A PowerPoint presentation for medical students about approach to hematuria (red urine) in children

1. APPROACH TO CHILD WITH
RED COLORED-URINE
IBRAHIM SANDOKJI, MD, FAAP
Pediatric Nephrologist, Assistant Professor
Board Certified by the American Board of Pediatrics
Taibah University
isandokji@taibahu.edu.sa
+966 50 632 5770

2. Ahmed is a healthy 5-year-old boy who presents with red urine for
one day
 What history questions you want to ask?
 What important and relevant examination you want to
perform?
 What investigations you would like to perform?
 How would you treat Ahmed?

3. HISTORY
 Trauma or vigorous exercise
 Dysuria, frequency, or urgency -> UTI
 Unilateral flank pain & radiate to groin -> obstruction (stone or
clot)
 Flank pain with fever & dysuria -> acute pyelonephritis
 Pharyngitis or impetigo (2-3 weeks prior) -> postinfectious
glomerulonephritis
 Upper respiratory infection (1-2 days prior) -> IgA nephropathy

4.  Color of urine
 Glomerulonephritis -> brown urine
 Bleeding from the lower urinary tract -> pink or red urine
 Family history (hematuria, kidney diseases, kidney stones or sickle cell
disease)
 Timing:
 Initial hematuria -> urethral bleeding
 Continuous bleeding -> bladder, ureter or kidneys
 Terminal bleeding -> bladder disease
HISTORY

5. EXAMINATION
 Blood pressure: elevated BP -> glomerular disease
 Edema and recent weight gain -> glomerular disease
 Skin examination: rash or purpura -> glomerular disease (eg, SLE
or Henoch-Schönlein purpura)
 Genitalia (penile urethral meatal erosion or female introitus
pathology)
 Abdominal discomfort or masses (eg, Wilms tumor).

6. SCREENING DIPSTICK

7. URINALYSIS

8. INVESTIGATIONS
 Trauma history -> CT scan of the abdomen and pelvis
 Signs or symptoms of UTI -> urine culture
 Concern for kidney stones:
 Renal US. (CT: most sensitive.) (AXR miss uric acid stones)
 Measurement of urine calcium/creatinine to detect possible hypercalciuria
 Concern for glomerular disease (proteinuria, RBC casts, edema, and hypertension):
 Serum creatinine, electrolytes & albumin
 Complete blood count (CBC)
 Complements (C3/C4)
 Antistreptolysin O (ASO) titer
 Antinuclear antibody (ANA)

9. KIDNEY BIOPSY?
 Rarely needed.
 Indications in the case of hematuria
 Worsening kidney function
 Significant proteinuria
 Unexplained HTN

13. >5 RBCs/hpf on centrifuged urine
Not visible to the naked eye

14. BLOOD + BUT NO RED BLOOD CELLS
Myoglobinuria
 Due to muscle break down (rhabdomyolysis)
 Muscle pain after strenuous exercise
 Muscle enzyme elevations (creatine kinase (CK),
electrolyte imbalances (potassium), and acute
kidney injury
 Treated with hydration and management of AKI
and electrolyte imbalances
Hemoglobinuria
 Due to intravascular hemolysis
 Examples:
 Acute hemolytic transfusion reaction
 Severe malaria (blackwater fever)

15. Pseudo-hematuria

16. SELECTED CAUSES OF HEMATURIA
Postinfectious glomerulonephritis
 Variable presentation: from
asymptomatic, microscopic
hematuria to the full-blown acute
nephritic syndrome
 There is usually a prior history of a
group A beta-hemolytic
streptococcal (GAS) skin or throat
infection. Usually 2-3 weeks prior.
 Hematuria generally resolves within
3-6 months
IgA nephropathy
 The most common cause of
primary glomerulonephritis
 Persistent microscopic hematuria
with episodes of gross hematuria
that occur during (or within few
days) upper respiratory tract or
gastrointestinal illnesses.
 Mesangial deposition of IgA
Other glomerular diseases and urinary tract
infections will be discussed in details in a separate
lecture

17. SELECTED CAUSES OF HEMATURIA
Alport syndrome
 Recessive X-linked disorder
 Typically seen in males
 Accompanied by
 Hearing loss
 Ocular abnormalities
 Progressive renal failure
 Caused by abnormality in
type IV collagen
Thin basement membrane disease
 Also called benign familial
hematuria
 Autosomal dominant disorder
 Thin glomerular basement
membrane on EM
 Family history of hematuria
 No history of progressive renal
disease

18. Nephrolithiasis
 Abdominal pain and gross hematuria
 Most common type: Ca-Oxalate
 If obstructed
 Small -> hydration & pain control
 Large -> urological removal
 Non-obstructive -> lifestyle
modifications
Nephrocalcinosis
 Calcium salt deposition in the renal
parenchyma (tubular epithelium and
interstitial renal tissue)
 Common in neonates, especially preterm
infants (renal tubular immaturity, & diuretic
use)
Hypercalciuria
 Most common metabolic abnormality
associated with kidney stones formation
 Combination of genetic environmental
factors
 Asymptomatic microscopic hematuria

19. HOME READING