Approach to a patient with hematuria

Hematuria means blood in urine. It may be Gross or microscopic hematuria.
Gross hematuria is seen by naked eyes while microscopic hematuria needs a microscope.
  • Hematuria is defined as the presence of at least 5 red blood cells per microliter of urine.
  • The prevalence of microscopic hematuria among school-aged children ranges from 0.5% to 2.0%.

    Causes of Hematuria:

    1. Glomerular hematuria

      Isolated renal disease
      -Postinfectious GN (Post streptococcal)
      - IgA nephropathy( Berger ds)
      - Alport syndrome( hereditary )
      - Thin Glomerular Basement membrane disease
      - Membranoproliferative GN
      - Membranous nephropathy
      - Focal segmental glomerulosclerosis
      - Antiglomerular basement membrane ds
      Multisystem disease
      -HSP nephritis
      -SLE nephritis
      -HUS
      -Wegener granulomatosis
      -Polyarteritis nodosa
      -Goodpasture syndrome
      -HIV nephropathy
      -Sickle cell glomerulopathy
    2. Extraglomerular hematuria

      • Upper Urinary tract
        Tubulointerstitial:
        • Pyelonephritis
        • Interstitial nephritis
        • ATN
        • Papillary necrosis
        • Nephrocalcinosis
        Anatomic:
        • Hydronephrosis
        • Polycystic kidney disease
        • Tumor (Wilms, Rhabdomyosarcoma, Angiomyolipoma)
        • Trauma
        Vascular:
        • Arterial/venous thrombosis
        • Malformation (aneurysms, hemangioma)
        • Hemoglobinopathy (Sickle cell disease)
        • Crystalluria: Calcium, Oxalate, Uric acid
        • Medications: NSAIDs, anticoagulants
      • Lower urinary tract
        • Inflammation- infectious and noninfectious
        • Cystitis
        • Urethritis
        • Urolithiasis
        • Trauma
        • Coagulopathy
        • Heavy exercise
      • Bladder tumor
        Factitious syndrome / by proxy

    Common causes of gross hematuria:

    • Urinary tract infection
    • Meatal stenosis
    • Perineal irritation
    • Trauma
    • Urolithiasis
    • Hypercalciuria
    • Coagulopathy
    • Tumor
    • Glomerular
      • IgA nephropathy
      • Alport syndrome
      • Thin glomerular basement membrane disease
      • Post-infectious glomerulonephritis
      • HSP nephritis
      • SLE nephritis

    Causes of Hematuria in the Newborn:

    • Renal vein thrombosis
    • Renal artery thrombosis
    • Autosomal recessive polycystic kidney disease
    • Obstructive uropathy
    • Urinary tract infection
    • Bleeding and clotting disorders
    • Trauma, bladder catheterization
    • Cortical necrosis
    • Nephrocalcinosis

    History:

    • Age: 2-5yrs: Wilms tumor 5-12yrs: PSGN
    • Sex: F>M UTI, SLE nephritis. Alport syndrome, IgA Nephropathy
    • Race: whites: Idiopathic hypercalciuria blacks: Sickle cell disease

    Colour of urine:

    ColourCauses
    Dark yellowNormal concentrated urine
    Dark brown or blackBile pigments Homogentisic acid, melanin, tyrosinosis, methemoglobinuria
    Cola coloredGlomerular hematuria
    Red or pink urineExtraglomerular hematuria, Hemoglobin, Myoglobin, Porphyrins, Chloroquine, Deferoxamine, Beets, blackberries, Rifampicin, Red dyes in food, Urates

    Characteristics of urine:

    • Amount of urine: Reduced in AGN, ARF
    • Clots in urine: Extraglomerular
    • Frequency, Dysuria, recent enuresis: UTI
    • Frothy urine: Suggests Proteinuria seen in Glomerular diseases
    • Timing:
    • Initial stream – from the urethra (Urethrorrhagia – spotting in underwear);
    • Terminal (with suprapubic pain, disturbance of micturition) – from the bladder
    • The recurrent episode of Gross Hematuria
    • IgA Nephropathy
    • Alport Syndrome
    • Thin Glomerular basement disease
    • Hypercalciuria
    • Urolithiasis

    Associated Symptoms:

    • Fever: Infections, SLE, AGN
    • Facial puffiness, Oedema of legs, weight gain, Cough, Shortness of breath: Acute Glomerulonephritis
    • Hypertension (Headache, visual changes, epistaxis, seizures): AGN, ARF
    • Abdominal pain: Urolithiasis (Loin to groin), UTI, clots, Nutcracker syndrome, Idiopathic hypercalciuria
    • Painless: Glomerular
    • Abdominal mass: Hydronephrosis, PCKD, Wilm’s tumor
    • Joint pain: HSP, SLE
    • Rashes: HSP, SLE, PAN
    • Neurologic: SLE, HUS (seizures, irritability)
    • Cutaneous Abnormalities Tuberous, Sclerosis, Von Hippel Lindau Syndrome
    • Jaundice: Hemolysis, Obstructive jaundice
    • H/o exercise, menstruation, recent bladder catheterization or passage of a calculus
    • Recent upper respiratory
    • 1-2wks back PSGN(Hematuria can last up to 4-6wk
    • 1-2 days IgA Nephropathy(Hematuria lasts up to 5 days)
    • 1-2 days (Alport Syndrome)
    • Skin infection (3-6 wks): PSGN
    • GI infection: HUS, HSP nephritis, IgA Nephropathy
    • H/o bleeding from other sites: Bleeding disorders, Hemoptysis in Good Pasture syndrome
    • H/o Trauma, Unexplained perineal Bruising (Child abuse), crush injury(Rhabdomyolysis)
    • H/o ingestion of drugs (ATT – Rifampicin, Ibuprofen, Chloroquine, Metronidazole, Iron), i.v. contrast agents (Toxic nephropathy)
    • H/O Black colored Stool HSP/HUS
    • H/o Vision or hearing defects: Alport syndrome
    • Family h/o: Hereditary Nephritis(Alport syndrome), Thin glomerular Basement Membrane Disease, SLE Nephritis, IgA Nephropathy), Urolithiasis, PCKD, Sickle cell disease/trait
    • H/o consanguinity or affected siblings in ARPKD, Metabolic disorders

