Differential Diagnosis for Painful Hematuria with Proteinuria

Single Most Likely Diagnosis

• Acute Glomerulonephritis (Post-Streptococcal Glomerulonephritis)
  • Most common cause of this presentation, especially in children
  • Typically occurs 1-2 weeks after streptococcal infection
  • Classic triad: hematuria, proteinuria, and hypertension
  • Pain often from inflammation and distension of the renal capsule
  • Usually self-limiting but can cause significant symptoms

Other Likely Diagnoses

• IgA Nephropathy (Berger's Disease)

  • Most common primary glomerulonephritis worldwide
  • Often presents with gross hematuria following upper respiratory infection
  • Variable proteinuria, can be painful during episodes of gross hematuria
  • More common in young adults

• Urinary Tract Infection/Pyelonephritis

  • Bacterial infection can cause both hematuria and proteinuria
  • Typically presents with flank pain, dysuria, frequency, urgency
  • Fever and elevated white blood cell count often present
  • Proteinuria usually mild to moderate

• Nephrolithiasis (Kidney Stones)

  • Causes severe colicky flank pain
  • Hematuria common due to mucosal damage from stones
  • May have mild proteinuria due to associated inflammation
  • Pain typically intermittent and radiating to groin

• Lupus Nephritis

  • Renal manifestation of systemic lupus erythematosus
  • Can present with hematuria, proteinuria, and renal pain
  • Often accompanied by other systemic symptoms (rash, joint pain, fatigue)
  • More common in women of childbearing age

Do Not Miss (Potentially Deadly)

• Rapidly Progressive Glomerulonephritis

  • Rapid decline in kidney function over days to weeks
  • Can lead to end-stage renal disease if not treated promptly
  • Various etiologies including ANCA-associated vasculitis, anti-GBM disease
  • Requires immediate immunosuppressive therapy

• Malignant Hypertension with Renal Involvement

  • Severely elevated blood pressure damaging kidneys
  • Can cause hematuria, proteinuria, and renal pain
  • Medical emergency with risk of stroke, heart failure, and renal failure
  • Often presents with headache, visual changes, and altered mental status

• Renal Vein Thrombosis

  • Clot in renal vein causing congestion and pain
  • Risk factors include nephrotic syndrome, hypercoagulable states
  • Can lead to renal infarction if not treated promptly
  • May present with sudden flank pain and worsening proteinuria

• Renal Cell Carcinoma

  • Classic triad (though uncommon): hematuria, flank pain, palpable mass
  • Can present with paraneoplastic syndromes
  • More common in older adults, smokers
  • Hematuria often painless but can be painful with clot passage

Rare Diagnoses

• Alport Syndrome

  • Hereditary nephritis with progressive renal failure
  • Often associated with hearing loss and ocular abnormalities
  • X-linked inheritance pattern most common
  • Microscopic hematuria from early childhood, proteinuria develops later

• Thin Basement Membrane Disease

  • Benign familial hematuria
  • Typically presents with persistent microscopic hematuria
  • Minimal proteinuria, usually good prognosis
  • Pain uncommon but can occur with superimposed conditions

• Loin Pain Hematuria Syndrome

  • Unexplained severe flank pain with hematuria
  • Diagnosis of exclusion after ruling out other causes
  • More common in young women
  • May be related to thin basement membrane disease in some cases

• Nutcracker Syndrome

  • Compression of left renal vein between aorta and superior mesenteric artery
  • Can cause left flank pain and hematuria
  • Proteinuria can occur but typically mild
  • More common in thin individuals with decreased retroperitoneal fat