This document discusses several causes of hematuria in pediatrics including IgA nephropathy, Alport syndrome, acute poststreptococcal glomerulonephritis (APSGN), and hemolytic-uremic syndrome (HUS). IgA nephropathy is the most common chronic glomerular disease in children characterized by IgA deposits in the glomeruli. Alport syndrome is a hereditary nephritis caused by mutations in type IV collagen genes. APSGN occurs 1-2 weeks after a streptococcal infection and presents with gross hematuria, edema, and renal impairment. HUS is characterized by microangiopathic hemolytic anemia, thrombocytopenia,

1. 1
PEDIATRICS HEMATURIA
Hematuria
Hematuria is defined as the presence of at least 5 red blood cells (RBCs) per microliter of
urine and occurs with a prevalence of 0.5-2.0% among school-age children.
The presence of 10-50 RBCs/μL may suggest underlying pathology, but significant hematuria
is generally considered as >50 RBCs/μL.
COMMON CAUSES OF GROSSE HEMATURIA
1. UTI common cause of hematuria
2. meatal stenosis
3. perinatal irritation
4. trauma
5. stone
6. coagulopathy
7. tumor
8. glomeruler diseases(IgA nephropathy, post infectious GN, HSP, SLE
Other Causes of Red Urine
• Hemoglobinuria
• Myoglobinuria
• Drugs
Chloroquine, Deferoxamine, Hydroxycobalamin,Ibuprofen, Iron, sorbitol……
• Dyes (Vegetable/Fruit)
• Metabolites Homogentisic acid, Melanin,Methemoglobin, Porphyrin, Tyrosinosis
IMMUNOGLOBULIN A NEPHROPATHY (BERGER NEPHROPATHY)
IgA nephropathy is the most common chronic glomerular disease in children.
It is characterized by a predominance of IgA within mesangial glomerular deposits in the
absence of systemic disease. serum level of IGA ‫عىل‬ ‫مانعتمد‬
Clinical and laboratory manifestations
• IgA nephropathy is seen more often in male than in female patients.
• A majority of children with IgA nephropathy present with gross hematuria.
• Gross hematuria often occurs within 1-2 days of onset of an upper respiratory or
gastrointestinal infection, in contrast to the longer latency period observed in acute
PSGN, and may be associated with loin pain.
• Proteinuria is often <1000 mg/24 hr in patients with asymptomatic microscopic
hematuria. ‫رينج‬ ‫النفروتك‬ ‫من‬ ‫اقل‬

2. 2
PEDIATRICS HEMATURIA
• Mild to moderate hypertension is most often seen in patients with nephritic or nephrotic
syndrome.
• Normal serum levels of C3 in IgA nephropathy help to distinguish this disorder from PSGN.
• Serum IgA levels have no diagnostic value because they are elevated in only 15% of
pediatric patients.
PROGNOSIS
Although IgA nephropathy does not lead to significant kidney damage in most children,
progressive disease develops in 20-30% of patients 15-20 yr after disease onset.
Poor prognostic indicators :
• include persistent hypertension
• diminished renal function
• significant, increasing, or prolonged
proteinuria
A more severe prognosis is correlated with histologic evidence of diffuse mesangial
proliferation, extensive glomerular crescents, glomerulosclerosis, and diffuse
tubulointerstitial changes, including inflammation and fibrosis.
TREATMENT
The primary treatment of IgA nephropathy is appropriate blood pressure control and
management of significant proteinuria.
• Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists are
effective in reducing proteinuria .
• Fish oil, which contains anti-inflammatory omega-3 polyunsaturated fatty acids
• Corticosteroids. ‫ي‬
‫عىل‬ ‫مختلف‬
• Tonsillectomy. ‫تنشا‬ ‫ما‬
‫ل‬
‫ال‬ ‫قبل‬
5
‫سنوات‬
• kidney transplantation.
ALPORT SYNDROME
AS, or hereditary nephritis, is a genetically heterogeneous disease caused by mutations in
the genes coding for type IV collagen, a major component of basement membranes.
Genetics
• Approximately 85% of patients have X-linked inheritance.
• An autosomal recessive 10%.
• An autosomal dominant 5% of cases.

