Hematuria slides for medical students

1. HEMATURIA
Hardi Hussein Qader
KUCOM

2. OBJECTIVES :
1. to know the definition and types of hematuria.
2. to identify the causes of hematuria.
3. How to investigate patient .
4. How to treat the patient.

3. DEFINITION
 Generally, hematuria is defined as the presence of 5
or more red blood cells (RBCs) per high-power field in
3 of 3 consecutive centrifuged specimens obtained at
least 1 week apart.
 Hematuria can be either gross (ie, overtly bloody,
smoky, or tea-colored urine) or microscopic(detected
by dipstick).
 It may also be either symptomatic or asymptomatic.
 either transient or persistent, and either
 isolated or associated with proteinuria and other
urinary abnormalities

5. PATHOPHYSIOLOGY :
 Structural disruption in the integrity of
glomerular basement membrane caused
by inflammatory or immunologic
processes
 Toxic disruptions of the renal tubules
 Mechanical erosion of mucosal surfaces
in the genitourinary tract

6. CAUSES OF RED URINE

8. APPROACH TO PATIENT WITH
HEMATURIA
1. History :
 Age: 2-5yrs: Wilms tumor
5-12yrs: PSGN•
 Sex: F>>M in >1-2yrs: UTI
F>>M: SLE nephritis
M>F : X-linked form of Alport syndrome•
 Race: whites: Idiopathic hypercalciuria blacks:
Sickle cell disease

9. Colour of urine
causes
Colour
Normal concentrated urine
Dark yellow
Bile pigment
Melanin
Tyrosinosis
Methemoglobinemia
Dark brown or
black
Glomerular hematuria
Cola coloured
Extra glomerular hematuria
Hemoglobin
Myoglobin
Chloroquine , refampin.
Beet , black berries , red dye in food.
Red or pink
urine

10. ASSOCIATED SYMPTOMS:
 Fever: Infections, SLE, AGN.
 Facial puffiness, Oedema of legs, weight gain, Shortness
of breath: Acute Glomerulonephritis.
 Hypertension : (Headache, visual changes, epistaxis,
seizures): AGN, ARF
 Abdominal pain: Urolithiasis (Loin to groin), UTI, clots,
Nutcracker syndrome
 Painless: Glomerular
 Abdominal mass: Hydronephrosis, PKD, Wilm’s tumour
 Joint pain : (HSP, SLE)
 Rashes :(HSP, SLE, PAN)
 Neurologic : – SLE, HUS (seizures, irritability)
 Jaundice: Hemolysis, Obstructive jaundice

11.  H/o exercise, menstruation, recent bladder catheterization
or passage of a calculus
 Recent upper respiratory (1-2wks back), skin infection (3-6
wks): PSGN
 GI infection: HUS, HSP nephritis
 Gross hematuria precipitated by URI: Alport syndrome, IgA
Nephropathy
 H/o bleeding from other sites: Bleeding disorders,
Hemoptysis in Good Pasture syndrome
 H/o Trauma, abdominal surgery, Child abuse (Social factors
- Munchausen), crush injury
 H/o ingestion of drugs (ATT – Rifampicin, Ibuprofen,
Chloroquine, Metronidazole, Iron), i.v. contrast agents (Toxic
nephropathy, RVT)

12. H/o Vision or hearing defects: Alport
syndrome
Family h/o: Hereditary glomerular diseases
(Alport syndrome, Thin glomerular
Basement Membrane Disease, IgA
Nephropathy), Urolithiasis, Hypercalciuria,
Sickle cell disease/trait
H/o consanguinity or affected siblings in
ARPKD, Metabolic disorders

13. EXAMINATION:
 Vitals:
– BP: in AGN, PKD
– Temperature
 Oedema: in AGN
 Pallor: Bleeding disorders, HUS, SLE, CRF
 JVP: Raised in CHF
 Per abdomen: Mass
– Kidney: Hydronephrosis (Urinary tract obstruction),
Wilms tumour; B/L in ARPKD, hydronephrosis
- Bladder palpable: Distal obstruction
 Tenderness: HSP

