This document discusses the approach to hematuria in children. It begins by defining hematuria and describing different types. It then outlines the most common etiologies of glomerular and non-glomerular hematuria. The document describes the relevant history, examination, investigations and management strategies for evaluating a child with hematuria. It provides case examples and algorithms to guide clinical decision making. The key points are evaluating for glomerular vs extraglomerular causes, identifying underlying etiologies through history, exam and testing, and managing the hematuria based on its cause.

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