2. OBJECTIVES :
1) to know the definition and types of hematuria.
2) to identify the causes of hematuria.
3) How to investigate patient .
4) How to treat the patient.

3. DEFINITION
 Generally, Microscopic haematuria, defined
as more than 3 to 5 red blood cells (RBCs) per high-
power
field on freshly voided and centrifuged urine.
 Hematuria can be either gross (ie, overtly bloody,
smoky, or tea-colored urine) or microscopic(detected
by dipstick).
 It may also be either symptomatic or asymptomatic.
 either transient or persistent, and either
isolated or associated with proteinuria and other
urinary abnormalities

5. PATHOPHYSIOLOGY:
 Structural disruption in the integrity of
glomerular basement membrane caused
by inflammatory or immunologic processes
Toxic disruptions of the renal tubules
Mechanical erosion of mucosal surfaces in
the genitourinary tract

8. CAUSES OF RED URINE

10. Case Presentations
1. A 12-year-old adolescent boy presents to the emergency department with a
chief complaint of urine the color of brown soda. He reports a recent upper
respiratory infection. On physical examination, his blood pressure is 145/72
mm Hg, and you note periorbital edema. Urine dipstick is positive for blood
and 2+ protein. You consider any emergent laboratory work you need to
perform to confirm the diagnosis and wonder if this child requires admission
to the hospital…
2. A 15-year-old adolescent girl is brought in by her parents with a chief
complaint of pink urine. Review of systems is significant for muscle soreness,
which she attributes to running a half-marathon for her cross-country team
the day prior to presentation. Urine dipstick is positive for large occult blood.
As you begin initial management, you consider other laboratory work that
should be performed…
3. A previously healthy 5-year-old girl presents to the emergency department
with pink urine after visiting her grandmother for the weekend. Review of
systems is otherwise negative, and the patient does not take any medications.
The physical examination is nonfocal, including the genitourinary examination.
Urine dipstick is negative for blood or protein. You wonder what other
questions you should ask to confirm the diagnosis. Does she require a repeat
urine dipstick and microscopic urinalysis with her pediatrician?

11. APPROACH TO PATIENT WITH
HEMATURIA
1. History:
Age :5-2 yrs: Wilms tumor 12-5 yrs: PSGN•
Sex:F>>M in >2yrs: UTI F>>M: SLE nephritis
M>F : X-linked form of Alport syndrome•
Race: whites: Idiopathic hypercalciuria
blacks: Sickle cell disease

12. olour of urine
Colour causes
Dark yellow Normal concentrated urine
Dark brown or
Cblack
Bile pigment
Melanin Tyrosinosis
Methemoglobinemia
Cola coloured Glomerular hematuria
Red or pink
urine
Extra glomerular hematuria
Hemoglobin Myoglobin Chloroquine , refampin.
Beet , black berries , red dye in food.

13. ASSOCIATED SYMPTOMS:
Fever: Infections, SLE, AGN.
Facial puffiness, Oedema of legs, weight gain, Shortness of breath :
sitirhpenoluremolG etucA.
Hypertension : FRA ,NGA :)seruzies ,sixatsipe ,segnahc lausiv ,ehcadaeH(
 Abdominal pain: Urolithiasis (Loin to groin), UTI, clots,
 Painless: Glomerular
 Abdominal mass: Hydronephrosis, PKD, Wilm’s tumour
 Joint pain : (HSP, SLE)
 Rashes :(HSP, SLE, PAN)
 Neurologic : – SLE, HUS (seizures, irritability)
 Jaundice: Hemolysis, Obstructive jaundice

14.  Recent upper respiratory (1-2wks back), skin infection (3-6
wks): PSGN
 GI infection: HUS, HSP nephritis
Gross hematuria precipitated by URI: Alport syndrome, IgA
Nephropathy
H/o bleeding from other sites: Bleeding disorders,
Hemoptysis in Good Pasture syndrome
H/o Trauma, abdominal surgery, Child abuse (Social factors
-Munchausen), crush injury
H/o ingestion of drugs (ATT –Rifampicin, Ibuprofen,
Chloroquine, Metronidazole, Iron), i.v. contrast agents (Toxic
nephropathy, RVT)

15.  H/o Vision or hearing defects: Alport
syndrome
Family h/o: Hereditary glomerular diseases
(Alport syndrome, Thin glomerular Basement
Membrane Disease, IgA
Nephropathy), Urolithiasis, Hypercalciuria,
Sickle cell disease/trait
H/o consanguinity or affected siblings
in ARPKD, Metabolic disorders

16. EXAMINATION:
 Vitals:
– BP: in AGN, PKD
– Temperature
 Oedema: in AGN
 Pallor: Bleeding disorders, HUS, SLE, CRF
 JVP: Raised in CHF
 Per abdomen: Mass
– Kidney: Hydronephrosis (Urinary tract obstruction),
Wilms tumour; B/L in ARPKD, hydronephrosis
- Bladder palpable: Distal obstruction
 Tenderness: HSP

