Red Urine – a mystery
Shaila Sukthankar
Haematuria
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Common presenting symptom of renal tract disorders
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Prevalence 0.5 - 6% on population screening in children
Haematuria - Definition
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Urine microscopy
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RBC > 5/uL in a fresh uncentrifuged specimen
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RBC > 5 -10/high power field in a midstream sample
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RBC morphology & presence of casts
Case Presentation - May 09
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5 years, male
Painless gross haematuria – frequent episodes 1 week
Initially red, later pink – no clots
No history of
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Fever, dysuria, back/ abdo pain
rashes, joint pains
Swelling
Trauma
Bleeding diathesis
Recent medication
No family h/o renal disease/ deafness/ renal stones/ haematuria
Tonsillitis 6 weeks before
Examination
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Normal vitals, BP 110/68, apyrexial
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No pallor or oedema
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No bruises or rash
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Systems review NAD
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ENT normal
Macroscopic haematuria with no features of
glomerulonephritis
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Painless
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IgA nephropathy
Benign familial nephropathy/ Alport’s syndrome
Exercise induced
Coagulopathy
Painful
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Infection
Trauma
Malignancy
Haematuria with features of
glomerulonephritis
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Primary renal diseases
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IgA nephropathy
MPGN 1 and 2
Anti GBM disease
Secondary renal diseases
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Postinfectious GN
HSP nephritis
SLE
Initial Investigations
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FBC, coagulation – normal
Urea 6.5, creatinine 40, Albumin 46
Electrolytes, bone profile normal
crp <3
Urine microscopy (X2) - <10 WCC, 50-100 RBC, no bacterial
growth, trace to 1+ proteinuria
Renal USS - NAD
Subsequent Investigations
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C3 and C4 normal
ANA, dsDNA negative
Immunoglobulins normal
ASOT 100 U/mL
antiDNASe B 600 U/mL
Urine calcium/ creatinine ratio 0.45
Intermittent 3+ blood on dipstick, no proteinuria and well with
normal BP over next 4 weeks
Urine dipstick
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Useful screening tool
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Very sensitive
Haematuria - Diagnosis
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Do not use urine dipstick to diagnose haematuria
12 weeks later (Aug 09)…
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Recurrence of painless gross haematuria for 1 week
Always towards the end of the day
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Clear in the morning
Bright red or cola coloured in the evening
Worse with exercise and vigorous activity
Some discomfort with micturition
No other significant positive history
Urine microscopy confirmed RBCs in some but not all red urine
samples
Causes of red or pink urine
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Haemoglobinuria
Myoglobinuria
Porphyrins
Urates (pink)
Foods – beetroot, blackberries
Drugs
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Rifampicin (orange)
Chloroquine, desferoxamine
Possibilities - 1
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Recurrent gross haematuria - ? Alport’s/ IgA nephropathy/ thin
basement membrane disease
? Bladder pathology (polyp, interstitial cystitis)
Exercise induced haematuria
? Not blood (Hburia or myoglobinuria)
? Renal AV malformation
Management
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Repeat haematology, biochemistry and immunology normal
Presence of blood without RBCs on some urine samples
Myoglobin screen positive on one occasion
No infection
MR renal angiogram (limited views) – normal
Cystoscopy – NAD
Family members’ urine microscopy – NAD
Review by haematology – no e/o intravascular hemolysis
Intermittent painless asymptomatic gross haematuria continues
Possibilities - 2
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Exercise induced haematuria – exercise test with urine
microscopy before and after
Nutcracker syndrome – Repeat MR/ direct renal angiogram
under GA – parents not keen for further invasive procedures/
GA
Evolving nephropathy (IgA/ Alport’s/ TBM) – no indication for
biopsy as asymptomatic, normotensive, no proteinuria and
normal renal function
Nutcracker syndrome
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Compression of L renal vein
between the aorta and sup
mesentric artery
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40% of children with
unexplained haematuria
Investigations in a child with haematuria
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Urine microscopy and culture
Urine protein creatinine ratio
FBC, coagulation
U&E, creatinine, albumin
Urine calcium creatinine ratio
ASOT, C3 and C4
US renal tract
Haematuria - Indications for renal biopsy
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Associated proteinuria
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Persistent low C3
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Impaired renal function
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Systemic disease with proteinuria
– SLE, HSP, ANCA associated vasculitis
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Family history suggestive of Alport’s syndrome
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Recurrent gross haematuria of unknown aetiology with extreme
parental anxieties
Haematuria - cystoscopy
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Seldom useful
Consider
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Negative preliminary investigations
Suspected bladder or urethral pathology
Vascular malformations
Bladder mass on US
To lateralise the source of bleeding
Progress – June 10 (12 months on)
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Well
Normally active
Occasional brown urine (once in 2-3 months)
Lasts for a day, resolves spontaneously
Occurs with activity
Occurs towards the end of the day
Normotensive
Parents and child opted for non-invasive observation for now
Haematuria - Summary
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In the absence of proteinuria is not usually indicative of
serious pathology
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Investigation are to be guided by presentation and likely
diagnosis
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In asymptomatic children, ensure serious conditions are not
missed and guidelines for further investigations are in place if
change in clinical course
Latest update (March 11)
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Well until 3 weeks before review!
Febrile coryzal illness with sore throat and recurrence of haematuria
Initially bright red, subsequently cola coloured
Lasted for 7-10 days, progressively cleared over 2-3 days thereafter
Asymptomatic (no headaches, oedema, oliguria etc)
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DID NOT SEE GP, COMMUNITY NURSES OR HOSPITAL
TEAM
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When attended clinic, back to normal self, urine NAD!!
Repeat haematology, biochemistry and immunology normal.
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ΔΔ??