Objectives:

• Evaluate a child with gross hematuria
• Generate a differential diagnosis for hematuria and proteinuria in a child
• Describe the usual course of post-streptococcal glomerulonephritis

A 10-year-old male presents with his mother, who appears very anxious. She reports several episodes of red-brown urine this morning. The patient reports feeling a bit tired, but otherwise has no complaints. At age 5, he had myringotomy tubes placed bilaterally, but his past medical history is otherwise unremarkable. He takes no medications. On review of systems, he reports a sore throat that completely resolved a few days ago.

On exam you find a pleasant young man in no acute distress. He is afebrile. His blood pressure is 140/94 mm Hg, and he has trace pretibial edema. The remainder of the exam is unrevealing.

1		You order all of the following tests EXCEPT:
			A)	Urinalysis.
			B)	Abdominal x-ray.
			C)	CBC.
			D)	Plasma electrolytes.
			E)	BUN and creatinine.

Urinalysis shows 2+ blood, 2+ protein, specific gravity 1.015, and numerous red blood cells with red cell casts. BUN is 35 mg/dL and creatinine is 1.8 mg/dL. CBC, coagulation studies, and electrolytes are pending.

2		At this point, all of the following should be considered in the differential diagnosis EXCEPT:
			A)	Minimal change disease.
			B)	Henoch-Schonlein purpura.
			C)	Post-streptococcal glomerulonephritis.
			D)	IgA nephropathy.
			E)	Membranoproliferative glomerulonephritis.

CBC, coagulation studies, and electrolytes are all normal. Throat culture grows group A beta-hemolytic streptococcus.

3		Which of the following statements best describes the usual course of post-streptococcal glomerulonephritis?
			A)	Most patients progress to renal failure.
			B)	After resolution of the initial episode, recurrent episodes of gross hematuria are common.
			C)	In most cases, hypertension and uremia subside within 1–2 weeks.
			D)	In most cases, hypertension is persistent and requires treatment.
			E)	Adults tend to recover more quickly than children.