To Pee Or Not To Pee

Screening Urinalysis in Healthy Children

Relevant Disclosure

Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial

relationships with commercial interests within the last 12 months.

Pascale H Lane, MD

I have no relevant financial relationships or affiliations with commercial interests to disclose.

Learning Objectives

At the end of the presentation the audience should be able to:

1. List important characteristics of screening programs2. State the current AAP recommendations for screening

urinalysis in otherwise healthy, asymptomatic children

Turn To Your Neighbors…

• Develop a consensus as a group regarding when you would screen children with no health issues or complaints with urinalysis

• You have 5 minutes…

Characteristics of Screening Programs

• Relatively simple tests with reproducible results

• High level of sensitivity and specificity• Effective treatment for the condition

Is UA Simple?

• Dipstick quite simple• Collecting urine can be problematic

Is UA Reproducible?

Proteinuria• Prevalence 6.3%• 89% false + or transient

Hematuria• Prevalence 1.6%• 88% false + or transient

Much variation, especially for proteinuria, can be minimized by using first morning voids.

Is UA Sensitive?

YES!“Trace” is negative…

Is UA Specific?

• Something in the urine, but no indication of cause or meaning.

Is There Effective Treatment?

• For some disorders, yes• But little or no evidence that early detection

improves prognosis of most chronic kidney diseases

National Mass School Screening Urinalysis Programs

Year Instituted

Country Frequency of Screening

Specimen Follow-up

1974 JapanBiannual 1974-79Annual 1979-present

Dipstick on midstream first morning specimen

Repeat UA in all patients with positive test

1990 Taiwan Biannual 1990-present

Dipstick on first morning specimen(Also BP measurement)

Repeat UA 10-15 days after initial positive test

1998 Korea Annual 1998-present

Dipstick on first morning specimen

Repeat UA after initial positive test with microscopic exam if both tests positive

Clin J Am Soc Nephrol 4:509, 2009

What About US?

Pediatric End-Stage Kidney Disease

United States 2010-2012Glomerulonephritis 23%Secondary GN/Vasculitis11%Congenital 38%

Glomerulonephritis in Japan1978-1980 69%1999 35%

Did screening do this?United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the

United States. National Institutes of Health, National Institute of Diabetes and Digestive and

Kidney Diseases, Bethesda, MD, 2014. Clin J Am Soc Nephrol 2:1360, 2007

American Academy of Pediatrics (AAP) Recommendations Over Time

1977 – 1995 InfancyEarly childhoodLate childhoodAdolescence

Costs of Screening UAs for 2000 Children

Components Cost (Mid-1990s)

Initial screening dipstick • 2000 dipsticks• Urine bags for children <12m of age $1290

Proteinuria Evaluation

• Second dipstick (126)• For 13 patients with persistent

proteinuria:First morning UA with microCBC; CMPReferral to Nephrology

$1968-$2962

Hematuria Evaluation

• Second dipstick (32)• For 4 patients with persistent

hematuria:First morning UA with microCBC; CMPReferral to Nephrology

$602-$908

Pediatrics 100:919, 1997

American Academy of Pediatrics (AAP) Recommendations Over Time

1977 – 1995 InfancyEarly childhoodLate childhoodAdolescence

Of note, no urinalysis recommended for sports participation…

2007 – Present None

1995 – 2007 PreschoolAdolescence

What About Sports?

• Most children with chronic kidney disease will benefit from physical activity– In adults, sedentary lifestyle at initiation of dialysis

results in 62% greater risk for death– Lowers blood pressure and helps maintain healthy

body weight• Probably wise to limit exertion in patients with

severe hypertension until controlled

Objectives RevisitedList important characteristics of screening programs

Relatively simple tests with reproducible resultsHigh level of sensitivity and specificityEffective treatment for the condition

State the current AAP recommendations for screening urinalysis in otherwise healthy, asymptomatic children

None