Dr.

YESHWINI
 Definition:- Presence of blood in urine

Microscopic v/s Gross

hematuria

Glomerular v/s non

HEMATURI glomerular Transient v/s

A Isolated v/s asso with
proteinuria persistent

Asymptomatic v/s symptomatic

Painful v/s painless

 Gross hematuria: Microscopic hematuria:

• Visible to naked eyes • Detected only

under microscope
• Presence of >5 RBC/HPF in a
centrifuged sample

• Trauma
TRANSIENT • Exercise
• Infection /fever

• Hypercalciuria
• IgA nephropathy
RECURRENT • Alports syndrome
• Nephrolithiasis
• Benign familial hematuria
• Alport’s syndrome
• IgA nephropathy
FAMILIAL • Thin BM disease
• Hypercalciuria
• Nephrolithiasis
 GLOMERULAR

Systemic
Glomerulonephritis Renal vasculitides Familial infections

PIGN HSP Alports syndrome Malaria

Thin basement
RPGN SLE basement disease
Leptospirosis

Nail patella Infective

MPGN ANCA syndrome endocarditis

IgAN HUS
 PAINLESS HEMATURIA
Hematuria, hypertension and edema :- triad of glomerulonephritis.

Recurrent gross hematuria or persistent microscopic hematuria :- IgA

nephropathy (IgAN), Lupus nephritis(LN), MPGN, FSGS and Alport’s
syndrome.
Infection/fever related glomerulonephritis (IRGN) is commonly seen
with post infectious glomerulonephritis(PIGN), IgAN and MPGN.

Hematuria with systemic features of skin rashes, joint aches and

unexplained fever should be evaluated for HSP and SLE.

Familial hematuria:- Alport syndrome, nail patella syndrome, thin BM

disease
 PAINFUL HEMATURIA
Painful hematuria is seen with acute cystitis and with calculi
in the lower urinary tract.
Presence of clots in cystitis.

Abdominal pain in the presence of an abdominal mass :-

Wilms tumor and in a neonate renal vein thrombosis
left flank pain, varicocele and hematuria:- Nut cracker
syndrome
Painful terminal hematuria is characteristic of
schistosomiasis
 Systemic causes of hematuria
• Coagulopathy
• Bleeding disorder
• Sickle cell disease
 EVALUATION OF HEMATURIA
1. History
2. Physical examination
3. urine analysis
4. other specific tests
Causes of red colour urine without hematuria

FOOD & DYES DRUGS METABOLITES

• Beets • Rifampin • Bile pigment
• Blackberries • Phenazopyridine • Homogentisic acid
• Food coloring • Nitrofurantoin • Melanin
• HCQ , Doxorubicin • Methaemoglobin
HEMOGLOBINURI • Deferoxamine • Porphyrin
A • Iodine, Bromide • Tyrosinosis
MYOGLOBINURIA • Urates
Evaluation of microscopic hematuria:
HISTORY:
-Is hematuria transient // recurrent // persistent
-Timing of hematuria- Throughout // at beginning // at end
-Colour of urine- fresh blood // cola colored
-Recent vigorous exercise /trauma
-UTI: New onset incontinence, dysuria, frequency, urgency
-Obstruction d/t calculus: U/l flank pain radiate to groin
-PSGN:-Pharyngitis/impetigo 2-3 weeks prior to hematuria
-Exposure to drugs : Cyclophosphamide
NSAIDS(Eosinophilic cystitis )
Ibuprofen(Interstitial nephritis)
• Family h/o Consanguinity, renal
disease, deafness, eye disorders
Clinical pointers
***
 EXAMINATION:
-Blood Pressure : glomerulonephritis
-Oedema/recent weight gain
-Skin rashes : SLE ,HSP

-Abdomen :Palpable mass

URINE ANALYSIS :

-Confirm hematuria
-Pyuria

-Red cell casts: glomerular

disease
-Urine protein excretion >4 mg/m2/hour
OR S/O significant renal disease
Urine PC ratio >0.2 (>2 years)

-Hypercalciuria without hypercalcemia: common cause of microscopic hematuria

(24 hr Urine Ca >4mg/kg/day OR Spot urine Ca/creatinine ratio>0.2 )
Detection of microscopic hematuria:
Urinary dipstick

- Most common screening test

- Reagent strip detects blood; utilizes hydrogen peroxide and
catalyses chemical reaction between Hb/Myoglobin and chromogen
(tetramethylbenzidine)

-Can detect even 1-5 RBC/hpf

-False negative : Formalin , high urinary concentration of ascorbic acid
-False positive : Alkaline urine, contamination with oxidising reagent

Positive results of dipstick test should be confirmed by urine

microscopy
Microscopic examination

Gold standard for microscopic

hematuria
Basic blood tests
-CBC : anemia, thrombocytopenia
-Peripheral smear: HUS
-Creatinine
-Electrolytes
-Albumin
 Specific tests
-Complement : C3,C4
-Antibody evaluation:
ASO, Anti DNAase B, ANA, ANCA, anti-GBM

-Urine culture : Pyuria/bacteriuria

-USG Abdomen:- structural anomalies, stones,
PCKD, Cystitis

-CT Scan of kidneys

Non contrast : Stone diseases
Contrast study : Parenchymal tumours
-Renal biopsy
Treatment :
-Treatment of haematuria is directed at the etiology of
hematuria
– IRGN: supportive care, Fluid & salt restriction,
antihypertensives,
– UTI: Antibiotic
– Isolated hypercalciuria: increase fluid intake, restrict
sodium, hydrochlorthiazide
– Immunosuppression in IgA nephropathy & SLE
– Heparin for RVT
– chemotherapywith/without surgical excision and
radiotherapy in Wilms tumor
– Followup for hematuria, hypertension,
proteinuria
THANK YOU
 Bibiliography
1. Approach to Diagnosis and Management of
Hematuria- Ramya Vedula1 & Arpana A. Iyengar-
IJP Aug 2020
2. Approach to a child with gross hematuria-
Sushmita Banerjee, Murari Bharadwaj-IJPP 2017
April
3. HEMATURIA- Pediatrics in review- October 2008
4. Pediatric nephrology-Arvind Bagga- 6th edn
5. Nelson textbook of pediatrics-21st edition