3. 3
PEDIATRICS HEMATURIA
CLINICAL MANIFESTATIONS
All patients with AS have asymptomatic microscopic hematuria, which may be intermittent
in girls and younger boys.
Single or recurrent episodes of gross hematuria commonly occurring 1-2 days after an upper
respiratory infection are seen in approximately 50% of patients.
Progressive proteinuria, often exceeding 1 g/24 hr, is common by the 2nd decade of life and
can be severe enough to cause nephrotic syndrome.
Bilateral sensorineural hearing loss (which is never congenital),develops in 90% of
hemizygous males with X-linked AS.
Ocular abnormalities, which occur in 30-40% of patients with X-inked AS include anterior
lenticonus (extrusion of the central portion of the lens into the anterior chamber) is
pathognomonic
DIAGNOSIS
A combination of careful family history, a screening urinalysis of 1st degree relatives,
an audiogram, and an ophthalmologic examination are critical in making the diagnosis of AS.

4. 4
PEDIATRICS HEMATURIA
PROGNOSIS AND TREATMENT
• The risk of progressive renal dysfunction leading to end stage renal disease (ESRD) is
highest among hemizygotes and autosomal recessive homozygotes.
• ESRD occurs before age 30 yr in approximately 75%.
• No specific therapy is available to treat AS, although ) angiotensin-2 receptor inhibitors)
can slow the rate of progression.
• Careful management of renal failure complications such as hypertension, anemia, and
electrolyte imbalance is critical.
• Patients with ESRD are treated with dialysis and kidney transplantation
ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS (APSGN)
Is a classic example of the acute nephritic syndrome characterized by the sudden onset of
gross hematuria, edema, hypertension, and renal insufficiency.
It is one of the most common glomerular causes of gross hematuria in children and is a
major cause of morbidity in group A β-hemolytic streptococcal infections.
‫ال‬ ‫استخدام‬ ‫بسبب‬ ‫قليل‬ ‫هسة‬
‫ة‬ ‫ر‬
‫بكث‬ ‫بايوتك‬ ‫ي‬
‫نت‬
ETIOLOGY AND EPIDEMIOLOGY
Poststreptococcal GN commonly follows
streptococcal pharyngitis (serotype 12)
during cold-weather months and
streptococcal skin infections or pyoderma
(serotype 49) during warm-weather
months.
PATHOLOGY
Glomeruli appear enlarged and relatively
bloodless and show diffuse mesangial cell
proliferation, with an increase in mesangial
matrix
PATHOGENESIS
circulating antibodies elicited by

5. 5
PEDIATRICS HEMATURIA
streptococcal antigens react with normal glomerular antigens
CLINICAL MANIFESTATIONS
• Poststreptococcal GN is most common in children ages 5-12 yr and uncommon before the
age of 3yr.
• The typical patient develops an acute nephritic syndrome 1-2 wk after a streptococcal
pharyngitis or 3-6 wk after a streptococcal pyoderma.
• The severity of kidney involvement varies from asymptomatic microscopic hematuria with
normal renal function to gross hematuria with acute renal failure.
• nephrotic syndrome develops in a minority (<5%) of childhood cases.
• Nonspecific symptoms such as malaise, lethargy, abdominal pain, or flank pain are
common.
• The acute phase generally resolves within 6-8 wk. Although urinary protein excretion and
hypertension usually normalize by 4-6 wk after onset.
• persistent microscopic hematuria can persist for 1-2 yr after the initial presentation.
DIAGNOSIS
• Urinalysis demonstrates red blood cells, often in association with red blood cell casts,
proteinuria, and polymorphonuclear leukocytes.
• mild normochromic anemia may be present from hemodilution and low-grade hemolysis.
• Blood urea and serum creatinine either normal or increase.
• The serum C3 level is significantly reduced and returns to normal 6-8 wk after onset.
• Although serum CH50 is commonly depressed, C4 is most often normal in APSGN, or
only mildly depressed.
Confirmation of the diagnosis requires clear evidence ‫لزم‬ of a prior streptococcal infection.
A rising antibody titer to streptococcal antigen(s) confirms a recent streptococcal infection.
The antistreptolysin O titer is commonly elevated after a pharyngeal infection but rarely
increases after streptococcal skin infections.
The best single antibody titer to document cutaneous streptococcal infection is the
antideoxyribonuclease B level.
A positive throat culture report might support the diagnosis or might represent the carrier
state.
Magnetic resonance imaging of the brain is indicated in patients with severe neurologic
symptoms and can demonstrate posterior reversible
encephalopathy syndrome in the parietooccipital areas on T2-weighted images.