14.  Skin lesions :
- Purpura(HSP)
- Butterfly rash (SLE)
- Bruises (Trauma, Child abuse)
 Signs of Congestive cardiac failure, HTNsive
encephalopathy: AGN
 Joint swelling, tenderness: HSP, SLE
 Ophthalmologic: Alport syndrome (Anterior lenticonus,
macular flecks, recurrent corneal erosions), Aniridia (Wilms)
 Hearing assessment: Alport (B/L SNHL)

17.  Urine C/S
 RFT: Blood urea nitrogen/serum creatinine, Na/K (↓Na in
AGN, ↑K in ARF)
 Complete blood counts (CBC): Hb - ↓ in bleeding, HUS,
SLE, CRF; Abnormal TC, DC in infections, HUS, ↓ in SLE;
 Platelet counts and Coagulation studies: (history
suggestive of bleeding disorder, HUS), Sickle cell
(Hemoglobin electrophoresis)
 PBS: Microangiopathic hemolytic anemia
 ESR, CRP – Infections
 24 hr urinary protein, Spot urinary protein: Creatinine ratio,
Serum albumin and cholesterol if associated proteinuria
(Nephrotic syndrome)
 Urine calcium: - Hypercalciuria is a relatively common
finding in children.
– 24-hour urinary calcium (>4mg/kg/d), or
– Spot urine calcium-creatinine ratio >0.21

18. IMAGING STUDIES
1. Renal and bladder sonography: Urinary tract anomalies,
such as hydronephrosis, hydroureter, nephrocalcinosis,
tumor, and urolithiasis, Renal parenchymal disease
2. X-Ray KUB: calculi
3. Doppler study of renal vessels and IVC: Renal vein
thrombosis
4. Intravenous urography
5. Spiral CT scan - Urolithiasis, Wilms tumor and polycystic
kidney disease, Renal trauma
6. Micturating cystourethrograms - Urethral and bladder
abnormalities (eg, cystitis), in recurrent UTI to r/o VUR,
anomalies
7. Radionuclide studies
8. Renal function and perfusion – Angiogram
9. Chest X-Ray (Pulmonary oedema, CHF)

19. RENAL BIOPSY
Relative indications :
1. Significant proteinuria (3+ or more) or nephrotic
syndrome +
2. Recurrent persistent hematuria (Microscopic >2yrs)
3. Abnormal renal function, Persistent HTN
4. Hematuria, Proteinuria, diminished renal function, low C3
level persist beyond 2 mo of onset of AGN
5. Absence of evidence of streptococcal infection
6. Serologic abnormalities (abnormal ANA or dsDNA levels)
7. A family history of end stage renal disease or evidence of
Chronic renal disease in patient

20. MANAGEMENT
According to cause
 Reassurance and F/U
 Treat cystitis, pyelonephritis, AGN: Antibiotics
 Supportive treatment: Diuretics, Fluid and salt restriction,
Antihypertensives
 Monitoring – BP, I/O, weight, Urine R/M
 Treat Hyperkalemia, ARF, CHF, acidosis, fluid overload, HTN
and its complications
 ACE inhibitors useful in proteinuria
 Immunosuppressive therapy: Depending on cause (Steroids,
cyclophosphamide)

21. Idiopathic Hypercalciuria:
Hydrochlorothiazide , Potassium citrate,
Sodium restriction
Calculi: Plenty of water
ESRD: Dialysis, Renal transplantation
Correct thrombocytopenia, anemia,
coagulation factor deficiency
Renal vein thrombosis: Anticoagulant therapy
or thrombectomy may be needed
Surgical correction: Calculi, PUJ obstruction,
Posterior urethral valves, Wilms tumour

22. REFERENCES:
1. Nelson Textbook of Pediatrics, 19th Ed
2. Nelson Essentials of Pediatrics, 6th Ed
3. Pediatric board study guide

23. THANK YOU