Hematuria in children

Jianhua Zhou
Prof. And Vice-Chair
Department of Pediatrics
Tongji Hospital

Tel: 83662684
e-mail: jhzhou@tjh.tjmu.edu.cn
 Key words
• Urinalysis
• Glomerular hematuria
• Dysmorphic RBC
• perforate RBC
• acanthocytes
• Glomerulonephritis
• idiopathic hypercalciuria
• IgA nephropathy
• TBMD: thin basement membrane disease
What is hematuria ?
By color of urine:
Red urine ?
Brownish,tea-colored
Coca-Cola-colored
 Definition of hematuria
in children
Microscopic exams of centrifuged urine ：
 3 个 RBCs /HP

Addis count of 12h-urine ：

＞ half a million RBCs

 Urine auto-analyzer
• Test for RBC, hemoglobin,myoglobin
• High sensitivity but low
specificity ， yield false positivity
• Suitable for screening, ， must be
confirmed by microscopic exams
 Isolated hematuria
• Asymptomatic hematuria
• Hematuria as sole symptom, without
edema, hypertension, mild or no
proteinuria （≤ ++ ， or ＜ 0.5g /24
h）
• Normal renal function
 Incidence of asymptomatic
hematuria

• 4-5% in a single urinalysis, but 0.5-1% on at least

2-3 consecutive urinalysis.
• 14.7% of 2315 biopsied children with renal
diseases, next to nephrotic syndrome (36.8%) , in a
national survey till 1996.
• 19.2% of hospitalized children with renal diseases,
next to acute nephritis (26.3%) and nephrotic
syndrome （ 24.7% ）
 Major problems in
hematuria evaluation
• Complicate causes
• Time-consuming , expensive
diagnostic studies and
unnecessary treatment.
• Variability in prognosis
 Causes of hematuria
• Systemic or intrinsic renal diseases
• Glomerular or Non-glomerular
• Surgeon concerned or physician
concerned
 Diagnostic evaluation of
children with hematuria

• First step ： hematuria confirmation

• Second step ： Glomerular or Non-
glomerular
• Third step ： disease causing
hematuria
hematuria confirmation

• False positive ?
excluding blood contamination and
color influence.
• Persistent or transient
• Symptomatic?
Glomerular or Non-glomerular
hematuria ?

• Morphologic evaluation
• Urine RBC mean volume and
volume distribution curve
• Tomn-Horsefall protein coated
RBC
• 它：
Morphologic evaluation of
urine RBC
• Dysmorphic RBC ： ring-like, perforate
, acanthocytes , G1 cell
• Dysmorphic RBC ＞ 30% or ＞
8000/ul: Glomerular hematuria
• Accuracy is 80-90%
• methods ： EM, phase contrast
microscopy , light microscopy
Isomorphic RBC in EM
Dysmorphic RBC in EM ： ring-like

Small bud
Serious distorted RBCin EM: G1 cell

various
bud
Acanthocytes in EM
 Acanthocyte
Acanthocytes (ring-formed RBCs with one
or more protrusions of different shapes and
sizes) is a more specific marker of glomerular
bleeding.
Studies suggest that if 5% of the total urinary
RBCs are acanthocytes, then an underlying
glomerular disease can be diagnosed with high
sensitivity (71%) and specificity (98%).
Various dysmorphic RBC in EM
Various dysmorphic RBC in phase
contrast microscopy
 普通光镜复合染色检
查 G1 红细胞
• 以 G1 红细胞≥ 5 % 为标准判断肾小球
性血尿
• 双盲法研究：灵敏性为 90 .9%, 特异性
为 96 .8%
尿 RBC 电镜检查：正常形
态
尿 RBC 电镜检查：环状形
态
尿 RBC 电镜检查：芽胞状（ G1 细
胞）
尿 RBC 电镜检查：穿孔状细胞
各种变形尿 RBC （位相镜）
 离心尿染色后普通光镜检查

光染法 非肾小球性血尿 肾小球性血尿

 尿液离心后不染色直接镜检

光染法 非肾小球性血尿 肾小球性血尿

Collar JE ， et al. UK . Kidney International (2001)
 Mean RBC size and size
distribution curve

• Glomerular origin ： MCV ＜ 72fl ， left

moved size distribution curve
• nonglomerular origin ： MCV ＞
72fl ， normal distribution curve
• method ： flow cytometry
• Accuracy over 90%
• Fairly Objective
 血尿红细胞 MCV 差值
• 肾小球性血尿：尿红细胞 MCV 值 43-
71fl 不等
• 血和尿中红细胞 MCV 差值： >13fl 为肾
小球性血尿， < 9fl 为非肾小球性血尿，
9~13fl 不能排除肾小球性血尿
• 灵敏性为 68.6%, 特异性为 100%
• 血 MCV<78fl 时有假阴性
 尿 RBC 电泳

观察尿 RBC 电泳时往返一定距离所需时

间亦可判断尿 RBC 来源。电泳时间长短除与
RBC 大小有关外，尚与其表面电荷有关。
肾小球源性血尿者为： 20.64±1.72 s
非肾小球源性血尿为： 27.27±1.66 s
尿 RBC 表面 Tamm-Horsfall 蛋白
检测
• Tamm-Horsfall 蛋白 (TH 蛋白 ) 来源；

• TH 蛋白阳性者提示为肾小球源性血尿；

• TH 蛋白阴性者提示为非肾小球源性血尿。
 Disease identification
1. Thorough history and careful physical exams
2. Further evaluation for glomerular hematuria
3. Further evaluation for nonglomerular hematuria
4. Coexistence of two diseases
5. Follow-up studies of asymptomatic hematuria
 Common causes of
hematuria
A ： anatomical abnormality
B: boulder
C: carcinoma
D: drug induced hematuria
E: exercise related hematuria
F: fever related hematuria
G: glomerulonephritides
H: hematological disorder
I: infection
 Co-existence of two diseases
causing hematuria
idiopathic hypercalciuria and other causes
urinary deformity or cystic kidney with
infection, nephrolithiasis
IgA nephropathy and TBMD
primary glomerulonephritides with
urinary diseases
Thank you