Approach to HaematuriaDR.RAVI KUMAR1ST YEAR PGDEPT OF PEDIATRICS MGMCRI

Case Scenario - 1 A 8 year old boy b/w c/o passing cola coloured urine with facial puffiness for 2days O/E

Alert, Active,AfebrileGeneralized facial puffiness +No pallorBP-140/90mmHg

S/E PA- Soft, mild distension+ BS+

Urine Routine>5 RBC/HPFRed cell casts +Dysmorphic RBCProtein 1+

Case Scenario - 2 A 2 year old girl child b/w c/o crying during micturition, increased frequency,

high grade fever a/w chills & rigors and passing red coloured urine for past 4 days.

O/EAlert, Active,Febrile 102*F

S/E PA- Soft, Suprapubic tenderness+

Urine Routine>5 RBC/HPFPus cells - PlentyNo RBC CastsNil Protein

Case Scenario - 3 A 12 year old child b/w c/o abdominal pain radiating to back & groin

a/w nausea, vomiting since yesterday night. h/o passing 2 episodes of red coloured urine for past 2days.

O/EAlert, Active,Afebrile

S/E PA- Soft, Tenderness+ over right lumbar region

Urine Routine>5 RBC/HPFNo RBC CastsCrystals +Nil Protein

Contents

Introduction Etiology History Examination Investigation Management

Introduction

Hematuria means blood in urine. Which can be either macroscopic or microscopic.

Gross or Macroscopic hematuria can be seen by naked eyes while Microscopic hematuria

are detected only in urine microscopy.

Microscopic hematuria is defined as the presence of >5 RBC per HPF in a centrifuged

sample.

Persistent hematuria is defined as presence of microscopic hematuria in >2 samples

over next 2-3 wks.

Glomerular Hematuria

ISOLATED RENAL DISEASE PSGN IgA Nephropathy Alport syndrome MPGN Membranous Nephropathy Thin glomerular basement

membrane Nephropathy RPGN FSGS

MULTISYSTEM DISEASE Systemic lupus erythematosus

nephritis Henoch-Schönlein purpura nephritis Granulomatosis with polyangiitis

(formerly Wegener granulomatosis) Polyarteritis nodosa Goodpasture syndrome Hemolytic-uremic syndrome Sickle cell glomerulopathy HIV nephropathy

Non-Glomerular Hematuria Hypercalciuria Hyperuricosuria Hyperoxaluria Renal stone disease Cystitis (viral hemmorrhagic, drug induced) Genitourinary anomalies with infection Tumors PCKD Trauma Foreign body Sickle cell hemoglobinopathy UTI

Causes of Hematuria in Newborns

Renal vein thrombosis (Asphyxia, dehydration, shock) Renal artery thrombosis Autosomal recessive polycystic kidney disease Obstructive uropathy Urinary tract infection Bleeding and clotting disorders Trauma, bladder catheterization Cortical necrosis (Hypoxic/ischemic perinatal insult) Nephrocalcinosis (Frusemide in premature)

History Age : 5 to 12 years – PSGN

Sex :

F>M – SLE Nephritis

M>F – X linked form of Alport syndrome

Discoloration of UrineDark yellow – Normal concentrated urineDark brown or black – Bile pigments, Homogentistic acid, melanin, tyrosinosis, methemoglobinemiaCola coloured – Glomerular hematuriaRed or Pink urine – Extraglomerular hematuria, haemoglobin, myoglobin, porphyrins, chloroquine, beets, blackberries, rifampicin, red dyes in food, urates.

History Characteristics of Urine : Amount of urine : Reduced in AGN, ARF Clots in urine : Extraglomerular Increased freqency , dysuria, recent enuresis : UTI Frothy urine : proteinuria seen in glomerular disease Timing :

Hematuria in initial stream – UrethraHematuria in terminal stream – Bladder

Associated symptoms : Fever : Infections, SLE, AGN Generalised facial puffiness, Pedal edema : AGN

