Approach to HEMATURIA

1. Approach to
Haematuria
DR.RAVI KUMAR
1ST YEAR PG
DEPT OF PEDIATRICS
MGMCRI

2. Case Scenario - 1
 A 8 year old boy b/w c/o passing cola coloured urine with facial puffiness for 2days
 O/E
Alert, Active,
Afebrile
Generalized facial puffiness +
No pallor
BP-140/90mmHg
 S/E
PA- Soft, mild distension+ BS+
 Urine Routine
>5 RBC/HPF
Red cell casts +
Dysmorphic RBC
Protein 1+

3. Case Scenario - 2
 A 2 year old girl child b/w c/o crying during micturition, increased frequency, high grade
fever a/w chills & rigors and passing red coloured urine for past 4 days.
 O/E
Alert, Active,
Febrile 102*F
 S/E
PA- Soft, Suprapubic tenderness+
 Urine Routine
>5 RBC/HPF
Pus cells - Plenty
No RBC Casts
Nil Protein

4. Case Scenario - 3
 A 12 year old child b/w c/o abdominal pain radiating to back & groin a/w
nausea, vomiting since yesterday night. h/o passing 2 episodes of red coloured
urine for past 2days.
 O/E
Alert, Active,
Afebrile
 S/E
PA- Soft, Tenderness+ over right lumbar region
 Urine Routine
>5 RBC/HPF
No RBC Casts
Crystals +
Nil Protein

5. Contents
 Introduction
 Etiology
 History
 Examination
 Investigation
 Management

6. Introduction
 Hematuria means blood in urine. Which can be either macroscopic or microscopic.
 Gross or Macroscopic hematuria can be seen by naked eyes while Microscopic hematuria are
detected only in urine microscopy.
 Microscopic hematuria is defined as the presence of >5 RBC per HPF in a centrifuged sample.
 Persistent hematuria is defined as presence of microscopic hematuria in >2 samples over next
2-3 wks.

7. Glomerular Hematuria
ISOLATED RENAL DISEASE
 PSGN
 IgA Nephropathy
 Alport syndrome
 MPGN
 Membranous Nephropathy
 Thin glomerular basement membrane
Nephropathy
 RPGN
 FSGS
MULTISYSTEM DISEASE
 Systemic lupus erythematosus nephritis
 Henoch-Schönlein purpura nephritis
 Granulomatosis with polyangiitis
(formerly Wegener granulomatosis)
 Polyarteritis nodosa
 Goodpasture syndrome
 Hemolytic-uremic syndrome
 Sickle cell glomerulopathy
 HIV nephropathy

8. Non-Glomerular Hematuria
 Hypercalciuria
 Hyperuricosuria
 Hyperoxaluria
 Renal stone disease
 Cystitis (viral hemmorrhagic, drug induced)
 Genitourinary anomalies with infection
 Tumors
 PCKD
 Trauma
 Foreign body
 Sickle cell hemoglobinopathy
 UTI

9. Causes of Hematuria in Newborns
 Renal vein thrombosis (Asphyxia, dehydration, shock)
 Renal artery thrombosis
 Autosomal recessive polycystic kidney disease
 Obstructive uropathy
 Urinary tract infection
 Bleeding and clotting disorders
 Trauma, bladder catheterization
 Cortical necrosis (Hypoxic/ischemic perinatal insult)
 Nephrocalcinosis (Frusemide in premature)

10. History
 Age : 5 to 12 years – PSGN
 Sex :
F>M – SLE Nephritis
M>F – X linked form of Alport syndrome
 Discoloration of Urine
Dark yellow – Normal concentrated urine
Dark brown or black – Bile pigments, Homogentistic acid, melanin, tyrosinosis, methemoglobinemia
Cola coloured – Glomerular hematuria
Red or Pink urine – Extraglomerular hematuria, haemoglobin, myoglobin, porphyrins, chloroquine,
beets, blackberries, rifampicin, red dyes in food, urates.

11. History
 Characteristics of Urine :
 Amount of urine : Reduced in AGN, ARF
 Clots in urine : Extraglomerular
 Increased freqency , dysuria, recent enuresis : UTI
 Frothy urine : proteinuria seen in glomerular disease
 Timing :
Hematuria in initial stream – Urethra
Hematuria in terminal stream – Bladder
 Associated symptoms :
 Fever : Infections, SLE, AGN
 Generalised facial puffiness, Pedal edema : AGN

