Hematuria

COLLEEN BADKE
FEBRUARY 2016
 Hematuria in Children

 Definition: 5 or more RBCs per HPF in 3

consecutive, fresh, centrifuged specimens obtained
over several weeks
 Prevalence: 0.5-2% among school-aged children
 Typically found from routine urinalysis, when evaluating
urinary tract symptoms, or when a child has gross hematuria
 Most cases are isolated and benign
 Most common cause is UTI
 Increased incidence with fever, exercise

 Typically a medical, rather than urologic issue

 Rarely requires further work-up
 Evaluating for Hematuria

 Qualitative assessment: Urine dipstick

 Peroxidase chemical reaction between hemoglobin (or myoglobin)
and a colorimetric color indicator
 Can detect 3-5 RBCs/uL of unspun urine
 Very sensitive
 False negatives
 Formalin (urine preservative)
 High urinary concentrations of ascorbic acid (>2,000 U Vitamin C per
day)
 False positives
 Alkaline urine (pH > 9)
 Contamination with oxidizing agents used to clean perineum
(hydrogen peroxide)
 Confirm with microscopy of 10-15 mL freshly centrifuged
urine
 Initial Evaluation of Child with Hematuria

 Determine level of hematuria

 Upper tract

 Lower tract

 Determine urgency
 Based on symptomatology

 Special considerations
 Family history, anatomic abnormalities, presence of gross
hematuria, hypertension, edema, heart failure
 The Urine Tells it All…

 Upper tract
 Nephron (glomerulus, collecting tubules, interstitium)
 Glomerulus? Brown, cola, tea, or burgundy color
 Will likely see proteinuria > 100 mg/dL, RBC casts, deformed urinary
RBCs (acanthocytes)
 Collecting tubules?
 Leukocytes, renal tubular epithelial cell casts
 Lower tract
 Pelvocalyceal system, ureter, bladder, urethra
 Gross hematuria, pink or bright red
 Terminal hematuria
 Blood clots
 Normal urinary RBC morphology
 Minimal proteinuria on dipstick (<100 mg/dL)
 Other Clinical Clues…

 Tea- or cola-colored urine, facial or body edema,

hypertension, oliguria?
 Acute nephritic syndrome
 Post-strep glomerulonephritis
 IgA nephropathy
 Membranoproliferative glomerulonephritis
 HSP nephritis
 SLE nephritis
 The disease formerly known as Wegener’s
 Microscopic polyarteritis nodosa
 Goodpasture syndrome
 HUS
 Other Clinical Clues…

 Recent upper respiratory, GI, or skin infection?

 Post-infectious glomerulonephritis

 HUS

 HSP nephritis
 Other Clinical Clues…

 Rash and joint complaints?

 HSP nephritis

 SLE nephritis
 Other Clinical Clues…

 Fever, dysuria, frequency?

 Urinary tract infection
 Renal colic?
 Nephrolithiasis
 Flank mass?
 Hydronephrosis, renal cystic disease, renal vein thrombosis, tumor
 Headache, mental status changes, visual changes
(diplopia), epistaxis, heart failure
 Hypertension
 Perineal bruising
 Child abuse
 Family History

 Hereditary renal disease

 Hereditary nephritis (Alport’s Syndrome)

 Thin glomerular basement membrane disease

 SLE nephritis

 IgA nephropathy (Berger disease)

 Polycystic kidney disease

 Urolithiasis

 Sickle cell disease

 Physical Examination

 Hypertension, edema, heart failure

 Acute glomerulonephritis

 Malformations
 VATER (vertebral body, anal atresia, tracheoesophageal
fistula, renal dysplasia)
 Abdominal mass
 Posterior urethral valves, hydronephrosis, PKD, Wilm’s tumor

 Neurologic or cutaneous abnormalities

 Tuberous sclerosis, von Hippel-Lindau, Zellweger
(cerebrohepatorenal) syndrome
Diagnostic Approach
 Microscopy Positive?

 If there are >5 RBCs per HPF, repeat dipstick in 2-3

weeks
 2/3 of these children will have negative test
 A positive reaction for blood on dipstick in absence of
proteinuria with negative microscopic analysis is not usually
associated with disease
 3 positive tests over 2-3 weeks?
 Still unlikely to be significant disease
 Evaluate with urine culture
 Spot urine for hypercalciuria with calcium:creatinine ratio in
culture-negative patients
 Sickle cell screen in African-American patients
 Work-Up Still Negative?

 Urinalysis of all first-degree relatives

 Consider renal-bladder ultrasound
 Evaluate for tumor, cyst, hydronephrosis, urolithiasis

 Work-Up Still Negative?

 Serum creatinine and electrolytes
 Additional Findings/Clinical Clues

 Anemia
 Acute renal failure -> hypervolemia -> intravascular dilution
 Chronic renal failure -> decreased RBC production
 Hemolysis 2/2 HUS or SLE
 Blood loss 2/2 pulmonary hemorrhage (Goodpasture)
 Melena 2/2 HSP or HUS

 Thrombocytopenia
 Decreased platelet production (malignancy) or increased destruction
(SLE, ITP, HUS, renal vein thrombosis)
 Peripheral Smear with Schistocytes
 HUS

 Coombs Positive
 Autoantibodies from SLE (also see + ANA, leukopenia, multisystem
disease)
 Coagulation studies NOT routinely obtained
 Routine Monitoring of Hematuria

 If work-up is negative…
 Monitor blood pressure and urine every 3 months until
hematuria resolves
 When to Refer

 Refer to pediatric nephrologist if hematuria lasts > 1 year

 Or, refer if there are comorbidities
 Nephritis
 Hypertension
 Renal insufficiency
 Urolithiasis
 Nephrocalcinosis
 Family history of renal disease
 Abnormal U/A in the setting of chronic diseases that increase the
risk for CKD

 Not recommended to refer asymptomatic children with

isolated hematuria or mild proteinuria (urine
protein/creatinine ratio <0.5)
 AAP Recommendations for Screening

 Not recommended to obtain routine urinalyses for

asymptomatic children (as of 2007)
 Due to high rate of false positives
 Obtain routine U/A for patients at risk of chronic
kidney disease
 Special Considerations in Screening

 Urinalysis at every health maintenance visit (until at

least several are negative):
 Diabetes mellitus
 History of post-infectious acute glomerulonephritis
 Acute renal failure
 HSP
 Urinalysis at every or every other health
maintenance visit:
 Sickle cell disease or trait
 Strong family history of renal disease
 Special Considerations in Screening

 Consider routine urinalysis in:

 Children with BMI > 97th %ile

 History of prenatal (or postnatal) hydronephrosis

 History of prematurity (< 32 weeks)

 Strong family history of nephrolithiasis

 Red urine without RBCs…

 Hemoglobinuria
 Myoglobinuria
 Drugs (metronidazole, rifampin)
 Foods (blackberries, beets, rhubarb)
 Food dyes
 Urinary metabolites (melanin, porphyrin, urates)
 References

 Clinical Evaluation of the Child with Hematuria.

Nelson’s Textbook of Pediatrics. 19th Edition.
Chapter 503. Accessed online.
 Massengill SF. Hematuria. Pediatrics in Review
2008;29(10).
 Primack W. AAP does not recommend routine
urinalysis for asymptomatic youths. AAP News,
November 29, 2010.