Paediatrics 4 Microteaching:Haematuria in children

Zara GallVictoria Hopkinson

Shahid Islam(Previous presentation by Satish Maddenini and Lynsey McHugh)

September 2011

MCQs

1) Macroscopic haematuria is more common than microscopic haematuria in children

2) Around half of children with macroscopic haematuria will have a UTI

3) Red coloured urine can be caused by food colouring

4) Absence of RBC casts on urine microscopy excludes glomerulonephritis as the cause of haematuria

5) Cystoscopy is a first line investigation of non-glomerular haematuria in children

Causes of haematuria in children

• Frank (visible) haematuria• Causes most concern but often benign and usually short lived• Uncommon – 1:1000 visits to doctor• Around 50% will have UTI

• Microscopic (non-visible) haematuria • Prevalence of around 1.5% in children and adolesents• Thus more common, but often more difficult to define

Causes of urine mimicking haematuria:

Dipstick (heme) positive:Haemoglobinuria, myoglobinuria, bacterial peroxidases, povidone, hypochlorite

Dipstick negative, red urine:Drugs (nitrofurantoin, salicylates), foods (beetroot, food colouring), metabolites

(porphyrin)

Causes of haematuria in children

• Microscopy positive for Eumorphic cells:

• Hypercalcuria• Present in approx 30% of children with noninfected urine

with non-glomerular haematuria• Nephrolithiasis• Nephrocalcinosis• UTI• Trauma• Exercise• Cystic kidney disease• Tumour• Haemangioma

Causes of haematuria in children

Microscopy positive for Dysmorphic RBC/RBC casts

• Proteinuria present• Poststreptococcal GN (early)• IgA nephropathy• Alport syndrome• HSP• Haemolytic uraemic syndrome• Membranoproliferative GN• Focal segmental GN• Diffuse proliferative GN• SLE• Sickle cell disease or trait• Hep B-associated GN

• Proteinuria not present• Family history of haematuria

• Alport syndrome (if FH of hearing loss/renal failure)

• Thin basement membrane disease

• Sickle cell disease or trait• No FH of haematuria

• IgA nephropathy• Poststreptococcal GN

(late)

Investigations

• Thorough history, examination (inc. BP check) and family history• Presence of haematuria must be confirmed by both dipstick and

microscopic evaluation• Microscopy particularly important

• Are RBC present?• RBC casts?• Dysmorphic RBC?

• Hallmark of glomerular bleeding has been RBC casts +/- proteinuria• But many children with glomerular or renal parenchymal disease have

neither RBC casts nor proteinuria• One study showed that if 10% RBC show dysmorphism, diagnosis

is GN with 94% specificity and 92% sensitivity

Investigations

No RBC casts/dysmorphic RBC

• Investigate further if

• Micro haematuria >5 RBC/hpf in 2 out of 3 urinalyses in asymptomatic child, or in single sample in symptomatic child

• Macroscopic haematuria

• Investigations directed towards finding non-glomerular or urological cause of haematuria

• Urine culture

• Renal USS

• Other Ix depending on the results of these – eg DMSA, MCUG

• And if these are normal

• Cystoscopy

• Esp if macroscopic haematuria

RBC casts/dysmorphic RBC present• ?proteinuria present

• Spot albumin/creatinine ratio• Abnormal if >10mg/mmol in children

• Proteinuria confirmed• Refer to a nephrologist for Ix such as:

albumin, cholesterol, FBC, U+E, C3, C4, ASO, ANCA etc

• No proteinuria• Repeat urine microscopy 3 times over

2 months• If negative reassure• If positive

• Sickle prep • USS• Screen for hypercalcuria

If tests negative and haematuria persists

• Refer to nephrologist

MCQs

1) Macroscopic haematuria is more common than microscopic haematuria in children F

2) Around half of children with macroscopic haematuria will have a UTI T

3) Red coloured urine can be caused by food colouring T

4) Absence of RBC casts on urine microscopy excludes glomerulnephritis as the cause of haematuria F

5) Cystoscopy is a first line investigation of non-glomerular haematuria in children F