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Hematuria
- 1. Hematuria in Children AliDerakhshan MD Shiraz University of Medical sciences Shiraz Nephro-Urology research Center Shiraz - IRAN
- 2. Introduction ◼ A commoncause for referral of children to pediatricians and pediatric nephrologists ◼ Prvalence of Hematuria:1% in girls and 0.5% in boys
- 3. Hematuria Hematuria Transient phenomenon of littlesignificance Transient phenomenon of little significance Sign of serious renal disease Sign of serious renal disease
- 4. Microscopic Hematuria Microscopic Hematuria •Definition > 5 RBC/HPF • > 5 RBC/ μL •Dipstick detects >3 RBC/ μL of urine •False Negative (formalin ,Ascorbic acid) •False positive (urine PH>9, oxidizing detergents •Screening U/A at 5 years and during 2nd decade •AAP: no recommendation for screening UA • Definition > 5 RBC/HPF • > 5 RBC/ μL •Dipstick detects >3 RBC/ μL of urine •False Negative (formalin ,Ascorbic acid) •False positive (urine PH>9, oxidizing detergents •Screening U/A at 5 years and during 2nd decade •AAP: no recommendation for screening UA
- 5. Causes of Hematuria Causesof Hematuria • Glomerular disease • Lesions along the urinary tract Conditions unrelated to kidney and urinary tract disease: following exercise, Febrile disorders, Gastroenteritis with dehydration, Contamination from external genitalia
- 6. Clinical Presentation of Hematuriain Children ◼ Microscopic hematuria incidental detection could be isolated or non-isolated ◼ Microscopic hematuria with symptoms ◼ Microscopic hematuria with intermittent gross hematuria with or without symptoms ◼ Gross hematuria ( intermittent or continuous)with or without symptoms
- 7. Causes Of DiscoloredUrine Red or pink urine ◼ Heme (+) : RBC (hematuria), Hburia, Myoglobinuria ◼ Heme (-) : Drugs: Chloroquine , Deferoxamine , ibuprofen, metronidazole, rifampin, phenazopyridine, salicylates, iron , sulphasalazine, Phenothiazines, phenolphthalein, Metabolites: Urates, porphyrins, Dyes(veg./fruits) :Beets, black berries, food coloring Dark brown or black urine ◼ Metabolites: Bile pigments, Meth.Hb, Alanine, Resorcinol,, Alkaptonuria(Homogenistic acid), Melanin, thymol, tyrosinosis
- 8. Glomerular vs Extraglomerular Hematuria Urinary finding GlomerularExtraglom- erular Red cell casts May be present Absent Red cell morphology Dysmorphic Uniform Proteinuria May be present Absent Clots Absent May be present Color Cola ,Red or brown Red ◼ Almost always associated with glomerulonephritis or vasculitis Virtually exclude extra-renal causes of bleeding
- 9. Clinical Approach to Hematuria ◼Not to miss serious conditions ◼ Avoid unnecessary and expensive tests ◼ First decision :watchful follow up ,need for rapid work ups and/or referral to a subspecialist ◼ Reassure the family when appropriate ◼ Guidelines for further studies according to changes in the course of illness ◼ Careful history
- 10. History ◼ Timing ofhematuria and associated symptoms ◼ Trauma, exercise, stone passage, URTI, skin infection and medications ◼ Dysuria, frequency, urgency, back pain, skin rash, joint symptoms and edema ◼ Sickle cell disease or trait ◼ Family History: hematuria, stone, hypertension, renal failure,Tx , deafness & coagulopathy ◼ Menarche
- 11. Purposeful Physical Examination ◼General P/E , Edema , BP , Pallor ◼ Hypertension and edema determines how urgent the diagnostic evaluation be done ◼ Rash , impetigo ◼ Ecchymosis , petechia , hemangioma ◼ Abdominal mass(tumors, hydronephrosis) ◼ Flank tenderness (pyelonephritis , stone) ◼ Inspection of External genitalia ◼ Growth parameters ◼ State of hearing
- 12. Purposeful Urinalysis ◼ Lookfor : Shape of RBC RBC cast Proteinuria Pyuria Crystals ◼ Repeat UA for persistence of Hematuria
- 13. Child with LowerUrinary Symptoms ◼ Hematuria with dysuria, frequency, urgency, flank or abdominal pain is suggestive for : UTI, hypercalciuria or nephrolithiasis ◼ UTI : In 1/3 of cases associated with hematuria usually microscopic ◼ Hemorrhagic cystitis by adenovirus type 11 and 21 (5days GH then 2-3days micro-hematuria) ◼ Schistosomiasis
- 14. Child with ClinicalFeatures of Glomerulonephritis ◼ Acute nephritic syndrome: edema, ↑BP, oliguria, hematuria, ↓renal function ◼ Work up for different types of glomerulonephritis according to the History: ASO, C3,C4,ANA, Anti-dsDNA, ANCA, Serum IgA.
