Hematuria

clinical approach to hematuria

1. Hematuria in Children
Ali Derakhshan MD
Shiraz University of Medical sciences
Shiraz Nephro-Urology research Center
Shiraz -IRAN

2. Introduction
◼A common cause for referral of children to
pediatricians and pediatric nephrologists
◼Prvalenceof Hematuria:1% in girls and
0.5% in boys

3. HematuriaHematuria
Transient phenomenon
of little significance
Transient phenomenon
of little significance
Sign of serious
renal disease
Sign of serious
renal disease

4. Microscopic HematuriaMicroscopic Hematuria
•Definition > 5 RBC/HPF
• > 5 RBC/ μL
•Dipstick detects >3 RBC/ μLof urine
•False Negative (formalin ,Ascorbic acid)
•False positive (urine PH>9, oxidizing detergents
•Screening U/A at 5 years and during 2
nd
decade
•AAP: no recommendation for screening UA
•Definition > 5 RBC/HPF
• > 5 RBC/ μL
•Dipstick detects >3 RBC/ μLof urine
•False Negative (formalin ,Ascorbic acid)
•False positive (urine PH>9, oxidizing detergents
•Screening U/A at 5 years and during 2
nd
decade
•AAP: no recommendation for screening UA

5. Causes of HematuriaCauses of Hematuria
•Glomerular disease
•Lesions along the urinary tract
Conditions unrelated to kidney and urinary tract
disease: following exercise, Febrile disorders, Gastroenteritis
with dehydration, Contamination from external genitalia

6. Clinical Presentation of
Hematuria in Children
◼Microscopic hematuria incidental detection could
be isolated or non-isolated
◼Microscopic hematuria with symptoms
◼Microscopic hematuria with intermittent gross
hematuria with or without symptoms
◼Gross hematuria ( intermittent or continuous)with
or without symptoms

7. Causes Of Discolored Urine
Red or pink urine
◼Heme (+) : RBC (hematuria), Hburia, Myoglobinuria
◼Heme (-) :
Drugs: Chloroquine , Deferoxamine , ibuprofen, metronidazole,
rifampin, phenazopyridine, salicylates, iron , sulphasalazine,
Phenothiazines, phenolphthalein, Metabolites: Urates,
porphyrins,
Dyes(veg./fruits) :Beets, black berries, food coloring
Dark brown or black urine
◼Metabolites: Bile pigments, Meth.Hb, Alanine, Resorcinol,,
Alkaptonuria(Homogenistic acid), Melanin, thymol, tyrosinosis

8. Glomerular vs Extraglomerular
Hematuria
Urinary
finding
Glomerular Extraglom-
erular
Red cell castsMay be present Absent
Red cell
morphology
Dysmorphic Uniform
Proteinuria May be present Absent
Clots Absent May be
present
Color Cola ,Red or
brown
Red
◼Almost always associated
with glomerulonephritis or
vasculitis Virtually exclude
extra-renal causes of
bleeding

9. Clinical Approach to
Hematuria
◼Not to miss serious conditions
◼Avoid unnecessaryand expensive tests
◼First decision :watchful follow up ,need for
rapid work ups and/or referral to a subspecialist
◼Reassure the family when appropriate
◼Guidelines for further studies according to
changes in the course of illness
◼Careful history

10. History
◼Timing of hematuria and associated symptoms
◼Trauma, exercise, stone passage, URTI, skin
infection and medications
◼Dysuria, frequency, urgency, back pain, skin
rash, joint symptoms and edema
◼Sickle cell disease or trait
◼Family History: hematuria, stone, hypertension,
renal failure,Tx , deafness & coagulopathy
◼Menarche

11. Purposeful Physical Examination
◼General P/E , Edema , BP, Pallor
◼Hypertension and edema determines how
urgent the diagnostic evaluation be done
◼Rash , impetigo
◼Ecchymosis , petechia , hemangioma
◼Abdominal mass(tumors, hydronephrosis)
◼Flank tenderness (pyelonephritis, stone)
◼Inspection of External genitalia
◼Growth parameters
◼State of hearing

