FCPS MCPS IMM MD Paediatrics TOACS

Observed Station | CPSP Format | 8 minutes

⏱️ TIME REMAINING
08:00
πŸ“‹ Data Interpretation Station

Hematuria – Clinical Scenarios with Lab Data

You will be presented with 12 clinical scenarios of children with hematuria. For each, interpret the lab data and provide the most likely diagnosis, mechanism, and next step. , .

Glomerular: Nonglomerular IgA: Alport:
Case 1 A 10-year-old boy presents with cola-colored urine, periorbital edema, and hypertension.
UrinalysisGross hematuria, RBC casts, protein 2+
Serum Creatinine1.2 mg/dL
C3 ComplementLow (30 mg/dL)
C4 ComplementNormal
ASO TiterElevated
Blood Pressure145/92 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Acute poststreptococcal glomerulonephritis (APSGN).
β€’ Evidence: Latency 1-2 weeks post-strep, gross hematuria with RBC casts, hypertension, edema, low C3 (classic pathway), normal C4, elevated ASO.
β€’ Next step: Monitor BP, fluid/salt restriction, furosemide if edema, treat hypertension. C3 normalizes in 8-10 weeks.
Case 2 A 12-year-old girl with recurrent gross hematuria occurring 1-2 days after upper respiratory infections. She is otherwise well.
UrinalysisGross hematuria, no RBC casts, mild protein (trace)
Serum Creatinine0.8 mg/dL
C3 ComplementNormal
C4 ComplementNormal
Serum IgAElevated
Blood Pressure110/70 mm Hg
βœ… Model Answer:
β€’ Diagnosis: IgA nephropathy (Berger disease).
β€’ Evidence: Synpharyngitic hematuria (1-2 days post-URI), normal C3, elevated serum IgA, normal BP, no renal dysfunction.
β€’ Next step: Monitor BP, proteinuria, creatinine. Renal biopsy if persistent proteinuria (>0.5 g/day) or hypertension.
Case 3 A 6-year-old boy with palpable rash on lower extremities, abdominal pain, and hematuria.
UrinalysisMicroscopic hematuria, protein 1+
Serum Creatinine0.7 mg/dL
C3 ComplementNormal
C4 ComplementNormal
Platelets300,000/Β΅L
Blood Pressure105/68 mm Hg
βœ… Model Answer:
β€’ Diagnosis: IgA vasculitis (Henoch-SchΓΆnlein purpura) with nephritis.
β€’ Evidence: Palpable purpura, arthritis, abdominal pain, hematuria, normal platelets (excludes ITP), normal C3.
β€’ Next step: Monitor BP, urinalysis weekly. If proteinuria >0.5 g/day, start ACE inhibitor. Renal biopsy if nephrotic-range proteinuria.
Case 4 A 14-year-old boy with persistent microscopic hematuria and sensorineural hearing loss.
UrinalysisMicroscopic hematuria, no protein
Serum Creatinine0.9 mg/dL
AudiometryHigh-frequency sensorineural hearing loss
OphthalmologyAnterior lenticonus
Family HistoryMaternal uncle with ESKD
Blood Pressure118/72 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Alport syndrome (X-linked COL4A5 mutation).
β€’ Evidence: Microscopic hematuria, sensorineural hearing loss, anterior lenticonus, X-linked family history (maternal uncle).
β€’ Next step: Skin biopsy (absent Ξ±5 chain of type IV collagen) or genetic testing (COL4A5). ACE inhibitor if proteinuria develops.
Case 5 A 7-year-old girl with recurrent gross hematuria, dysuria, and abdominal pain. .
UrinalysisGross hematuria, no protein, no casts
Serum Creatinine0.6 mg/dL
Serum Calcium9.5 mg/dL
Spot Urine Ca:Cr0.35
24-hour Urine Calcium5.2 mg/kg/day
Blood Pressure108/70 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Idiopathic hypercalciuria.
β€’ Evidence: Recurrent hematuria, Ca:Cr >0.2 (>2 years), 24-hour urine Ca >4 mg/kg/day, normal serum calcium, normal ultrasound.
β€’ Treatment: High fluid intake (2-3 L/day), low sodium diet, normal calcium intake. Hydrochlorothiazide if recurrent symptoms.
Case 6 A neonate with gross hematuria, and left flank mass. Born after a difficult delivery with perinatal asphyxia.
UrinalysisGross hematuria
Platelet Count40,000/Β΅L
Serum Creatinine1.0 mg/dL
Blood Pressure65/40 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Renal vein thrombosis (neonatal).
β€’ Evidence: Perinatal asphyxia, gross hematuria, flank mass, thrombocytopenia, absent venous flow on Doppler.
β€’ Treatment: Supportive care. Anticoagulation (heparin) if bilateral or IVC extension. Monitor renal function.
Case 7 A 6-year-old boy with sickle cell disease presents with gross hematuria, left flank pain, and fever.
UrinalysisGross hematuria, no casts
Hemoglobin8.0 g/dL
Serum Creatinine0.8 mg/dL
CT UrographyMedullary clefts, sloughed papillae
Blood Pressure110/70 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Papillary necrosis (sickle cell nephropathy).
β€’ Evidence: Sickle cell disease, gross hematuria, flank pain, CT showing medullary clefts and sloughed papillae.
β€’ Treatment: Hydration, pain control, avoid NSAIDs. If severe hematuria, consider Ξ΅-aminocaproic acid or desmopressin.
Case 8 A thin 14-year-old girl with intermittent gross hematuria, and left flank pain . Symptoms worse after exercise.
UrinalysisGross hematuria, no casts, trace protein
Serum Creatinine0.7 mg/dL
Doppler UltrasoundLeft renal vein compression between aorta and SMA
Blood Pressure108/68 mm Hg
Body Mass Index17 (underweight)
βœ… Model Answer:
β€’ Diagnosis: Nutcracker syndrome (left renal vein compression).
β€’ Evidence: Thin adolescent, left flank pain, hematuria, orthostatic proteinuria, Doppler showing LRV compression.
β€’ Treatment: Conservative (weight gain, hydration). If severe hematuria/pain, consider surgical intervention (LRV transposition).
Case 9 A 4-year-old girl with gross hematuria, dysuria, and frequency. She has a palpable mass at the urethral meatus.
UrinalysisGross hematuria, WBCs +
Serum Creatinine0.5 mg/dL
Blood Pressure100/65 mm Hg
Urine CultureNegative
βœ… Model Answer:
β€’ Diagnosis: Urethral prolapse.
β€’ Evidence: Prepubertal girl, donut-shaped friable mass at urethral meatus, hematuria, dysuria.
β€’ Treatment: Topical estrogen cream, sitz baths. Surgical reduction if severe or urinary retention.
Case 10 A 7-year-old boy with microscopic hematuria found on routine urinalysis. He has normal hearing and vision.
UrinalysisMicroscopic hematuria, no protein, no casts
Serum Creatinine0.6 mg/dL
AudiometryNormal
OphthalmologyNormal
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Blood Pressure105/68 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Thin basement membrane disease (benign familial hematuria).
β€’ Evidence: Isolated microscopic hematuria, normal hearing/vision, autosomal dominant family history, normal renal function.
β€’ Next step: Reassurance. Electron microscopy shows diffuse GBM thinning. No treatment needed. Monitor annually.
Case 11 A 5-year-old boy with gross hematuria, left flank pain, and a palpable abdominal mass. He has hypertension.
UrinalysisGross hematuria, no casts
Hemoglobin10.5 g/dL
Serum Creatinine0.8 mg/dL
Abdominal UltrasoundLarge left renal mass
Blood Pressure135/85 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Wilms tumor (nephroblastoma).
β€’ Evidence: Abdominal mass, hematuria, hypertension (renin secretion), palpable mass.
β€’ Next step: CT chest/abdomen, surgical nephrectomy, chemotherapy based on staging (NWTS/COG protocol).
Case 12 A 6-year-old boy known case of leukemia , now on treatment, presents with gross hematuria, dysuria, and suprapubic pain.
UrinalysisGross hematuria, WBCs +, no bacteria
Serum Creatinine0.6 mg/dL
Urine CultureNegative
Blood Pressure110/70 mm Hg
βœ… Model Answer:
β€’ Diagnosis: Hemorrhagic cystitis (cyclophosphamide-induced - acrolein metabolite).
β€’ Evidence: Cyclophosphamide use, gross hematuria, dysuria, sterile urine.
β€’ Treatment: Hydration, bladder irrigation. Prevention: mesna + hydration before and after cyclophosphamide. Long-term risk: bladder cancer.