17.  Skin lesions :
- Purpura(HSP)
- Butterfly rash (SLE)
- Bruises (Trauma, Child abuse)
 Signs of Congestive cardiac failure, HTNsive
encephalopathy: AGN
 Joint swelling, tenderness: HSP, SLE
Ophthalmologic: Alport syndrome (Anterior lenticonus,
macular flecks, recurrent corneal erosions), Aniridia (Wilms)
Hearing assessment: Alport (B/L SNHL)

20. 
 RFT: Blood urea nitrogen/serum creatinine, Na/K (↓Na in AGN, ↑K in ARF)
- bH :)CBC( stnuoc doolb etelpmoC-↓ in bleeding, HUS,
- SLE, CRF; Abnormal TC, DC in infections, HUS, ↓in SLE;
- llec elkciS ,)SUH ,redrosid gnideelb fo evitseggus yrotsih( :seiduts noitalugaoC dna stnuoc teletalP
- (Hemoglobin electrophoresis)
- aimena citylomeh cihtapoignaorciM :SBP
- PRC ,RSE– Infections
- 24 hr urinary protein, Spot urinary protein: Creatinine ratio, Serum albumin and cholesterol if
associated proteinuria
- (Nephrotic syndrome)
- :muiclac enirU-nerdlihc ni gnidnif nommoc ylevitaler a si airuiclacrepyH.
- 24- hour urinary calcium (>4mg/kg/d), or
- Spot urine calcium-creatinine ratio >0.21

21. IMAGING STUDIES
1.Renal and bladder sonography: Urinary tract anomalies,
such as hydronephrosis, hydroureter, nephrocalcinosis,
tumor, and urolithiasis, Renal parenchymal disease
.2X-Ray KUB: calculi
.3Doppler study of renal vessels and IVC: Renal vein
thrombosis
4. Intravenous urography
5. Spiral CT scan - Urolithiasis, Wilms tumor and polycystic
kidney disease, Renal trauma
6. Micturating cystourethrograms - Urethral and bladder
abnormalities (eg, cystitis), in recurrent UTI to r/o VUR,
anomalies
7. Radionuclide studies
8. Renal function and perfusion – Angiogram
Chest X-Ray (Pulmonary oedema, CHF)

22. RENAL BIOPSY
1.Significant proteinuria (3+ or more) or nephrotic
syndrome +
2. Recurrent persistent hematuria (Microscopic >2yrs)
3. Abnormal renal function, Persistent HTN
4. Hematuria, Proteinuria, diminished renal function, low C3
level persist beyond 2 mo of onset of AGN
5.Absence of evidence of streptococcal infection
6.Serologic abnormalities (abnormal ANA or dsDNA
levels)
7.A family history of end stage renal disease or evidence
of Chronic renal disease in patient

23. MANAGEMENT
According to cause
 Reassurance and F/U
 Treat cystitis, pyelonephritis, AGN: Antibiotics
 Supportive treatment: Diuretics, Fluid and salt restriction,
Antihypertensives
 Monitoring – BP, I/O, weight, Urine R/M
 Treat Hyperkalemia, ARF, CHF, acidosis, fluid overload, HTN
and its complications
ACE inhibitors useful in proteinuria
Immunosuppressive therapy: Depending on cause
(Steroids, cyclophosphamide)

24. Idiopathic Hypercalciuria
Sodium restriction
Calculi: Plenty of water
ESRD: Dialysis, Renal transplantation
Hydrochlorothiazide , Potassium citrate,
Correct thrombocytopenia, anemia, coagulation factor
deficiency
ypareht tnalugaocitnA :sisobmorht niev laneR
or thrombectomy may be needed
larhteru roiretsoP ,noitcurtsbo JUP ,iluclaC :noitcerroc lacigruS
ruomut smliW ,sevlav

25. Case conclusion
1.You diagnosed the 12-year-old adolescent boy with poststreptococcal
glomerulonephritis after you performed laboratory studies that showed a normal BUN
and creatinine, a low C3, and an elevated ASO titer. He was admitted to the hospital
for hypertension management and discharged home to follow up with nephrology in 6
to 8 weeks.
2.After completion of laboratory studies, the 15-year-old adolescent girl was found to
have rhabdomyolysis due to strenuous exercise. The urine dipstick was positive for a
large amount of blood, but there were no RBCs on microscopic examination, which
was consistent with myoglobinuria. Her creatine kinase level was elevated to 35,000
IU/L. You started her on intravenous hydration and admitted her for further
management.
3.The previously healthy 5-year-old girl was discharged home after further history
revealed that she had eaten a significant number of blackberries with her
grandmother the day prior. Although not necessary, you recommended that a repeat
urine dipstick should be completed at her pediatrician’s office.

26. REFERENCES:
1. Nelson Textbook of Pediatrics, 19th Ed
2. Nelson Essentials of Pediatrics, 6th Ed
3. Pediatric board study guide