Hematuria

Hematuria is defined as >5 red blood cells per high-power field in a freshly voided, spun urine specimen. Macroscopic (gross) hematuria is less common, is more likely to be attributed to an identified cause, and is always “pathologic.” Cola-colored urine, hematuria with proteinuria, hypertension, or dysmorphic urinary RBCs suggest “upper tract” disease (involving the kidney itself). “Lower tract” (ureter/bladder) findings include terminal hematuria, visible clots, or absence of proteinuria.

Differential Diagnosis

• Transient (fever, dehydration, exercise)
• Urinary tract infection
  –Most common cause of gross hematuria
• Hypercalciuria (common)

• Primary glomerulonephritis (GN)
  –Acute poststreptococcal GN: Gross hematuria ±hypertension, oliguria; 5 days to several weeks after Group A strep pharyngitis or pyoderma; can also occur after other infections
  –IgA nephropathy (Berger disease): recurrent gross hematuria occurs at or near onset of a URI
  –Membranoproliferative GN

• GN associated with systemic disease
  –HSP
  –SLE
  –Other vasculitis (rare) e.g.,Wegener
• Other glomerular disease
  –Benign familial hematuria
  –Alport syndrome: Usually X linked, high- frequency deafness, progression to renal failure
  –Glomerular disease (e.g., FSGS) usually presents as nephrotic syndrome
• Tubulointerstitial disease
  –Polycystic kidney disease, interstitial nephritis, papillary necrosis, ATN
• Urinary pelvic junction obstruction
• Urolithiasis/nephrolithiasis
  –Painless in up to 50% of children
• Urethrorrhagia
  –Recurrent gross hematuria (spotting on the underwear)
  –Most common in peripubertal males
• Malignancies (e.g., Wilms tumor)
• Vascular (e.g., renal vein thrombosis)
• Trauma
• Non-urinary tract blood
  –Menses, perineal irritation, pinworms, masturbation, STDs, sexual abuse
• Munchausen/Munchausen by proxy (rare)

Workup and Diagnosis

• History
  –Antecedent illness (including timing)
  –Prior episodes, medication/food exposure
  –Quality of gross hematuria (if present): Color, terminal vs present throughout stream, clots
  –Symptoms: Fever, flank pain, dysuria, rash, hemoptysis, breathing difficulty, joint complaints
  –Family history: Kidney stones, kidney disease, deafness (Alport)
• Physical exam
  –Blood pressure, growth parameters, skin or pharyngeal lesions, cardiac gallop, rales, edema, CVAT, genitourinary exam (external)
  • Labs/studies
    –U/A (dipstick and microscopy), urine culture
    –Dipstick negative =foods, medications
    –Dipstick positive, no RBCs =myoglobin, hemoglobin
    –Dipstick positive, with RBCs =hematuria
    –Macroscopic or microscopic with symptoms (e.g., HTN): Serum chemistries, CBC, ASO, C3, ANA, sickle prep, spot urine calcium/creatinine, STD screen (if sexually active), renal/bladder ultrasound, consider noncontrast helical CT if kidney stones suspected
    –Microscopic hematuria, no symptoms: Repeat U/A two times, 1 week apart; if persists, check serum chemistries, urine culture, sickle prep, spot urine calcium/creatinine and U/As of parents/siblings

  Treatment

  • UTI: Empiric antibiotic (e.g., co-trimoxazole)
  • Manage hypertension
    –ACE inhibitors or calcium channel blockers
    –Consider diuretics if edematous
  • Suspected acute glomerulonephritis
    –Low C3, evidence of recent strep or other infection
    –Monitor urine output, weight, BP closely
    –Daily outpatient visits until stable
    –Inpatient admission if oliguria/edema is severe
    –Once acute phase is over, monitor every 1–2 weeks and recheck C3 in 6–8 weeks
  • Nephrolithiasis: Increase fluid intake
    –Sodium-restrict (do not calcium-restrict)
    –Consult urology for severe pain or obstruction
  • Consult nephrology if hematuria persists or is associated with proteinuria, hypertension, persistently decreased C3, or abnormal creatinine

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Kidney symptoms: Introduction (review 1070 causes)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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