12. Purposeful Urinalysis
◼Look for :
Shape of RBC
RBC cast
Proteinuria
Pyuria
Crystals
◼Repeat UA for persistence of Hematuria

13. Child with Lower Urinary Symptoms
◼Hematuria with dysuria, frequency, urgency,
flank or abdominal pain is suggestive for : UTI,
hypercalciuriaor nephrolithiasis
◼UTI : In 1/3 of cases associated with hematuria
usually microscopic
◼Hemorrhagic cystitis by adenovirus type 11 and
21 (5days GH then 2-3days micro-hematuria)
◼Schistosomiasis

14. Child with Clinical Features of
Glomerulonephritis
◼Acute nephritic syndrome: edema, ↑BP, oliguria,
hematuria, ↓renal function
◼Work up for different types of glomerulonephritis
according to the History: ASO, C3,C4,ANA,
Anti-dsDNA, ANCA, Serum IgA.

15. Asymptomatic Child : Incidental
Microscopic Hematuria in U/A
◼In routine check up or in a child with febrile illness or any
other presentation
◼Repeat U/A after resolution of current illness
◼Repeat U/A twice within1-2 weeks (+ in all)
◼UA of siblings and Parents
◼US ,BUN,Cr,Electrolytes, UCa/Cr ratio, U uric acid/Cr ratio
◼Color doppler US of renal vessels
◼Common causes of persistent micro-hematuria: Benign
familial hematuria (TBMN), idiopathic hypercalciuria, IgA
nephropathy and Alport syndrome

16. Hypercalciuria
◼Noted in 1981.
◼Increase urinary excretion calcium with normal
serum calcium levels.
◼Ca/Cr ratio>0.21mg/mg*or >4mg/kg/day
◼Measurement of urinary calcium excretion has
become the standard part of the evaluation of
hematuria in children.
◼Had family history of renal stones.
◼Rx: hydrochlorothiazide,do not restrict Ca
* >7 years old

18. Causes of Hematuria
Glomerular:
◼Post infectiousGN
◼IgA-Nephropathy
◼Henoch –Schonlein
nephritis
◼Hereditary nephritis
◼Benign familial hematuria
◼MPGN
◼Lupus nephritis
◼Vasculitis associated GN
◼Others
Non glomerular:
◼Nephrocalcinosis,stone,
hypercalciuria
◼Interstitial Nephritis, UTI
◼Renalvein Thrombosis
◼Sickle cell Dis.
◼Vascular Malformations :
Hemangiomaand AVF,
nutcracker syndrome
◼Wilm’sTumor
◼Renal cell carcinoma
◼Cystic disease
◼Trauma

19. Follow up of Isolated
Hematuria
◼Permanent disappearance of hematuria
◼Change in nature with new symptoms or
signs: further work ups
◼persists and needs regular follow up with
UA every 3-6MO, serum Cr and eventually
may need a kidney Biopsy in case of
persistence for one or 2 years
◼When a cause is found treatment
accordingly

20. Indications of Renal Biopsy
◼In follow up of Hematuria if any of the following:
-Proteinuria
-Hypertension
-Renal isufficiency
◼Persistent low C3 following PSAGN
◼Systemic disease with proteinuria: SLE, HSP,
ANCA+vasculitis
◼Family history suggestive of Alport syndrome
◼Recurrent gross hematuria of unknown etiology
◼Keeping in mind that all modalities of tissue study
including light, EM, IF must be available
◼Important Consideration For Family Anxiety,
Insurance.

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Summary

22. Summary
◼The urinalysis, history and physical examination
guides to the cause of hematuria in most of the
cases
◼Significant renal dis.is ruled out with Hx, PE and a
minimal amount of work ups in most of the
children
◼Simultaneous presence of hematuria with any of
the followings: proteinuria , rise in serum
creatinine, FTT and Hypertension increases the
likelihood of significant renal dis.

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