History Hypertension : AGN, ARF Abdominal Pain : Urolithiasis, UTI, Nutcracker syndrome Painless : Glomerular Abdominal mass : Hydronephrosis, PKD, Wilm’s tumor Joint pain : HSP, SLE Rashes : HSP, SLE, PAN Jaundice : Obstructive Jaundice Recent URI, Skin infection : PSGN Trauma, Child abuse Drug ingestion : Rifampicin, Chloroquine, Metronidazole Vision or Hearing defects : Alport syndrome Family h/o : hereditary glomerular diseases(TGBMD), Sicklecell disease

Examination Vitals:

Elevated BP : AGN, PKDHigh Temperature : UTI

Edema : AGN Pallor : Bleeding disorders, HUS, SLE JVP : Raised in CHF Per abdomen : Mass

Kidney: Hydronephrosis, wilms tumorBladder palpable : Distal obstruction

Skin lesions : Purpura(HSP), Butterfly rash(SLE), Bruises(Trauma,Abuse) Joint swelling, tenderness : HSP, SLE

Investigations Urine Dipstick test : Based on oxidation of ortho-toluidine by organic peroxide

in presence of Hb that serves as a catalyst. The product of reaction has a blue colour, intensity is matched with colour chart

It can detect trace Amounts of Hb and myoglobin with 100% Sensitivity & 99% Specificity in detecting 1-5 RBC per HPF.

False + : Urine sample is concentrated or contaminated with povidone iodine

False - : High Ascorbic acid, pH- alkaline

Urine Albumin Urine M/E : Presence of >5 RBC per HPF in a centrifuged sample

Investigations Urine C/S RFT CBC :

Reduced Hb : Bleeding, HUS, SLE, CRFAbnormal TC/DC : Infections, HUS

Platelet counts & Coagulation studies : Bleeding disorders, Sickle cell PS : Microangiopathic haemolytic anemia ESR, CRP : Infections 24 hrs Urinary protein, Spot PCR, Sr.Albumin, Sr.Cholesterol &

associated Proteinuria (Nephrotic) Urine Calcium : 24 hrs urinary ca >4mg/kg/dl or spot urine calcium

creatinine ratio >0.21(Hypercalciuria)

Investigations Imaging Studies

Renal & Bladder sonogram : Ureter Anomalies, Urolithiasis X-Ray KUB : Calculi Doppler study of Renal vessels & IVC : Renal vein thrombosis Spiral CT Scan : Wilms tumor & PCKD

Renal Biopsy : Relative Indications : Significant Proteinuria 3+ or more Recurrent persistent Hematuria Abnormal Renal function, Persistent HTN No evidence of streptococcal infection Abnormal ANA or dsDNA levels Family H/O ESRD

AlgorithmHistory & P/E

Urine Analysis

Hb/RBC absent RBC +/- Hb Hb only no RBC

Look for other causes of Red

UrineCheck RBC Morphology

Myoglobinuria or Hemoglobinuria

Glomerular Nonglomerular

Cola/brown urine ?Proteinuria >30mg/dl ?

RBC casts ?Acute nephrotic syndrome ?

YES NOGlomerular Hematuria

• CBC• Sr.E, Ca• BUN, Creat• Sr.protein/albumin• Cholesterol• C3/C4• ASO/Anti-DNase B• ANA• Antineutrophil antibody• Throat/ skin culture• 24 hrs urine tot protein

creatinine clearance

Extraglomerular Hematuria

Step1 : urine c/sStep2 : urine ca/creat, Renal/bladder USGStep3 :

• Urine analysis : siblings, parents• Sr.E , Ca, Creat• If cystalluria, urolithiasis or

nephrocalcinosis : 24 hrs urine for Ca, Creat, Uric acid, Oxalate

• If hydronephrosis/pyelocaliectasis : Cystogram, renal scan

Management Managed according to cause : Reassurance & Follow-up Use of Antibiotics : cystitis, pyelonephritis, AGN Supportive treatment : Diuretics, fluid & restriction, Anti-

hypertensives Monitoring – BP, I/O, Weight, Urine Routine To correct hyperkalaemia, ARF, CHF, Acidosis, Fluid overload, HTN

and its complications Use of Hydrochlorothiazide, Potassium citrate, Sodium restriction in

Idiopathic hypercalciuria Calculi : Plenty of water ESRD : Dialysis, Renal transplantation Renal vein thrombosis : Anti coagulant therapy or thrombectomy Surgical correction : PUJ obstruction, Wilms tumor.

Thankyou