Briefly describes various etiologies and analysis of Pediatric hematuria (red urine)

1. Dr. Habeeb Rehman KM
DNB Resident, Pediatrics
Aster MIMS, calicut

2. Definition:- Presence of blood in urine
HEMATURIA
Microscopic v/s Gross hematuria
Glomerular v/s non glomerular
Transient v/s persistent
Isolated v/s asso with proteinuria
Asymptomatic v/s symptomatic
Painful v/s painless

3. TRANSIENT
• Trauma
• Exercise
• Infection /fever
RECURRENT
• Hypercalciuria
• IgA nephropathy
• Alports syndrome
• Nephrolithiasis
• Benign familial hematuria
FAMILIAL
• Alport’s syndrome
• IgA nephropathy
• Thin BM disease
• Hypercalciuria
• Nephrolithiasis
Gross hematuria:
• Visible to naked eyes
Microscopic hematuria:
• Detected only under
microscope
• Presence of >5 RBC/HPF in a
centrifuged sample

4. GLOMERULAR
Glomerulonephritis
PIGN
RPGN
MPGN
IgAN
Renal vasculitides
HSP
SLE
ANCA
HUS
Familial
Alports syndrome
Thin basement
basement disease
Nail patella
syndrome
Systemic
infections
Malaria
Leptospirosis
Infective
endocarditis

7. PAINLESS HEMATURIA
Hematuria, hypertension and edema :- triad of glomerulonephritis.
Recurrent gross hematuria or persistent microscopic hematuria :- IgA
nephropathy (IgAN), Lupus nephritis(LN), MPGN, FSGS and Alport’s
syndrome.
Infection/fever related glomerulonephritis (IRGN) is commonly seen
with post infectious glomerulonephritis(PIGN), IgAN and MPGN.
Hematuria with systemic features of skin rashes, joint aches and
unexplained fever should be evaluated for HSP and SLE.
Familial hematuria:- Alport syndrome, nail patella syndrome, thin BM
disease

8. PAINFUL HEMATURIA
Painful hematuria is seen with acute cystitis and with calculi
in the lower urinary tract.
Presence of clots in cystitis.
Abdominal pain in the presence of an abdominal mass :-
Wilms tumor and in a neonate renal vein thrombosis
left flank pain, varicocele and hematuria:- Nut cracker
syndrome
Painful terminal hematuria is characteristic of schistosomiasis

9. Systemic causes of hematuria
• Coagulopathy
• Bleeding disorder
• Sickle cell disease

10. EVALUATION OF HEMATURIA
1. History
2. Physical examination
3. urine analysis
4. other specific tests

11. Causes of red colour urine without hematuria
FOOD & DYES
• Beets
• Blackberries
• Food coloring
DRUGS
• Rifampin
• Phenazopyridine
• Nitrofurantoin
• HCQ , Doxorubicin
• Deferoxamine
• Iodine, Bromide
METABOLITES
• Bile pigment
• Homogentisic acid
• Melanin
• Methaemoglobin
• Porphyrin
• Tyrosinosis
• Urates

12. Evaluation of microscopic hematuria:
HISTORY:
-Is hematuria transient // recurrent // persistent
-Timing of hematuria- Throughout // at beginning // at end
-Colour of urine- fresh blood // cola colored
-Recent vigorous exercise /trauma
-UTI: New onset incontinence, dysuria, frequency, urgency
-Obstruction d/t calculus: U/l flank pain radiate to groin
-PSGN:-Pharyngitis/impetigo 2-3 weeks prior to hematuria
-Exposure to drugs : Cyclophosphamide
NSAIDS(Eosinophilic cystitis )
Ibuprofen(Interstitial nephritis)

13. • Family h/o Consanguinity, renal disease,
deafness, eye disorders

14. Clinical pointers

15. ***

16. EXAMINATION:
-Blood Pressure : glomerulonephritis
-Oedema/recent weight gain
-Skin rashes : SLE ,HSP
-Abdomen :Palpable mass

