Hematuria
11/14/2014
• Pediatric Continuity Clinic
Curriculum
• Created by: Faris Hashim
6/27/2016
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Objectives
1. Be able to define hematuria
2. List the common conditions associated with
hematuria
3. Plan a practical and systematic approach to the
evaluation of hematuria
4. Understand when referral is warranted
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Case #1
Parents present to your clinic with their 10 y/o son
for WCC. He said some time “It hurt when I pee”.
Urine dipstick was +ve for blood.
Parents never noted any blood or redness in their
son’s urine and are extremely worried.
The patient is otherwise asymptomatic and is an
active and healthy child.
The mom states that her father had a history of
kidney stones. You ordered a urinalysis with urine
sediment and found microscopic hematuria with no
proteinuria.
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Q1: Should every patient get a screening
urinalysis in WCC?
• Urine dipstick is inexpensive, but it is a poor
screening test for CKD and a cost-ineffective
procedure for the primary care provider.
• In 2007, the American Academy of Pediatrics
issued a new recommendation to discontinue this
screening.
• Pediatrics 2007;120;1376
Recommendations for Preventive Pediatric Health Care
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Q2: How do you define microscopic hematuria?
• Hematuria is defined as the presence of ≥5
RBCs per HPF (40X) in 3 consecutive fresh,
centrifuged specimens obtained over 2-3
weeks before initiating further evaluation.
• Microscopic hematuria is far more common
than macroscopic hematuria.
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Q3: What is isolated Hematuria?
• It is an asymptomatic hematuria which rarely found to
have significant renal disease and, therefore, do not
warrant an extensive evaluation.
• FHx is particularly important to assess for possible
benign familial hematuria(thin BM disorder). Often,
multiple family members have hx of hematuria but are
free of the long-term complications of progressive
renal insufficiency, hearing, or ocular abnormalities
that seen in those who have Alport’s syndrome.
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Q4: What is hypercalciuria ?
- Hypercalciuria frequently associated with asymptomatic
hematuria, some affected chilren are at risk for developing
symptomatic urolithiasis.
- Hypercalciuria is defined as a urinary ca/cr ratio of > 0.2 (or >0.8
in <6 m ; >0.6 in 7-18 m ) confirmed by 24-hour urinary calcium
excretion >4 mg/kg/d.
- Hypercalciuria in most cases is idiopathic, but other
considerations include immobilization, diuretics, vitamin D
intoxication, hyperparathyroidism, and sarcoidosis.
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Case #2
• An 8 y/o M presents with cola-colored urine without
blood clots. He was well until 2 days ago, when he
developed a sore throat with URI symptoms. He denies
any dysuria, frequency, urgency, flank pain, or trauma.
On physical examination, his temp is 37.8, HR is 84, RR
18 , and BP 118/78. He has no costovertebral
tenderness, abdominal tenderness, or edema.
• UA reveals: SG 1.025, pH 6.0, 3+ blood, 3+ protein, 1+
LE, -ve Nitrite. Microscopy shows ≥100 RBC/HPF and 510 WBC cells/hpf. BUN 24 , Cr 0.9 ,C3 140, C4 30 , ANA
negative .
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Q1: What is the difference in hematuria
presentation between IgA and Post infectious
GN?
• In IgA there is 2-day lag period between the URI
symptoms and the nephritis is sometimes described
as synpharyngitic, which is characteristic for IgA GN.
• In postinfectious or PSGN, 7- to 21-day lag period is
seen between the onset of pharyngitis and the
development of gross hematuria.
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Q2: Which presentation has better
prognosis in IgA nephropathy ?
• IgA nephtopathy can also present with
asymptomatic hematuria or hematuria/proteinuria.
• Patients who have gross hematuria have a better
prognosis.
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Case #3
- An 8 y/o F is referred for evaluation of hematuria,
proteinuria, and HT. She has had recurrent episodes of gross
hematuria. The first was at 3 y and was attributed to UTI, but
a Ucx was -ve. She was treated with 10 days of Abx, and the
symptoms resolved. The second episode, at age 5 y, was
attributed to acute PSGN, although an ASO titer was normal,
and complement studies were not ordered. BP at that time
was 120/80 mm Hg (normal for age and height is 94/54 mm
Hg).
- The girl was lost to follow-up and presents 3 years later with HT,
gross hematuria, and generalized edema.
- UA is cola colored, shows heavy to count dysmorphic (RBCs),
proteinuria, and RBC casts.
*
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Pediatrics in Review 2008
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Q1: How we can confirm hematuria?
• Confirmation of hematuria is critical. A positive urine
dipstick test may result from myoglobinuria or Hb uria, in
which the urine often is discolored, but no RBCs are noted
on microscopic evaluation.
