approach to a child with hematuria

1. Dr Nehal Shah
PGR Peads medicine ii
Services hospital lahore

2.  Hematuria
The presence of atleast 5 red blood cells per
HPF of centrifuged urine or 5 RBC per microliter
in centrifuged specimen
Hematuria means blood in urine
 Gross hematuria is seen by naked eyes
 microscopic hematuria needs microscope.

3. 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

4. Glomerular
 Brown coloured urine
 Rbc cast
 Dysmorphic rbcs
 Proteinuria
 Hematuria is painless
Non glomerular
 Reddish or pink urine
 Passage of clots
 Normal size rbcs

5. Glomerular hematuria
Isolated renal disease
 Postinfectious GN
 IgA nephropathy
 Alport syndrome
 Thin Glomerular Basement membrane disease
 Membranoproliferative GN
 Membranous nephropathy
 Focal segmental glomerulosclerosis

6.  HSP nephritis
 SLE nephritis
 HUS
 Wegener granulomatosis
 Polyarteritis nodosa
 Goodpasture syndrome
 HIV nephropathy
 Sickle cell glomerulopathy

7. Upper Urinary tract
 Pyelonephritis
 Interstitial nephritis
 ATN
 Nephrocalcinosis
Anatomical
 Hydronephrosis
 Polycystic kidney disease
 Tumor (Wilms)

8.  Vascular:
 Arterial/venous thrombosis
 Malformation (aneurysms, hemangioma)
 Nutcracker syndrome
 Hemoglobinopathy (Sickle cell trait/disease)
 Crystalluria: Calcium, Oxalate, Uric acid
 Medications: NSAIDs, anticoagulants

9. Lower urinary tract
 Cystitis
 Urethritis
 Urolithiasis
Other causes
 Trauma
 Foreign body
 Coagulopathy
 Heavy exercise
 Bladder tumor
 Mensturation in girls

10. Common causes of gross hematuria:
 Urinary tract infection
 Meatal stenosis
 Perineal irritation
 Trauma
 Urolithiasis
 hypercalciuria
 Coagulopathy
 Tumor

11. Glomerular cause of gross hematuria
 IgA nephropathy
 Alport syndrome
 Thin glomerular basement membrane disease
 Post infectious glomerulonephritis
 HSP nephritis
 SLE nephritis

12.  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)

13. History

14. • Age: 2-5yrs: Wilms tumor
5-12yrs: PSGN
• Sex: Females >1-2yrs: UTI
SLE nephritis
Males: X-linked form of Alport syndrome
• Race: whites: Idiopathic hypercalciuria
blacks: Sickle cell disease

15.  Fever: UTI, SLE, AGN
 Facial puffiness, edema of legs, weight gain,
Shortness of breath: Acute Glomerulonephritis
 Headache, visual changes, epistaxis, Seizures
due to hypertention: AGN, ARF
 Abdominal pain: Urolithiasis (Loin to groin),
UTI, clots, Nutcracker syndrome

16.  Abdominal mass: Hydronephrosis, PKD,
Wilm’s tumor
 Joint pain (HSP, SLE)
 Rashes (HSP, SLE)
 Jaundice, hemolysis

17. • H/o bleeding from other sites: Bleeding
disorders, Hemoptysis in Good Pasture
syndrome
• H/o Trauma, abdominal surgery, Child abuse
crush injury
• H/o ingestion of drugs (ATT – Rifampicin,
Ibuprofen
 Chloroquine, Metronidazole, Iron), i.v.
contrast
agents (Toxic nephropathy)

18.  H/o exercise, menstruation, recent bladder
catheterization or passage of a calculus
 Recent upper respiratory (1-2wks back),
skin infection (3-6 wks): PSGN
 GI infection: HUS, HSP nephritis

19. • H/o Vision or hearing defects: Alport
syndrome
• Family h/o: Hereditary glomerular diseases
(Alport syndrome, Thin glomerular Basement
Membrane Disease, IgA Nephropathy)
• H/o consanguinity or affected siblings in
ARPKD, Metabolic disorders

20. Amount of urine: Reduced in AGN, ARF
Clots in urine: Extraglomerular
Frequency, Dysuria : UTI
Frothy urine: Suggests Proteinuria seen in
Glomerular diseases
Timing of hematuria
hematuria at start of void is from urethra
hematuria at end of void is from bladder

21. Colour causes
Dark yellow Normal concentrated urine
Dark brown or
black
Bile pigments
Homogentisic acid, melanin,
tyrosinosis, methemoglobinuria
Cola coloured Glomerular hematuria
Red or pink urine Extraglomerular hematuria,
Hemoglobin, Myoglobin,
Porphyrins, Chloroquine,
Deferoxamine, Beets, blackberries,
Rifampin, Red dyes in food, Urates

