they're you know if you send them for labs and they have elevated creating these are patients you should probably just sent to the year. Um So going back to Rebecca right so she's now seven years old. She presents to your clinic for a sick visit. Her father reports that her eyes were puffy when she woke up this morning and her urine looks really dark Provide all signs are remarkable for a blood pressure of 125 over 86. Which you confirm using um using a manual reading and the results of her point of care ultra your analysis are shown. So now you can see she has significant protein area and hematite area. Um What further work up would you perform in this patient? What are you thinking about? Right. So you can have protein, very anti materia and infection. But urine that's quite dark or coca cola colored should tip you off to a glamorous color process. And in particular if there's hypertension. And so in a patient like Rebecca, I would be worried about an acute glomeruli linda, Fridays. So you can um so the acute nephritis is characterized by humanitarian and protein area decreased primarily filtration rate, increased blood blood pressure and dysmorphic appearing red blood cells or red blood cell casts. Red blood cell casts are from two from red blood cells in the renal tubules and they kind of clump together with things like highland or other proteins. Um and form these um these casts of the of the two gills um you can have glamorous celebrities without having all of these pieces. But the more of them you have together, the higher your risk that it is going very well in a phrase. Yeah. And the things like I said that should really worry you are any patient with a decreased um Gloria, the filtration rate, high blood pressure or significant part in area particularly with fluid overload. The most common cause of acute glamorously nephritis and Children is um post infectious um grammarian and arthritis that's usually associated with streptococcus A. Um So that can be after um strep throat or after a strep skin infection tends to present a little bit quicker after strep throat versus the skin infection for whatever reason. Um it's most common in ages 5-12. And these patients will have hypoxia complimenting me a so they have low C. three. The characteristically they have normal c. four. Um usually these patients do quite well. The treatment is supportive. Um the grossly material usually resolves in 123 weeks protein area typically resolves in the acute period. Um And then we watched the C. Three levels and they should normalize within three months. Um So and then like I said this prognosis for these patients is excellent. So any one time you were suspicious for post infectious. These are kids that we would want to see in clinic and pediatric nephrology because sometimes they do have significant Britain area. They may have a Dema and fluid overload and they may have hypertension and require things like diuretics or blood pressure medications in that acute period. Um They can actually have microscopic human area for even years after presentation. It can take quite a long time to um to resolve. But that is still as long as the prison area improves. As long as the renal function is better. We don't really worry too much about persistent microscopically materia and these patients and generally that resolves within about a year. Um Now we watch the C. Three levels the compliment three levels in these patients. Um And if they don't normalize after three months we do get a little bit more nervous. And then the other thing is that um if you have a patient who has been diagnosed with post infectious G. N. Um sorry my slides are not advancing and they come in with post infectious G. N. For a second time that should be raving waving huge red flags in your face. Um Post infectious grammarian and this really shouldn't recurve. Um But there are other more um rarer diseases um that called a member. No proliferated glamorous alan arthritis that can mimic post infectious GNN. And it can actually be triggered by episodes of M. P. G. N. Proliferated glamour really nephritis can actually be triggered by infection. So um it's anytime you think you're patient may have a second episode of post infectious material nephritis want to make sure that they are being followed by a nephrologist. And this is a that's a time when I would do a biopsy to look for one of these other kidney diseases another common cause of blueberry and nephritis in pediatrics um is uh nga nephritis previously known as Inaction Lane purpura. And I'm sure every pediatrician has seen this at least a few times. Um So these patients universally present with a vascular it'd purported crash usually on the lower extremities. Um they can have drink pain and abdominal pain and about half of them will have renal involvement. And I. G. A. What we call a G. A. Nephritis. Um Most patients who will develop renal involvement present within two months of diagnosis and nearly all within six months. So there are some screening recommendations. So they recommend following basically doing weekly um urine testing um for about six months just to make sure that there is no blood or protein in the air. And these are patients where uh huh. Doing urine dip sticks is actually appropriate. Right? If you see something abnormal you can send them for um for microscopic your analysis. But because we're just you know, doing screening um dip sticks are fine. Um and patients who present with renal anomalies at the time of diagnosis. Um then we're doing a little bit more like at least monthly blood pressure and creating measurements. Most patients with, I gave escalators even if they have renal involvement. Um the prognosis is quite good. Um But we do have some that require further intervention or that may have um chronic may develop chronic kidney disease and renal dysfunction. Um So then I just wanted to kind of go over some of those common things. Of course I didn't hit all your whole differential for Hugh material. And I lift off a few things like lupus, right. Um but these are some of the more common things that you may see in clinical practice. Um So in summary transient microscopic humanitarian is a common benign finding in pediatric patients. But persistent microscopic Hugh materia requires further evaluation and that can be initiated in the primary care setting. Um That's like I said, you know, real function testing, imaging, doing that calcium to creatinine ratio, making sure you're doing the mic the microscopic your analysis. Um and then any humanitarian, the setting of preliminary or systemic symptoms should prompt urgent evaluation and specialty referral. Um and in the case where you have a patient who appears fluid overloaded his hypertension um that's a patient who should probably be seen emerging lee potentially in a pediatric emergency room. Um So if you have a patient that you're worried about, please send them our way. So here's some information on referring to UCSF pediatric nephrology. Um And remember so we have san Francisco and Oakland clinics but I have um I am now in clinic in Modesto basically once a week on Thursdays and I am happy to take patients from the from the valley. If that's if it's easier for them to come to Modesto. Great, thank you. Dr Black. We do have one question in here and then we will hopefully give time for other people to submit questions that they have any. Um Diane Hallberg asked what is the interval between urine checks? Oh okay. That's a great question. So are you talking um I assume the interval between urine checks to confirm persistent microscopic Hugh materia and you should wait at least a week between those checks is the general recommendation. Great thank you. I'm gonna pause for a manages to let people type in a question if they have any. I do want to let all the attendees know. We will be sending out dr black slides to all the attendees and so you can reference it. Um If you have any further questions and reach out to her also. Um And you can expect that in your inbox later this week. Another question just came in. Do you have parents used the urine strips at home to follow microscopic human urea? I personally generally don't. But that is an option if they can do the dips at home and if they're comfortable with it. Um We um frequently have patients check for protein at home. Um but they haven't done I haven't done urine dips at home to look for a few materia. Great. Thank you. Give it one more moment. If any additional questions come in. Thank you so much for speaking with us today. It was a great talk. We'll give people a couple more minutes um back on their lunches and we hope that you join us next week for our CMi lecture on headaches. Thanks again. Dr black. And everybody. We hope you have a great Tuesday. Bye. Thank you so much.