17. URINE ANALYSIS :
-Confirm hematuria
-Pyuria
-Red cell casts: glomerular disease
-Urine protein excretion >4 mg/m2/hour
OR S/O significant renal disease
Urine PC ratio >0.2 (>2 years)
-Hypercalciuria without hypercalcemia: common cause of microscopic hematuria
(24 hr Urine Ca >4mg/kg/day OR Spot urine Ca/creatinine ratio>0.2 )

18. Detection of microscopic hematuria:
Urinary dipstick
- Most common screening test
- Reagent strip detects blood; utilizes hydrogen peroxide and catalyses
chemical reaction between Hb/Myoglobin and chromogen
(tetramethylbenzidine)
-Can detect even 1-5 RBC/hpf
-False negative : Formalin , high urinary concentration of ascorbic acid
-False positive : Alkaline urine, contamination with oxidising reagent
Positive results of dipstick test should be confirmed by urine
microscopy

19. Microscopic examination
Gold standard for microscopic hematuria

23. Basic blood tests
-CBC : anemia, thrombocytopenia
-Peripheral smear: HUS
-Creatinine
-Electrolytes
-Albumin

24. Specific tests
-Complement : C3,C4
-Antibody evaluation:
ASO, Anti DNAase B, ANA, ANCA, anti-GBM
-Urine culture : Pyuria/bacteriuria
-USG Abdomen:- structural anomalies, stones, PCKD,
Cystitis
-CT Scan of kidneys
Non contrast : Stone diseases
Contrast study : Parenchymal tumours
-Renal biopsy

25. INDICATIONS FOR RENAL BIOPSY :
Biopsy should be considered if there is evidence of progressive
disease as manifested by :
-Elevation in creatinine
-Significant proteinuria
-Unexplained rise in BP

28. Evaluation of gross hematuria

30. Evaluation of microscopic hematuria:
The diagnostic evaluation depends upon clinical
presentation
1)Isolated microscopic hematuria
2)Asymptomatic microscopic hematuria with proteinuria

33. Treatment :
-Treatment of haematuria is directed at the etiology of
hematuria
– IRGN: supportive care, Fluid & salt restriction,
antihypertensives,
– UTI: Antibiotic
– Isolated hypercalciuria: increase fluid intake, restrict
sodium, hydrochlorthiazide
– Immunosuppression in IgA nephropathy & SLE
– Heparin for RVT
– chemotherapywith/without surgical excision and
radiotherapy in Wilms tumor
– Followup for hematuria, hypertension, proteinuria

34. Nut shell
-Microscopic haematuria is a common finding in children
with 1-2 % of normal school-age children having positive
dipstick for blood
• A detailed history and clinical examination directed towards
identifying glomerular and non-glomerular etiology is critical.
• Unlike microscopic hematuria, clinically important cause is
much more common in macroscopic hematuria
• The most frequent asymptomatic cause for macroscopic
hematuria is hypercalciuria; while symptomatic causes include
the renal stone disease, IRGN, IgAN and viral hemorraghic
cystitis
• Most common cause of persistent microscopic haematuria
beyond 6 months are IgA nephropathy& thin basement
membrane disease

35. -Most common screening test: urine dipstick
-Confirmation : By microscopy
-Presence of red cell casts, proteinuria, dysmorphic RBC
indicates glomerular pathology
-Treatment is directed towards cause of hematuria

36. THANK YOU

37. Bibiliography
1. Approach to Diagnosis and Management of
Hematuria- Ramya Vedula1 & Arpana A. Iyengar-
IJP Aug 2020
2. Approach to a child with gross hematuria-
Sushmita Banerjee, Murari Bharadwaj-IJPP 2017
April
3. HEMATURIA- Pediatrics in review- October 2008
4. Pediatric nephrology-Arvind Bagga- 6th edn
5. Nelson textbook of pediatrics-21st edition