What is the Differential and Management of Pediatric Hematuria?

A previously healthy 3 year-old boy was brought in by his mom who reported pink urine after visiting his grandmother over the Christmas break. Review of systems is otherwise negative. The patient has no medical history and does not take any medications. He is well-appearing and afebrile. The physical exam is normal including an unremarkable genitourinary exam.

This is the first time you are seeing a pediatric patient presenting with hematuria. As soon as you order a urinalysis, you type in “hematuria in children” in Google’s search bar.

1- What is hematuria?

Hematuria is defined > 5 RBC per high-powered field (HPF). Gross hematuria is when hematuria is visible to the naked eye, while microscopic hematuria is when hematuria is seen on urine dipstick or urinalysis.

(1 ml of blood in 1000ml of urine is sufficient to make urine appear pink or red)

The etiology of hematuria in children can be divided into the three broad categories: Glomerular and non-glomerular renal causes and extra-renal causes

2- What are the most common glomerular renal causes of hematuria in children?

-Post-streptococcal glomerulonephritis

-IgA nephropathy

-Alport Syndrome

-Hemolytic Uremic Syndrome (HUS)

-Henoch-Schonlein Purpura

3- What are the most common non-glomerular renal causes of hematuria?

-Urinary tract infection (most common cause overall)

-Pyelonephritis

-Hemorrhagic cystitis

-Hypercalciuria

-Posterior urethral valve or any other congenital abnormalities (2nd most common cause)

-Wilms tumor and renal cell carcinoma

4- What are the most common extra-renal causes of hematuria?

-Sickle cell disease

-Strenuous exercise

-Hemophilia

-Von Willebrand disease

5-How can you differentiate between glomerular and non-glomerular causes of hematuria?

	Glomerular Causes	Non Glomerular Causes
History	-Oliguria or polyuria -Recent respiratory, skin, or GI infection -Deafness -Medication exposure -Rash -Family history of renal failure -Hemoptysis	-Dysuria or polyuria -Renal colic/abdominal pain -Fever -Trauma history -Family history of sickle cell disease or hemophilia -Strenuous exercise
Physical Exam	-Elevated blood pressure -Edema -Rash -Arthritis -Pallor	-Normotension -CVA tenderness -Suprapubic pain -Signs of trauma
Urinalysis	-Brown, tea, or cola colored urine -Proteinuria often present -RBC casts	-Bright red urine -+/- proteinuria -No RBC casts -Positive nitrites or leukocyte esterase
Laboratory testing	-Elevated BUN and creatinine -Anemia -Abnormal Complement levels (C3 & C4)	-Normal BUN and creatinine

6-What is the first test you order?

Urine dipstick or urinalysis.

7- True/False: “Hematuria can account for 3+ protein in the urine”?

False. Proteins are excreted with hematuria; however, gross hematuria cannot account for >+2 proteinuria on the dipstick. Any level >+2 should raise concern for glomerular disease.

8-True/False: “Normotensive patients with post-streptococcal glomerulonephritis should be admitted or observed for blood pressure monitoring”?

False. Patients without edema or hypertension can be discharged and followed up closely with primary care provider. Hematuria or proteinuria usually resolves within a few weeks to months.

After reading about different causes of hematuria in children, the urinalysis comes negative for blood and protein.

-Foods (beets, blackberries)

-Myoglobin

-Metabolites (porphyrins, bile pigment, methemoglobin)

-Drugs (chloroquine, sulfonamides, iron, lead, deferoxamine, etc)

You call the patient’s grandmother to obtain more history, and she tells you that he ate 3 beets earlier in the morning.

Thanks to Drs. deSouza & Willis.