• Medications (sulfonamides, nitrofurantoin, salicylates,
phenazopyridine), toxins (lead, benzene), and foods (food
coloring, beets, blackberries) may falsely discolor urine, in
which case the urine dipstick test is negative for heme.
• In newborns, a red or pink discoloration in the diaper can
be seen when urate crystals precipitate in the urine.
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Hallmarks of glomerular bleeding are coloa
colored urine, RBC casts, and distorted RBC
morphology
Red blood cell cast
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Phase-contrast microscopy showing
dysmorphic red blood cells
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Q2: What are important questions in the
history of a child with hematuria?
 History of fever, dysuria, and increased urgency may suggest an infectious
etiology.
 Flank pain may point to kidney stones.
 Color of the urine can help distinguish between problems of the urinary
tract (bright red blood) or a glomerular bleed (tea or cola-colored).
 Hx of trauma or medications.
 -Hematuria in the family points to benign familial hematuria, high rate of
kidney stones makes hypercalciuria probable, and hearing loss suggests
Alport’s Syndrome.
 It is also important to elicit if any relatives are on dialysis or are candidates
for renal transplant.
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Q3: What are important elements of
the physical exam?
Vitals should include measurement of BP and
assessment for recent weight gain.
Pertinent findings on physical exam include
edema, abdominal masses, suprapubic or
flank pain, genital/urethral trauma, or
evidence of purpura or rashes.
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Q4: What are initial laboratory
evaluations to consider in a child with
hematuria?
• First, it is important to repeat the urine test to see if
the hematuria persists.
• UA with microscopic exam should be done to
evaluate for RBC, RBC casts, protein, or WBC within
the urine sediment.
• Obtain a spot calcium to creatinine ratio and if >0.2,
get a renal ultrasound to evaluate for urolithiasis.
• CBC and BMP.
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• Further evaluation should be based on the history.
• For a child with recent infection and proteinuria,
send an ASO, anti-Dnase B, and C3 level (may be
decreased) to evaluate for PSGN. Anytime there is
hematuria with proteinuria, also add an ANA to
check for SLE.
• In AA children, get hemoglobin electrophoresis to
look for SS trait or disease.
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When to Refer to a Pediatric
Nephrologist
 Hematuria with proteinuria is always pathologic
and should be referred to nephrology.
 The patient who has asymptomatic hematuria
needs periodic evaluation every 1 to 2 years to
re-evaluate for coexisting symptoms or
proteinuria and to revisit the family history with
respect to other family members having
hematuria or hearing deficits.
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PREP Question
• A 2-y/o M presents with a 3-day hx of diarrhea that is now
resolving. His mother is concerned because he has developed
mild swelling associated with fewer wet diapers per day. His
review of systems is negative for fever, gross hematuria,
rashes, and apparent pain with urination. PE of the febrile
child reveals HR 110 ,RR 22, BP 116/82, wt 14 kg (75th%), and
HT 90 cm (75th%). MM are moist and oropharynx is clear.
Chest examination reveals no crackles; cardiac examination is
negative for a gallop rhythm, and extremities reveal mild pedal
swelling with capillary refill of less than 2 seconds and full
pulses. A small amount of urine was produced and sent for
urinalysis. Laboratory tests reveal the following results:
• Na, 140 ,K, 5.9, Cl 100 , Hco2, 14, BUN 44, Cr 2.3 , Ph, 6.5, Mg
2.3, Alb, 3.1, CBC: wbc, 18,500, Hb, 8.4, HCT 26%, Plat 82000.
UA: SG , 1.015, pH, 6, 3+ blood, 3+ protein, LE, neg, Nitrite, neg
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PREP Question
Of the following, the next BEST step in the management of this child
is to administer intravenous:
A. 5% albumin at 10 mL/kg over 1 hour
B. 0.9% NaCl at 20 mL/kg over 1 hour
C. fluids (5% dextrose) at 12 mL/h + urine replacement (mL for mL)
D. fluids (5% dextrose + 0.22% NaCl) at 50 mL/hour
E.fluids (5% dextrose + 0.9% NaCl) at 50 mL/hour
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PREP Question
Of the following, the next BEST step in the management of this child
is to administer intravenous:
A. 5% albumin at 10 mL/kg over 1 hour
B. 0.9% NaCl at 20 mL/kg over 1 hour
C. fluids (5% dextrose) at 12 mL/h + urine replacement (mL for mL)
D. fluids (5% dextrose + 0.22% NaCl) at 50 mL/hour
E.fluids (5% dextrose + 0.9% NaCl) at 50 mL/hour
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References and Future Reading
Pediatrics in Review 2008, 2014
Pediatrics 2007;120;1376
Prep 2012
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