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Pediatr Integral 2025; XXIX (4): 311.e1 – 311.e2
M. Sánchez Martín*, M. Gómez de Pablos Romero**
*Adjunto de Pediatría del Hospital Universitario La Paz. Madrid. **Adjunto de Pediatría de la Clínica Universidad de Navarra. Pamplona
43. Resident-attending in the ED: Hematuria
Resident: María Sánchez Martín. Adjunto de Pediatría del Hospital Universitario La Paz. Madrid
Attending/Mother: Mónica Gómez de Pablos Romero. Adjunto de Pediatría de la Clínica Universidad de Navarra. Pamplona
Resident: Good afternoon Dr. Cooper. Could I tell you about a patient I just saw?
Attending: Of course, Emily.
Resident: It’s a 10-year-old boy with red brownish gross hematuria for 3 days. He says he has been feeling more tired lately, but doesn’t report pain, dysuria, urgency, fever, skin rash, arthralgia or any other symptom. He had an upper respiratory tract infection 2 weeks ago that got better with antibiotics and no recent trauma, vigorous exercise or travel. Apart from the antibiotic treatment, he hasn’t taken any other medication. He has no other relevant medical history and his vaccinations are up-to-date.
Attending: What about his vital signs and physical examination?
Resident: His HR is 90 bpm, RR 18 bpm, BP 150/95 mmHg, capillary refill time 2s and temperature 36.2ºC. He has pitting edema on both ankles and lower legs, painless to palpation and no skin lesions. He doesn’t have trouble breathing and his cardiopulmonary auscultation is normal. The abdomen and genitals are normal. He doesn’t show lymph node enlargement.
Attending: Have you asked for any lab tests?
Resident: Yes, a urinary dipstick test, which is positive for blood and proteins and negative for leukocyte esterase and nitrite, a microscopic examination of the urine sediment that has shown red blood cells and a urine culture.
Attending: So what diagnosis do you have in mind?
Resident: I believe this is a case of nephritic syndrome. Hypertension, edema and proteinuria suggest a glomerular source for the hematuria. The past upper respiratory tract infection could suggest a poststreptoccocal glomerulonephritis, a postinfectious glomerulonephritis or an IgA nephropathy.
Attending: I agree with you, Emily. Therefore, we should call the pediatric nephrologist and check his blood labs, including complete blood count, coagulation, electrolytes, serum creatinine, urea and albumin, liver enzymes, ESR and CRP. You can also perform a strep test and we should also order a chest X-ray to rule out pulmonary edema. Tomorrow, when it’s available, he will also need complement C3 and C4, ASLO titer and ANA, anti-dsDNA and ANCA testing, as well as an abdominal ultrasound to check his kidneys.
Resident: Yes Dr. Cooper, I’ll order the tests right away, call the nephrologist and explain to his mother that he will need in-hospital management.
Attending: Thank you Emily. Ask the nurse to place an IV line, but don’t start him on IV fluids until the nephrologist evaluates him because he will need fluid restriction. This patient is likely to have a decreased glomerular filtration rate and retention of sodium and water, resulting in an elevated blood pressure and edema. You can start him on IV furosemide 1 mg/kg every 8 hours and monitor his urine output and water balance. He will also need IV hydralazine to treat the hypertension at 0.15 mg/kg every 8 hours for starters.
Resident: OK. Do you think he will need a kidney biopsy?
Attending: The need for a kidney biopsy will depend on the lab results.
Resident: I see. Thank you Dr. Cooper. I’ll update you when everything is done.
…
Resident: Hello. Your son’s blood in the urine is called hematuria. This, associated with proteins in the urine, elevated blood pressure and leg swelling, is called nephritic syndrome. It is caused by a kidney glomerular disease called glomerulonephritis. The kidneys, which are the organs that make urine, have two parts, a part that filters blood and removes waste and excess salt and water and a part that collects urine. In glomerular disease, the part of the kidney that filters the blood doesn’t work normally and as a result, substances that shouldn’t be in the urine, such as blood and protein, can get into the urine.
Mother: Why did he get glomerular disease?
Resident: There are different types of glomerular disease with different causes. That is why we have to draw some blood, place an IV line and perform other tests. Most glomerulonephritis are due to an autoimmune response of the body to a variety of different agents including previous infections.
Mother: What is the treatment?
Resident: It depends on the symptoms, the cause and how quickly it happened. For instance, people with mild glomerular disease or a glomerular disease that appeared after an infection might not need specific treatment and only blood and urine tests over time to follow their condition. However, in other cases, different medications or more complex treatments are needed. Nevertheless, it’s a bit too early to talk about all that without knowing what your son has exactly. For now, he will have to be admitted to the hospital to continue further studies and receive general symptomatic treatment and over the days the nephrologist will inform you as the pending results come out.
Mother: Alright, thank you Doctor.
KEY WORDS
Hematuria: hematuria.
Doesn’t report pain: no refiere dolor.
Urgency: urgencia miccional.
Ankles: tobillos.
Nephritic syndrome: síndrome nefrítico.
Glomerular source: origen glomerular.
Glomerulonephritis: glomerulonefritis.
ESR (Erythrocyte Sedimentation Rate): velocidad de sedimentación eritrocitaria/globular.
CRP (C-reactive protein): proteína C reactiva.
Glomerular filtration rate: tasa de filtración glomerular.
For starters: para empezar.
Kidney biopsy: biopsia renal.
Kidney glomerular disease: enfermedad renal glomerular.
Filters (to filter): filtrar.
Removes waste (to remove waste): eliminar residuos.
Collects (to collect): recoger.
Draw some blood (to draw blood): sacar sangre.
Further studies: estudios adicionales.
Over the days: a lo largo de los días.
Short stature