22. Examination

23.  Vitals:
BP: in AGN, PKD
Temperature
 edema: in AGN
 Pallor: Bleeding disorders, HUS, SLE, CRF
 Abdominal examination
palpable Kidneys: Hydronephrosis , Wilms
tumor
Polycystic kidney disease
Bladder palpable: Distal obstruction
Tenderness in abdomen : HSP

24. • Skin lesions
Purpura (HSP)
Butterfly rash (SLE)
Bruises (Trauma, Child abuse)
Abnormal external genitalia e.g. ambiguous
genitalia
Joint swelling, tenderness: HSP, SLE
• Ophthalmologic: Alport syndrome (Anterior
lenticonus, macular flecks, recurrent corneal
erosions)
• Hearing assessment: Alport syndrome

25.  Urine dipstick test:
 Based on the peroxidase-like activity of
Hemoglobin
It can detect trace amounts of hemoglobin and
myoglobin.
 False +ve: Urine pH >9, H2O2
 False –ve: High ascorbic acid,
 formalin

26. Glomerular
 Brown, cola coloured or
smoky
 RBC casts
 Proteinuria 2+ or more
 Deformed urinary
RBCs
Non - glomerular
 Bright red, pink
 Passage of clots
 Proteinuria of < 2+
 Normal morphology of
RBCs

27. • Urine C/S
• RFT: Blood urea nitrogen/serum creatinine,
Na/K (↓Na in AGN, ↑K in ARF)
• Complete blood counts (CBC):
Hb - ↓ in bleeding, HUS, SLE, CRF; Abnormal
TC, in infections, HUS, ↓ in SLE;
• Platelet counts and Coagulation studies:
(history suggestive of bleeding disorder, HUS),
Sickle cell (Hemoglobin electrophoresis)

28. • blood smear : Microangiopathic hemolytic
anemia
• ESR, CRP – Infections
• 24 hr urinary protein,
 Spot urinary protein: Creatinine ratio
 Serum albumin
 Urine calcium
 ASO titer

29. Imaging Studies
Renal and bladder USG:
Hydronephrosis ,tumor, and urolithiasis, Renal
parenchymal disease
X-Ray KUB: calculi
Doppler study of renal vessels:
Renal vein thrombosis

30. Intravenous urography
Spiral CT scan - Urolithiasis, Wilms tumor and
polycystic kidney disease, Renal trauma
Micturating cystourethrograms
Urethral and bladder abnormalities (eg,
cystitis), in recurrent UTI to r/o VUR anomalies
Radionuclide studies – Renal function and
perfusion
Angiogram
Chest X-Ray (Pulmonary oedema, CHF)

31. indications -
 Resistant nephrotic syndrome
 Recurrent persistent hematuria (Microscopic >2yrs)
 Abnormal renal function, Persistent HTN
 low C3 level persist beyond 2 mo of onset of AGN
 Serologic abnormalities (abnormal ANA or dsDNA
levels)
 • A family history of end stage renal disease or
evidence of Chronic renal disease in patient

32.  Cystourethroscopy:
 Terminal hematuria,
 disturbances of micturition, suprapubic pain
(Only if strong suspicion of bladder ulceration,
tumours)
 Screening of first degree relatives in
persistent
 hematuria

35. diagnosis Clinical features Lab findings
APSGN Hematuria,hypertentio
n
Hx of throat infection
Aso titer positive,
decrease complement
level
IGA nephropathy Intermittent gross
hematuria,family
hx,hx of recent throat
infection
Increase serum IGA
level
HSP Purpura,joint
pain,hematuria,abdom
inal pain
No specific test
SLE Hematuria,
proteinuria,
hypertension,
joint pains,
rashes
Abnormal C3, C4,
ANA, dsDNA,
anemia,
thrombocytopenia

36. Diagnosis Clinical features Labs
Alport syndrome Sensorineural
hearing loss, corneal
abnormalities,
hematuria, renal
failure
No specific
investigation
Thin basement
membrane disease
Persistent
microscopic or gross
hematuria,
significant family
history
No specific test
Mesangioproliferative
GN
Hematuria,
proteinuria,
hypertension
Decrease compliment
level

37.  According to cause:
Reassurance and F/U
 Treat cystitis, pyelonephritis, AGN:Antibiotics
 Supportive treatment: Diuretics, Fluid and salt
restriction, Antihypertensives

38.  Treat Hyperkalemia, ARF, CHF, acidosis, fluid
overload, HTN and its complications
 ACE inhibitors useful in proteinuria
 Immunosuppressive therapy: Depending on
cause

39.  Idiopathic Hypercalciuria: Hydrochlorothiazide,
Potassium citrate, Sodium restriction
 Calculi: Plenty of water
 ESRD: Dialysis, Renal transplantation
 Correct thrombocytopenia, anemia, coagulation
factor deficiency
 Renal vein thrombosis: Anticoagulant therapy or
thrombectomy may be needed
 Surgical correction: Calculi, PUJ obstruction,
Posterior urethral valves, Wilms tumour