This document provides an overview of hematuria in children, including definitions, causes, evaluation, and diagnostic approach. It begins by defining hematuria and discussing qualitative urine dipstick tests. Potential causes of hematuria are then outlined, separated into upper and lower urinary tract sources as well as isolated renal, multisystem, tubulointerstitial, and anatomic disorders. Evaluation involves history, exam, urinalysis to determine hematuria level and urgency. Further tests may include CBC, chemistry, coagulation studies, C3 level, ANA, cystoscopy. Children with isolated microscopic hematuria and normal evaluation should be monitored every 3 months until resolved. Renal biopsy is indicated for persistent hematuria with other abnormalities.

1. Dr Jitendra verma
Assistant prof.
Dept of pediatric medicine
RVRS Medical collage,Bhilwara
Clinical Evaluation of the Child
With
Hematuria

2. Defination
Hematuria, persistent presence of more than 5 red blood cells (RBCs)/high power field
(HPF) in uncentrifuged urine.
In the clinical setting, qualitative estimates are provided by a urinary dipstick that uses
a very sensitive peroxidase chemical reaction between hemoglobin (or myoglobin)
and a colorimetric chemical indicator impregnated on the dipstick.
Chemstrip (Boehringer Mannheim), a common commercially available dipstick, is very
sensitive and capable of detecting 3-5 RBCs/HPF of unspun urine. The presence of 10-
50 RBCs/μL may suggest underlying pathology,
significant hematuria is generally considered as > 50 RBCs/HPF. False-negative results
can occur in the presence of formalin (used as a urine preservative) or high urinary
concentrations of ascorbic acid (i.e., in patients with vitamin C intake > 2,000 mg/day).
False-positive results may be seen in a child with an alkaline urine (pH > 8), or more
commonly following contamination with oxidizing agents such as hydrogen peroxide
used to clean the perineum before obtaining a specimen.

3. Other Causes of Red Urine
HEME POSITIVE
Hemoglobin
Myoglobin
HEME NEGATIVE
Drugs
Adriamycin
Chloroquine
Deferoxamine
Hydroxycobalamin
Ibuprofen
Iron sorbitol
Levodopa
Metronidazole
Nitrofurantoin
Phenazopyridine
(Pyridium)
Phenolphthalein
Phenothiazines
Phenytoin
Quinine
Rifampin
Salicylates
Sulfasalazine
Dyes
(Vegetable/Fruit)
Beets
Blackberries
Blueberries
Food and candy
coloring
Paprika
Rhubarb
Metabolites
Homogentisic acid
Melanin
Methemoglobin
Porphyrin
Tyrosinosis
Urates

4. Evaluation of the child with hematuria begins with a careful history, physical
examination, and microscopic urinalysis. This information is used to determine the
level of hematuria (upper vs lower urinary tract) and to determine the urgency of the
evaluation based on symptomatology.

5. →Upper urinary tract sources of hematuria originate within the nephron (glomerulus,
tubular system, or interstitium).
•Color-brown, cola- or tea-colored, or burgundy urine.
•Proteinuria- > 100mg/dL via dipstick.
•microscopic findings - RBC casts, and deformed urinary RBCs (particularly
acanthocytes).
→Lower urinary tract sources of hematuria originate from the pelvocaliceal system,
ureter, bladder, or urethra.
•Color-bright red or pink.
•microscopic findings -blood clots, normal urinary RBC.
•proteinuria on dipstick is minimal (<100 mg/dL).

6. Causes of Hematuria in
Children
Isolated Renal Disease
1.IgA nephropathy (Berger
disease)
2.Alport syndrome (hereditary
nephritis)
3.Thin glomerular basement
membrane nephropathy
4.Postinfectious GN (PSGN)*
5.Membranous
nephropathy(MGN)
6.Membranoproliferative
GN(MPGN)
7.Rapidly progressive
GN(RPGN)
8.Focal segmental
glomerulosclerosis
(FSGS)
9.Anti–glomerular basement
membrane disease
Multisystem
Disease
1.SLE-nephritis*
2.HSP-nephritis
3.Granulomatosis
with polyangiitis
(formerly
4.Wegener
granulomatosis)
5.PAN
6.Goodpasture
syndrome
7.HUS
8.Sickle cell
glomerulopathy
9.HIV
nephropathy
Tubulointerstitial
Disease
1.Pyelonephritis
2.Interstitial nephritis
3.Papillary necrosis
4.Acute tubular necrosis
Vascular Disorders
1.Arterial or venous
thrombosis
Malformations
(aneurysms,
hemangiomas)
2.Nutcracker syndrome
3.Hemoglobinopathy
(sickle cell trait/disease)
4.Crystalluria

7. Anatomic Disorders
1.Hydronephrosis
2,Cystic-syndromic kidney disease
3.Polycystic kidney disease
4.Multicystic dysplasia
5.Tumor (Wilms tumor, rhabdomyosarcoma, angiomyolipoma, medullary
carcinoma)
6.Trauma
LOWER URINARY TRACT DISEASE
1. Inflammation (infectious and noninfectious)
2. Cystitis
3. Urethritis
4. Urolithiasis
5. Trauma
6. Coagulopathy
7. Heavy exercise
8. Bladder tumor
9. Factitious syndrome, factitious syndrome by proxy