⚑ Quick FCPS‑style MCQ

A child with recurrent gross hematuria 1-2 days after URI, normal C3, and mesangial IgA deposits on biopsy. The most likely diagnosis is:

A. IgA nephropathy B. Poststreptococcal glomerulonephritis C. Alport syndrome D. Thin basement membrane disease
⚠️ Key concept: Hematuria – Nelson Ch 558
β€’ Glomerular: Tea/cola urine, RBC casts, dysmorphic RBCs (acanthocytes), proteinuria, hypertension, edema.
β€’ Nonglomerular: Bright red/pink urine, clots, normal RBC morphology, minimal proteinuria.
β€’ IgA nephropathy: Synpharyngitic hematuria (1-2 days post-URI), normal C3, mesangial IgA deposits.
β€’ Alport syndrome: Hematuria + sensorineural hearing loss + anterior lenticonus. X-linked COL4A5.
β€’ Hypercalciuria: Spot urine Ca:Cr >0.2. Treat with hydration, low sodium, thiazide.
β€’ APSGN: Latency 1-2 weeks post-strep, low C3 (returns 8-10 weeks).
β€’ Thin basement membrane: Benign familial hematuria, normal prognosis.

🎯 Examiner Scoring Checklist

  • β€’ Correctly identifies glomerular vs nonglomerular hematuria
  • β€’ Recognizes IgA nephropathy (synpharyngitic, normal C3)
  • β€’ Identifies Alport syndrome (triad: hematuria, deafness, ocular)
  • β€’ Recognizes hypercalciuria (Ca:Cr >0.2)
  • β€’ Identifies poststreptococcal GN (low C3, latency)
  • β€’ Recognizes vascular causes (RVT, nutcracker, sickle cell)
πŸ“Œ Key Hematuria Differentiation:
β€’ Glomerular: RBC casts, dysmorphic RBCs, proteinuria, hypertension
β€’ Nonglomerular: Clots, normal RBCs, no proteinuria
β€’ IgA: Post-URI hematuria, normal C3
β€’ APSGN: Post-strep, low C3, latency 1-2 weeks
β€’ Alport: Hematuria + deafness + family history
β€’ Hypercalciuria: Ca:Cr >0.2, normal ultrasound
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