    Examination:

    • Vitals:
      • Pulse
      • BP: in AGN, PKD
      • Temperature
    • Edema: in AGN
    • Pallor: HSP, HUS, SLE, CRF, Goodpasture Syndrome
    • JVP: Raised in CHF
    • Anthropometry
    • Throat: pharyngitis
    • Face
      • Malar flush
    • Skin lesions: Purpura(HSP)
      Bruises (Trauma, Child abuse)
    • Malformations: VATER (vertebral body anomalies, anal atresia, tracheo-oesophageal fistula, renal dysplasia
    • Joint swelling, tenderness: HSP, SLE
    • Ophthalmologic: Alport syndrome (Anterior lenticonus, macular flecks, recurrent corneal erosions), Aniridia (Wilms)
    • Hearing assessment: Alport (B/L SNHL)
    • Abdominal examination
      • Bladder distention in posterior urethral valves,
      • Abdominal masses- hydronephrosis, tumor, polycystic kidney
      • Bruit
      • Renal angle tenderness
      • Examination of the urethra, external genitalia
    Abnormal external genitalia e.g. ambiguous genitalia in WAGR syndrome (Wilms, aniridia, genital anomalies, mental retardation)
    • Chest/ CVS examination-
      • Cardiomegaly
      • Murmur (anemia, IE)
      • Pericarditis(CRF)
      • Lung field( Basal crepts-fluid overload)

    Investigations:

    Urine dipstick test
    • It can detect trace amounts of hemoglobin and myoglobin.
    • Can detect 5-10 intact RBC
    • False +ve: Urine pH >9, H2O2
    • False –ve: High ascorbic acid, formic acid
    • Also for urine albumin
    Urine microscopy: Presence of RBCs and casts (> 5 RBCs per HPF) in centrifuged urine
    • Urine C/S
    • RFT: Blood urea nitrogen/serum creatinine, Na/K (↓Na in AGN, ↑K in ARF)
    • Complete blood counts (CBC): Hb - ↓ in bleeding, HUS, SLE, CRF; Abnormal TC, DC in infections, HUS, ↓ in SLE
    • Platelet counts and Coagulation studies: (history suggestive of bleeding disorder, HUS), Sickle cell (Hemoglobin electrophoresis)
    • PBS: Microangiopathic hemolytic anemia
    • ESR, CRP – Infections
    • 24 hr urinary protein, Spot urinary protein: Creatinine ratio, Serum albumin, and cholesterol if associated proteinuria (Nephrotic syndrome)
    • Urine calcium: Hypercalciuria is a relatively common finding in children.
      • 24-hour urinary calcium (>4 mg/kg/d), or
      • Spot urine calcium-creatinine ratio >0.2
    • Imaging Studies
      • Renal and bladder sonography: Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, Renal parenchymal disease
      • X-Ray KUB: calculi
      • Micturating cystourethrograms - Urethral and bladder abnormalities (eg, cystitis), in recurrent UTI to r/o VUR, anomalies
      • Intravenous urography
      • Radionuclide studies – Renal function and perfusion
      • Doppler study of renal vessels and IVC: Renal vein thrombosis
      • Spiral CT scan - Urolithiasis, Wilms tumor and polycystic kidney disease, Renal trauma
      • Angiogram
      • Chest X-Ray (Pulmonary edema, CHF)
    • Renal biopsy is indicated for
      • children with persistent microscopic hematuria
      • children with recurrent gross hematuria associated with decreased renal

    For Asymptomatic, isolated microscopic hematuria:

    • The recurrent episode of Gross Hematuria
    • IgA Nephropathy
    • Alport Syndrome
    • Thin Glomerular basement disease
    • Hypercalciuria
    • Urolithiasis

    Management:

    According to causes:
    • Reassurance and F/U
    • Treat cystitis, pyelonephritis, AGN: Antibiotics
    • Supportive treatment: Diuretics, Fluid and salt restriction, Antihypertensives
    • Monitoring – BP, I/O, weight, Urine R/M
    • Treat Hyperkalemia, ARF, CHF, acidosis, fluid overload, HTN, and its complications
    • ACE inhibitors useful in proteinuria
    • Immunosuppressive therapy: Depending on a cause (Steroids, cyclophosphamide)
    • Idiopathic Hypercalciuria: Hydrochlorothiazide, Potassium Citrate, Sodium Restriction
    • Calculi: Plenty of water
    • ESRD: Dialysis, Renal transplantation
    • Correct thrombocytopenia, anemia, coagulation factor deficiency
    • Renal vein thrombosis: Anticoagulant therapy or thrombectomy may be needed
    • Surgical correction: Calculi, PUJ obstruction, Posterior urethral valves, Wilms tumor



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