- 15. Asymptomatic Child :Incidental Microscopic Hematuria in U/A ◼ In routine check up or in a child with febrile illness or any other presentation ◼ Repeat U/A after resolution of current illness ◼ Repeat U/A twice within1- 2 weeks (+ in all) ◼ UA of siblings and Parents ◼ US ,BUN,Cr,Electrolytes, UCa/Cr ratio, U uric acid/Cr ratio ◼ Color doppler US of renal vessels ◼ Common causes of persistent micro-hematuria: Benign familial hematuria (TBMN), idiopathic hypercalciuria, IgA nephropathy and Alport syndrome
- 16. Hypercalciuria ◼ Noted in1981. ◼ Increase urinary excretion calcium with normal serum calcium levels. ◼ Ca/Cr ratio>0.21mg/mg *or >4mg/kg/day ◼ Measurement of urinary calcium excretion has become the standard part of the evaluation of hematuria in children. ◼ Had family history of renal stones. ◼ Rx: hydrochlorothiazide,do not restrict Ca * >7 years old
- 18. Causes of Hematuria Glomerular: ◼Post infectious GN ◼ IgA-Nephropathy ◼ Henoch –Schonlein nephritis ◼ Hereditary nephritis ◼ Benign familial hematuria ◼ MPGN ◼ Lupus nephritis ◼ Vasculitis associated GN ◼ Others Non glomerular: ◼ Nephrocalcinosis,stone, hypercalciuria ◼ Interstitial Nephritis, UTI ◼ Renal vein Thrombosis ◼ Sickle cell Dis. ◼ Vascular Malformations : Hemangioma and AVF, nutcracker syndrome ◼ Wilm’s Tumor ◼ Renal cell carcinoma ◼ Cystic disease ◼ Trauma
- 19. Follow up ofIsolated Hematuria ◼ Permanent disappearance of hematuria ◼ Change in nature with new symptoms or signs: further work ups ◼ persists and needs regular follow up with UA every 3-6MO, serum Cr and eventually may need a kidney Biopsy in case of persistence for one or 2 years ◼ When a cause is found treatment accordingly
- 20. Indications of RenalBiopsy ◼ In follow up of Hematuria if any of the following: - Proteinuria -Hypertension -Renal isufficiency ◼ Persistent low C3 following PSAGN ◼ Systemic disease with proteinuria: SLE, HSP, ANCA+vasculitis ◼ Family history suggestive of Alport syndrome ◼ Recurrent gross hematuria of unknown etiology ◼ Keeping in mind that all modalities of tissue study including light, EM, IF must be available ◼ Important Consideration For Family Anxiety, Insurance.
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- 22. Summary ◼ The urinalysis,history and physical examination guides to the cause of hematuria in most of the cases ◼ Significant renal dis.is ruled out with Hx , PE and a minimal amount of work ups in most of the children ◼ Simultaneous presence of hematuria with any of the followings: proteinuria , rise in serum creatinine, FTT and Hypertension increases the likelihood of significant renal dis.
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