HEMATURIA causes, etiology, management in children

Hematuria is the presence of blood in urine .

1. An Approach to Haematuria

2. DEFINITION: Gross hematuria- visible with naked eyes Microscopic hematuria- 5 RBCs /HPF in Uncentrifuged urine 5RBC s/ Cumm in Uncentrifuged urine Significant hematuria- >50RBCs/HPF

3. Possibilities of red urine: RBC Hemoglobin /myoglobin Excess metabolites/food. Drugs/Toxins/dyes ingested Blood or dye added.

4. How to approach? Step 1- Make sure it is actually hematuria? Is it a food? Is it a drug? Is it an excess metabolite Is anything added after voiding BEET ROOT RIFAMPACIN IRON DESFERIOXAMINE ADRIAMYCIN METRONIDAZOLE PORPHYRIN URATE METHEMOGLOBIN HOMOGENTISIC ACID

5. Possibilities of red urine: RBC Hemoglobin /myoglobin Excess metabolites/food. Drugs/Toxins/dyes ingested Blood or dye added .

6. CENTRIFUGE THE URINE Sediment Red HEMATURIA Supernatant Red URINE DIPSTICK POSITIVE NEGATIVE Plasma colour Foods,metabolites Clear- myoglobinuria Red- hemoglobinuria

7. From where can blood come from? Lower urinary tract-

8. Upper urinary tract

9. Causes by location- Glomeruli

10. Causes by location- whole kidney Hydronephrosis Polycystic kidney disease Multicystic dysplasia Tumour ( wilms tumour,rhabdomyosarcoma , Angiomyolipoma ) Trauma

11. Causes by location- lower urinary tract Inflammation- infectious or non infections including pyelonephritis Cystitis- infections or drugs Bladder tumour Urethritis trauma

12. Causes by location- systemic disease

13. Causes by location- Vascular

14. How to know clinically? Renal vs systemic Upper or lower urinary tract Glomerular or Non-glomerular

15. Renal vs systemic Past history of bleeding Rash or arthritis Loss of weight or appetite Pain crisis

16. Upper vs lower urinary tract Painful with or without radiation Frequency, urgency, dysuria Fresh blood/terminal hematuria Intact RBC

17. More than 30% of deformed RBCs More than 5% acanthocytes Edema +hypertension

18. How to evaluate a child? GROSS HEMATURIA SYMPTOMATIC ASYMPTOMATIC MICROSCOPIC HEMATURIA SYMPTOMATIC ASYMPTOMATIC

19. Evaluation of a child with Gross symptomatic hematuria H/O trauma- CT abdomen and pelvis H/s/O glomerular cause- do investigation for PSGN and SLE H/s/O Lowe urinary tract symptom- rule out UTI- USG abdomen, local cause History and examination suggestive of mass- USG abdomen H/S/O Nephrolithiasis- USG whole abdomen, xray pelvis, ideal- spiral CT

20. Gross asymptomatic hematuria Idiopathic hypercalciuria - Urinary ca/ creat ratio>0.2 IGA Nephropathy- hypertension, proteinuria, Progressive kidney disease,kft PSGN- C3 Levels Thin basement glomerular disease familial Nutcracker syndrome

21. Evaluation of symptomatic Microscopic hematuria All the investigations of gross symptomatic hematuria Ca/ cr ratio- idiopathic hypercalcuria Familial hematuria Hb electrophoresis- sickle cell trait Doppler studies- nutcracker syndrome

22. Asymptomatic Microscopic hematuria ISOLATED PROTEINURIA

23. Isolated Microscopic hematuria Transient No associated systemic illness Ascertain persistence/transient state by Repeated testing Evaluation

24. Isolated asymptomatic Microscopic hematuria