8. Specific symptoms
1.Tea- or cola-colored urine, facial or body edema, hypertension, and oliguria classic
symptoms of glomerulonephritis.
2.A history of recent upper respiratory, skin, or gastrointestinal infection suggests
postinfectious glomerulonephritis, hemolytic-uremic syndrome, or HSP.
3.Rash and joint complaints suggest HSP or SLE nephritis.
4. Hematuria associated with glomerulonephritis is typically painless, but can be
associated with flank pain when acute or unusually severe.
5. Frequency, dysuria, and unexplained fevers suggest a urinary tract infection,
whereas renal colic suggests nephrolithiasis
,

9. 6. A flank mass can suggest hydronephrosis, renal cystic diseases, renal vein
thrombosis, or tumor.
7. Hematuria associated with headache, mental status changes, visual changes
(diplopia), epistaxis, or heart failure suggests associated severe hypertension.
8. Child abuse must always be suspected in the child presenting with unexplained
perineal bruising and hematuria.
9. family history is critical in the initial assessment of isolated Alport syndrome, thin
glomerular basement membrane disease; SLE nephritis, HANAC, IgA
nephropathy,PCKD.
10. Physical examination may also suggest possible causes of hematuria.
11.Several malformation syndromes are associated with renal disease, including VATER
(vertebral-body anomalies, anal-atresia, trache-oesophageal fistula, and renal
dysplasia) syndrome.

10. 12.Abdominal masses may be caused by bladder distention in posterior urethral
valves, hydronephrosis in ureteropelvic junction obstruction, polycystic kidney disease,
or Wilms tumor.
13. Hematuria seen in patients with neurologic or cutaneous abnormalities may be the
result of a number of syndromic renal disorders, including tuberous sclerosis, von
Hippel-Lindau syndrome, and Zellweger (cerebrohepatorenal) syndrome.
14. Anatomic abnormalities of the external genitalia may be associated with hematuria
and/or renal disease.
15.Urethrorrhagia --which is urethral bleeding in the absence of urine, is associated
with dysuria and blood spots on underwear after voiding. in pre-pubertal boys ,benign
self-limited course.
16.Recurrent episodes of gross hematuria suggest IgA nephropathy, Alport syndrome,
or thin glomerular basement membrane disease.
17.Dysuria and abdominal or flank pain are symptoms of idiopathic hypercalciuria, or
urolithiasis.

11. Asymptomatic patients with isolated microscopic
hematuria should not undergo extensive diagnostic
evaluation, because such hematuria is often
transient and benign.

12. Common Causes of Gross Hematuria--
1. Urinary tract infection--MCC
2. Meatal stenosis with ulcer
3. Perineal irritation
4. Trauma
5. Urolithiasis
6. Hypercalciuria
7. Obstruction
8. Coagulopathy
9. Tumor
10.Glomerular disease
11.Postinfectious glomerulonephritis
12.Henoch-Schönlein purpura nephritis
13.IgA nephropathy
14.Alport syndrome (hereditary nephritis)
15.Thin glomerular basement membrane disease
16.Systemic lupus erythematosus nephritis

13. CAUSE OF ANAEMIA
1.acute kidney injury --Anemia in this setting may be caused by hypervolemia with
dilution
2. chronic kidney disease --decreased RBC production(REDUCED ERYTHROPOITIN)
3.hemolytic-uremic syndrome- hemolysis
4. SLE – chronic hemolytic anemia,.
5. Goodpasture syndrome --blood loss from pulmonary hemorrhage.
6. HSP or hemolytic-uremic Syndrome—melena.

14. Diagnostic
algorithm

15. INVESTIGATIONS
1.CBC-- A. Thrombocytopenia
decreased platelet production--
(malignancies)
increased platelet consumption--
(SLE, idiopathic thrombocytopenic
purpura,
hemolytic-uremic syndrome, renal vein
thrombosis, or congenital hepatic
fibrosis with portal hypertension
secondary to autosomal recessive
polycystic
kidney disease)
B. Low Hb
C.Reduced RBCs
2. PBF-- A. microangiopathic process consistent with the hemolytic-uremic
syndrome
B. Shape of RBCs-upper and lower urinary tract.
3. Chemistry
- Electrolytes, BUN/ Creatinine /Creatinine clearance, Serum protein/Albumin
/Cholesterol

16. ‘’ A bleeding diathesis is an unusual cause of hematuria,
and coagulation studies are not routinely obtained unless a
personal or family history suggests a bleeding tendency.’’
4. Level of C3---Low in PIGN in 90% cases (due to activation of compliment
pathway.
return to normal within 6 weeks.
C4 level remains normal.
Reduced C3 in - Post infectious glomerulonephritis
- Systemic lupus nephritis (and low C4)
- Nephritis with chronic infection
- Membrano proliferative
glomerulonephritis
5. ANA
6.ASO/Anti-DNase B

17. 5.voiding cystourethrogram-- only required in patients with a urinary tract
infection, renal scarring, hydroureter, or pyelocaliectasis.
6 Cystoscopy --an unnecessary and costly procedure in most pediatric
patients with hematuria, and carries the associated risks of anesthesia. This
procedure should be reserved for
evaluating the rare child with a bladder mass noted on ultrasound, urethral
abnormalities caused by trauma, posterior urethral
valves, or tumor.
7. Children with persistent asymptomatic isolated hematuria and a completel
normal evaluation should have their blood pressure and urine checked every
3 mo until the hematuria resolves.
8. Renal biopsy is indicated for some children with persistent microscopic
hematuria and for most children with recurrent gross hematuria associated with
decreased renal function, proteinuria, or hypertension.

18. Source. 1.Nelson 21st edition
2. Kishor pediatric
nephrology

19. THANK YOU
Dr Jitendra verma
Assistant prof.
Dept of pediatric medicine
RVRS Medical collage,Bhilwara