12. History
 Hypertension : AGN, ARF
 Abdominal Pain : Urolithiasis, UTI, Nutcracker syndrome
 Painless : Glomerular
 Abdominal mass : Hydronephrosis, PKD, Wilm’s tumor
 Joint pain : HSP, SLE
 Rashes : HSP, SLE, PAN
 Jaundice : Obstructive Jaundice
 Recent URI, Skin infection : PSGN
 Trauma, Child abuse
 Drug ingestion : Rifampicin, Chloroquine, Metronidazole
 Vision or Hearing defects : Alport syndrome
 Family h/o : hereditary glomerular diseases(TGBMD), Sicklecell disease

13. Examination
 Vitals:
Elevated BP : AGN, PKD
High Temperature : UTI
 Edema : AGN
 Pallor : Bleeding disorders, HUS, SLE
 JVP : Raised in CHF
 Per abdomen : Mass
Kidney: Hydronephrosis, wilms tumor
Bladder palpable : Distal obstruction
 Skin lesions : Purpura(HSP), Butterfly rash(SLE), Bruises(Trauma,Abuse)
 Joint swelling, tenderness : HSP, SLE

14. Investigations
 Urine Dipstick test : Based on oxidation of ortho-toluidine by organic peroxide in
presence of Hb that serves as a catalyst.
 The product of reaction has a blue colour, intensity is matched with colour chart
 It can detect trace Amounts of Hb and myoglobin with 100% Sensitivity & 99% Specificity in
detecting 1-5 RBC per HPF.
 False + : Urine sample is concentrated or contaminated with povidone iodine
 False - : High Ascorbic acid, pH- alkaline
 Urine Albumin
 Urine M/E : Presence of >5 RBC per HPF in a centrifuged sample

15. Investigations
 Urine C/S
 RFT
 CBC :
Reduced Hb : Bleeding, HUS, SLE, CRF
Abnormal TC/DC : Infections, HUS
 Platelet counts & Coagulation studies : Bleeding disorders, Sickle cell
 PS : Microangiopathic haemolytic anemia
 ESR, CRP : Infections
 24 hrs Urinary protein, Spot PCR, Sr.Albumin, Sr.Cholesterol & associated
Proteinuria (Nephrotic)
 Urine Calcium : 24 hrs urinary ca >4mg/kg/dl or spot urine calcium creatinine
ratio >0.21(Hypercalciuria)

16. Investigations
 Imaging Studies
 Renal & Bladder sonogram : Ureter Anomalies, Urolithiasis
 X-Ray KUB : Calculi
 Doppler study of Renal vessels & IVC : Renal vein thrombosis
 Spiral CT Scan : Wilms tumor & PCKD
 Renal Biopsy :
 Relative Indications :
 Significant Proteinuria 3+ or more
 Recurrent persistent Hematuria
 Abnormal Renal function, Persistent HTN
 No evidence of streptococcal infection
 Abnormal ANA or dsDNA levels
 Family H/O ESRD

17. Algorithm
History & P/E
Urine Analysis
Hb/RBC absent RBC +/- Hb Hb only no RBC
Look for other
causes of Red
Urine
Check RBC
Morphology
Myoglobinuria or
Hemoglobinuria
Glomerular Nonglomerular

18. Cola/brown urine ?
Proteinuria >30mg/dl ?
RBC casts ?
Acute nephrotic syndrome ?
YES NO
Glomerular Hematuria
• CBC
• Sr.E, Ca
• BUN, Creat
• Sr.protein/albumin
• Cholesterol
• C3/C4
• ASO/Anti-DNase B
• ANA
• Antineutrophil antibody
• Throat/ skin culture
• 24 hrs urine tot protein creatinine
clearance
Extraglomerular Hematuria
Step1 : urine c/s
Step2 : urine ca/creat, Renal/bladder USG
Step3 :
• Urine analysis : siblings, parents
• Sr.E , Ca, Creat
• If cystalluria, urolithiasis or
nephrocalcinosis : 24 hrs urine for Ca,
Creat, Uric acid, Oxalate
• If hydronephrosis/pyelocaliectasis :
Cystogram, renal scan

19. Management
 Managed according to cause :
 Reassurance & Follow-up
 Use of Antibiotics : cystitis, pyelonephritis, AGN
 Supportive treatment : Diuretics, fluid & restriction, Anti-hypertensives
 Monitoring – BP, I/O, Weight, Urine Routine
 To correct hyperkalaemia, ARF, CHF, Acidosis, Fluid overload, HTN and its
complications
 Use of Hydrochlorothiazide, Potassium citrate, Sodium restriction in Idiopathic
hypercalciuria
 Calculi : Plenty of water
 ESRD : Dialysis, Renal transplantation
 Renal vein thrombosis : Anti coagulant therapy or thrombectomy
 Surgical correction : PUJ obstruction, Wilms tumor.

20. Thankyou