6. 6
PEDIATRICS HEMATURIA
Chest x-ray is indicated in those with signs of heart failure or respiratory distress, or physical
exam findings of a heart gallop, decreased breath sounds, rales, or hypoxemia.
The clinical diagnosis of poststreptococcal GN is quite likely in a child presenting with
acute nephritic syndrome, low C3 level, and evidence streptococcal infection.
Differential Diagnoses
IgA
SLE
HSP
Endocarditis
membranoproliferative GN
an acute exacerbation of chronic GN.
RENAL BIOPSY ‫مهم‬
should be considered only in the presence of
1.acute renal failure
2.nephrotic syndrome
3.absence of evidence of streptococcal
infection
4.normal complement C3, C4 levels.
5.hematuria and proteinuria, diminished renal
function, and/or a low C3 level persist more
th an 2 mo after onset.
COMPLICATIONS
Acute complications result from hypertension and acute renal dysfunction.
Hypertension is seen in 60%, and hypertensive encephalopathy in 10% of cases
Other potential complications include heart failure, hyperkalemia, hyperphosphatemia,
hypocalcemia, acidosis, and seizures
PREVENTION
1.Early systemic antibiotic therapy for streptococcal throat and skin infections does not
eliminate the risk of GN.
2.Family members of patients with acute GN, especially young children, should be
considered at risk and be cultured for group A β-hemolytic streptococci and treated if

7. 7
PEDIATRICS HEMATURIA
positive.
3.Family pets, particularly dogs, have also been reported as carriers.
TREATMENT
1. Management is directed at treating the acute effects of renal
insufficiency and hypertension.
2. Although a 10 day course of systemic antibiotic therapy with penicillin is recommended
to limit the spread of the nephritogenic organisms, antibiotic therapy does not affect the
natural history of APSGN.
3. Sodium restriction, diuresis (usually with intravenous furosemide), and pharmacotherapy
with calcium channel antagonists, vasodilators, or ACEI are standard therapies used to treat
hypertension.
PROGNOSIS
Complete recovery occurs in >95% of children with APSGN. Sometime patient still complain
from microscopic hematuria 2 year
Recurrences are extremely rare. ‫عليها‬‫كز‬
‫ر‬
HEMOLYTIC-UREMIC SYNDROME (HUS)
is a common cause of community acquired acute
kidney injury in young children. It is characterized
by the triad of
❶microangiopathic hemolytic anemia.
❷thrombocytopenia ❸ renal insufficiency.
ETIOLOGY
The various etiologies infection-induced, genetic,
medication-induced and associated with systemic
diseases.
The most common form of HUS is caused by toxin-
producing Escherichia coli that causes prodromal
acute enteritis and is commonly termed diarrhea.
PATHOGENESIS

