Hematuria in children

(Visible and Non-Visible)

DR. SUKANYA GOVINDAN, MD(PAEDS), DM (NEPH),

FISN (UK)
CONSULTANT PEDIATRIC NEPHROLOGIST,
INTERVENTION NEPHROLOGIST & TRANSPLANT PHYSICIAN
MEHTA CHILDREN'S HOSPITAL, CHETPET
MEHTA HOSPITAL, GLOBAL CAMPUS, VELLAPANCHAVADI
We will discuss...

Definition
What to see?
How and when to investigate?
Treat it or ignore it?
DEFINITION
 Definition

Presence of > 3-5 RBCs per hpf (40) in 2 of 3 specimens

obtained over the span of several weeks

AAP - Presence of >5 RBCs per hpf (40) in 3

All of us have RBCs in urine – 1 million /day
consecutive specimens obtained Microscopic examination of Spun urine in a
high power field – 1-3 RBCs
over the span of several weeks
 Urine examination
• Freshly voided, midstream, clean catch
specimen
• 10 ml urine - 2000 rpm for 5 min
• 9ml decanted – sediment resuspended
• Examined at magnification x 400
• Average of at least 20 fields

• Gross hematuria – unspun urine

Urine dipstick - ?
Value
Peroxidase(psuedo) based strips
• Detects free hemoglobin, myoglobin
• Betadine
• Ascorbic acid

• Sensitivity – 100, specificity of 99 in detecting 1-

5 RBCs/hpf
• Equates to approximately 5 to 10 intact RBCs/lL urine
Scenarios
• Gross hematuria – true or pseudo

• Microscopic hematuria
• Urine microscopy
• Dipstick
• Counter
• Renal

• Glomerular
• Non glomerular
(interstitium, tubules, pelvis, vascular)

• Non renal
(ureters, bladder, urethra)
GLOMERULAR HEMATURIA
Glomerular hematuria

> 4mg/m2/hr or uPCR>0.2

RBCs IN URINE

• Isomorphic
• Crenated

• Dysmorphic > 40%

• Acanthocytes > 5%

Urinalysis: Core Curriculum 2008:AJKD

RBC casts
Cast
• Glomerular origin of RBCs RBC

• Tomm Horsfall Protein (mTAL)

THP

• Cast formation = THP+ RBC

RBC casts
Cast
RBC

THP
Clues for glomerular hematuria
Cola coloured or brown urine

Proteinuria

Dysmorphic RBCs

RBC casts

Clinically:

• Hypertension
• Edema
• Systemic features
Compartmental Diagnosis
• Renal

• Glomerular
• Non glomerular
(interstitium, tubules, pelvis, vascular)

• Non renal
(ureters, bladder, urethra)
 RENAL CAUSES
Macro and microvascular
Systemically unwell

Glomerular diseases
IgA nephropathy
Benign familial hematuria Recurrent hematuria
Alport’s syndrome

PSGN
MPGN
SLE
RPGN Extrarenal manifestations
HSP/IgA vasculitis
Goodpasture’s disease
History of preceding illness
or extrarenal symptoms,
BP, urinalysis, Serological
tests
RENAL CAUSES

Interstitial
Acute pyelonephritis
Acute interstitial nephritis
Tuberculosis
Hematologic

Tubular
Obstruction – stones or other
Calciuria
Cystic disease
Tumors
Drugs
Interstitial disease: (Bulky kidneys)
Pyelonephritis – WBC, WBC casts
Interstitial nephritis – eosinophils, serum sickness like
Tuberculosis – imaging, urinary AFB
*History of concurrent illness or symptoms
*Normal BP
*Urinalysis
*Infection screen
*USG/CT
*Biopsy
• Family history +ve
• Alport’s Syndrome
• Familial Hematuria
• IgA nephropathy
Hypertension
Edema
• Extrarenal manifestations
• Sore throat Glomerular hematuria
• Preceding or current rash ANA, Complements,
• Arthritis ANCA, antiGBM antibodies
• Gut
• ENT, eyes
• Lungs
Lower urinary tract

• Stones
• Obstruction – PUJO
• Infections
• Drugs
CLINICAL GROUPS
Clinical groups
Gross hematuria

Microscopic hematuria with clinical symptoms

Asymptomatic microscopic (isolated) hematuria

Asymptomatic microscopic hematuria with proteinuria

Gross hematuria
• Unselected pediatric population –0.13%

Ingelfinger JR et al Frequency and etiology of gross hematuria in a general pediatric setting. Pediatrics. 1977
Gross hematuria
• Unselected pediatric population –0.13%
26% UTI
11% perineal irritation
7% trauma
7% meatal stenosis
3% coagulopathy
2% stones

Ingelfinger JR et al Frequency and etiology of gross hematuria in a general pediatric setting. Pediatrics. 1977
Gross hematuria
• Unselected pediatric population –0.13%

23% unproven UTI

5% recurrent hematuria
4% acute nephritis
1% each – obstruction,
tumors, etc..

Ingelfinger JR et al Frequency and etiology of gross hematuria in a general pediatric setting. Pediatrics. 1977
 GROSS HEMATURIA

ETIOLOGY
C3, ASO titres, ANA,
UROLOGIST H/S/O Glomerulonephritis Complements
REFERRAL • Brownish urine
• Stone • Hypertension
• Trauma • Edema
• Tumors • RBC casts SEVERITY
• Proteinuria Azotemia,
hyperkalemia
Encephalopathy
LV failure
Family h/o
Trauma / UTI No history
stones

Renal US/CT, Renal US/CT, Test parents, urine

Urine culture metabolic workup Ca/Creat ratio
KEC Meyers et al. UCNA 2004
 MICROSCOPIC HEMATURIA

SYMPTOMS - General, Renal, Non renal, Family history

• Family history of progressive renal • No progressive renal disease in family

disease • Urinalysis – Isolated hematuria
• Urinalysis – glomerular hematuria • Urinary tract symptoms – pain
• Proteinuria
• Non –renal symptoms
Urinary ca/cr ratio

Eye, hearing test
Serological tests
Kidney biopsy
KEC Meyers et al. UCNA 2004
high
Normal
• Confirm with 24 hr urinary - ve family history of + ve family history
calcium hematuria of hematuria
• Treat for hypercalciuria –
hydration /thiazide observe and repeat
urinalysis in 6-12 months
Stones - Renal US
(Obstructive/non-
obstructive)
Isolated MH Familial MH
How and when to investigate?
• Biopsy
• Glomerular etiology
• Unexplained hematuria – monitoring is the key
• Parental anxiety

• Cystoscopy
• Lower urinary tract
• Persistent symptoms
How and when to investigate?

The American Academy of Pediatrics recommends a screening urinalysis

at school entry (4–5 years of age) and once during adolescence (11–21
years of age) as a component of well child–care
Follow up?
• Galveston epidemiology study (1977) - Texas
• 4% microscopic hematuria in asymptomatic school kids (1 of 3
samples)
• 1% when 2 of 3 samples tested
• <0.5% when all 3 tested
(37% had persistent hematuria at 1 year
7.6% had persistent hematuria at 5 years)
Treat it or ignore it?
Isolated microscopic hematuria which is asymptomatic

• Cost effective investigations

• US, parental and sibling urinalysis, urinary ca/creat ratio

• Choose between extensive workup and regular monitoring

• Investigate when
• Hypertension
• Proteinuria
• Extra renal symptoms
Is this hematuria?