PEDIATRIC NEPHROLOGY: Basic Approach to Hematuria

APPROACH TO HEMATURIA

We should exclude other causes of red urine without RBCs by urine analysis (Dipstick) which includes:-

A.     Heme positive:

a.      Hemoglobinuria in case of acute hemolytic anemia.

          CBC shows fragmented RBCs & reticulocytosis and Hemoglobin in urine

b.      Myoglobinuria in case of rhabdomyolysis (myositis, crush)

  High serum creatine kinase.

B. Heme negative: Foods e.g. Beet roots, black berries.

Drugs e.g. Rifamipicin, Desferal, Nitrofurantoin.

Urate crystals (red diaper).

History

A.     Glomerulonephritis: sore throat/rashes/body swelling

B.      UTI: fever/frequency/dysuria.

C.      Renal stones: colicky abdominal pain/family history.

D.     Coagulopathy: easy bruising.

E.      Trauma

F.      Family history: hematuria, deafness (Alport’s), sickle cell disease.

Examination

A.     Blood Pressure (use age,sex and height appropriate blood pressure centiles)

B.      Abdomen: palpable masses (polycystic kidneys, tumors, hydronephrosis).

C.      Skin: rashes.

D.     Joints: pain/swelling.

Investigations

A.      It is important to identify serious, treatable, and progressive conditions.

B.      During an acute illness, exclude UTI by urine culture.

C.     Asymptomatic or ‘benign haematuria’ in children without growth failure,        hypertension, oedema, proteinuria, urinary casts, or renal impairment is a      frequent finding.

Localize hematuria:

	Glomerular	Extra glomerular
Acute nephritic syndrome	Present	Absent
Color	Cola or tea colored	Bright red
Clots	Absent	May present
RBCS Shape	Dysmorphic (distorted)	Normal
RBCS casts	Present	Absent
Proteinuria	> 30 mg / dL.	< 30 mg / dL.

For Glomerular hemturia:

A.     Hematology

  CBC with differential

B.      Chemistry

  Electrolytes, Ca

  BUN/ Creatinine /Creatinine clearance

  Serum protein/Albumin /Cholesterol

  Urine protein

C.   Immunology

  C3/C4

  ASO/Anti-DNase B

  ANA

  Antineutrophil antibody

Reduced C3 in

-        Post infectious glomerulonephritis

-        Systemic lupus nephritis (and low C4)

-        Nephritis with chronic infection

-        Membrano proliferative glomerulonephritis

D.   Renal Biopsy

Unexplained persistent or recurrent gross hematuria

Lupus nephritis

Glomerulonephritis with:

Nephritic nephrosis

Absent low C3

Unexplained acute renal

For extra glomerular hematuria

Step 1: Urine culture

Step 2: Urine calcium/creatinine ratio, rule out sickle cell anemia, renal/bladder ultrasound

Step 3: Urinalysis: siblings, parents, serum electrolytes, Cr, Ca, if crystalluria, urolithiasis, or nephrocalcinosis: 24-hour urine for Ca, creatinine, uric acid, oxalate and if hydronephrosis/pyelocaliectasis: Cystogram, renal scan.

Treatment:

A.     If obvious cause (e.g. UTI), treat.

B.    If complex diagnosis (impaired renal function, proteinuria, or family history)   refer to paediatric nephrology unit.

C.   If no cause found and normal renal function, BP, and no proteinuria, monitor   until resolves.

D.  If no resolution after 6mths or change in any of above parameters refer to paediatric nephrology unit.