simply discussing causes of red urine and how to evaluate hematuria in pediatric age group with guideline for management

1. HEMATURIA
Hardi Hussein Qader
KUCOM

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, hematuria is defined as the presence of 5
or more red blood cells (RBCs) per high-power field in
3 of 3 consecutive centrifuged specimens obtained at
least 1 week apart.
 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

6. CAUSES OF RED URINE

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

9. Colour of urine
causesColour
Normal concentrated urineDark yellow
Bile pigment
Melanin
Tyrosinosis
Methemoglobinemia
Dark brown or
black
Glomerular hematuriaCola coloured
Extra glomerular hematuria
Hemoglobin
Myoglobin
Chloroquine , refampin.
Beet , black berries , red dye in food.
Red or pink
urine

10. ASSOCIATED SYMPTOMS:
 Fever: Infections, SLE, AGN.
 Facial puffiness, Oedema of legs, weight gain, Shortness
of breath: Acute Glomerulonephritis.
 Hypertension : (Headache, visual changes, epistaxis,
seizures): AGN, ARF
 Abdominal pain: Urolithiasis (Loin to groin), UTI, clots,
Nutcracker syndrome
 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

11.  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
 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)

12. 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

13. 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

14.  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)

17.  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, DC in infections, HUS, ↓ in SLE;
 Platelet counts and Coagulation studies: (history
suggestive of bleeding disorder, HUS), Sickle cell
(Hemoglobin electrophoresis)
 PBS: Microangiopathic hemolytic anemia
 ESR, CRP – Infections
 24 hr urinary protein, Spot urinary protein: Creatinine ratio,
Serum albumin and cholesterol if associated proteinuria
(Nephrotic syndrome)
 Urine calcium: - Hypercalciuria is a relatively common
finding in children.
– 24-hour urinary calcium (>4mg/kg/d), or
– Spot urine calcium-creatinine ratio >0.21

18. IMAGING STUDIES
1. Renal and bladder sonography: Urinary tract anomalies,
such as hydronephrosis, hydroureter, nephrocalcinosis,
tumor, and urolithiasis, Renal parenchymal disease
2. X-Ray KUB: calculi
3. Doppler 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
9. Chest X-Ray (Pulmonary oedema, CHF)

19. RENAL BIOPSY
Relative indications :
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

20. 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)

21. 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

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

23. THANK YOU