8. 8
PEDIATRICS HEMATURIA
• Microvascular injury with endothelial cell damage is characteristic of all forms of HUS.
• In each form of HUS, capillary and arteriolar endothelial injury in the kidney leads to
localized thrombosis, particularly in glomeruli, causing a direct decrease in glomerular
filtration.
• Progressive platelet aggregation in the areas of microvascular injury results in
consumptive thrombocytopenia.
• Microangiopathic hemolytic anemia results from mechanical damage to red blood cells as
they pass through the damaged and thrombotic microvasculature.
CLINICAL MANIFESTATIONS
• HUS is most common in preschool and school-age children, but it can occur in adolescents
and adults.
• In HUS caused by toxigenic E. coli, onset of HUS occurs a few days after onset of
gastroenteritis with fever, vomiting, abdominal pain, and diarrhea.
• The diarrhea is often bloody, but not necessarily so.
• The sudden onset of pallor, irritability, weakness, and lethargy heralds the onset of HUS.
Oliguria can be present in early stages but may be masked by ongoing diarrhea, because the
prodromal enteritis often overlaps the onset of HUS, particularly with ingestion of large
doses of toxin.
• Thus, patients with HUS can present with either significant dehydration or volume
overload.
• HUS can be relatively mild, or can progress to a severe and fatal multisystem disease.
• Leukocytosis, severe prodromal enteritis, and hyponatremia.
• Patients with HUS who appear mildly affected at presentation can rapidly develop severe,
multisystem, lifethreatening complications.
• Renal insufficiency can be mild but also can rapidly evolve into severe oliguric or anuric
renal failure.
• The combination of rapidly developing renal failure and severe hemolysis can result in life-
threatening hyperkalemia.
• Volume overload, hypertension, and severe anemia can all develop soon after onset of
HUS, and together can precipitate heart failure.
• The majority of patients with HUS have some central nervous system (CNS) involvement.
• Most have mild manifestations, with significant irritability, lethargy, or nonspecific
encephalopathic features.

9. 9
PEDIATRICS HEMATURIA
• Severe CNS involvement occurs in ≤20% of cases. Mostly non diarrhea associated.
• Seizures and significant encephalopathy are the most common manifestations in those
with severe CNS involvement, resulting from focal ischemia secondary to microvascular CNS
thrombosis.
• Patients can develop petechiae, but significant or severe bleeding is rare despite very low
platelet counts.
DIAGNOSIS
The diagnosis is made by the combination of
1. microangiopathic hemolytic anemia with schistocytes (the anemia can be mild at
presentation, but rapidly progresses)
2. thrombocytopenia (Thrombocytopenia is an invariable finding in the acute phase, with
platelet counts usually 20,000-100,000/mm3 )
3. some degree of kidney involvement(vary from mild elevations in serum blood urea
nitrogen and creatinine to acute anuric kidney failure)
Differential Diagnoses
SLE, malignant hypertension, and bilateral renal vein thrombosis
PROGNOSIS
• The mortality for diarrhea-associated HUS is <5% ‫كنوسس‬ ‫ر‬
‫بالث‬
‫نوع‬ ‫احسن‬ in most major
medical centers.
• Up to half of patients may require dialysis support during the acute phase of the disease.
• Most recover renal function completely, but of surviving patients, 5% remain dependent
on dialysis
• up to 30% are left with some degree of chronic renal insufficiency.
• The prognosis for HUS not associated with diarrhea, and the familial, genetic forms of HUS
are have a poor prognosis
TREATMENT
Supportive care
includes careful management of fluid and electrolytes, including prompt correction of
volume deficit, control of hypertension, and early institution of dialysis if the patient
becomes significantly oliguric or anuric, particularly with hyperkalemia.

10. 10
PEDIATRICS HEMATURIA
Red cell transfusions are usually required as hemolysis can be brisk and recurrent until the
active phase of the disease has resolved.
Despite low platelet counts, serious bleeding is very rare in patients with HUS.
Anticoagulation, antiplatelet, and fibrinolytic therapies are specifically contraindicated
because they increase the risk of serious hemorrhage.
Antibiotic therapy to clear enteric toxigenic organisms (STEC) can result in increased toxin
release, potentially exacerbating
Plasma infusion or plasmapheresis has been proposed for patients suffering severe
manifestations of HUS with serious CNS involvement.