Hematuria Clinical Presentation
- Author: Sanjeev Gulati, MBBS, MD, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada); Chief Editor: Craig B Langman, MD more...
History
The first step in the evaluation of hematuria is a detailed review of the history and a thorough physical examination. An attempt should be made to distinguish glomerular causes of hematuria from extraglomerular ones, as this helps in prioritizing the investigations.
- A history of passage of clots in urine suggests an extraglomerular cause of hematuria.
- A history of fever, abdominal pain, dysuria, frequency, and recent enuresis in older children may point to a urinary tract infection as the cause of hematuria.
- A history of recent trauma to the abdomen may be indicative of hydronephrosis.
- A history of early-morning periorbital puffiness, weight gain, oliguria, the presence of dark-colored urine, and the presence of edema or hypertension suggests a glomerular cause.
- Hematuria due to glomerular causes is painless.
- A history of a recent throat or skin infection may suggest postinfectious glomerulonephritis.
- A history of joint pains, skin rashes, and prolonged fever in adolescents suggests a collagen vascular disorder.
- The presence of anemia cannot be accounted for by hematuria alone, and, in a patient with hematuria and pallor, other conditions such as systemic lupus erythematosus and bleeding diathesis should be considered.
- Skin rashes and arthritis can occur in Henoch-Schönlein purpura and systemic lupus erythematosus.
- Information regarding exercise, menstruation, recent bladder catheterization, intake of certain drugs or toxic substances, or passage of a calculus may also assist in the differential diagnoses.
- Because certain diseases that present with hematuria are inherited or familial, asking for a family history that is suggestive of Alport syndrome, collagen vascular diseases, urolithiasis, or polycystic kidney disease is important.
Physical
In the general physical examination, the most important step is to measure the blood pressure (with an appropriate-sized cuff) and evaluate for the presence of periorbital puffiness or peripheral edema.[2, 3]
- A detailed skin examination is necessary to look for purpura.
- An abdominal examination is indicated to look for palpable kidneys (Wilms tumor or hydronephrotic kidneys).
- A careful examination of the genitalia is also important.
Causes
Hematuria can be of glomerular or nonglomerular origin. Brown-colored urine, RBC casts, and dysmorphic (small deformed, misshapen, sometimes fragmented) RBCs and proteinuria are suggestive of glomerular hematuria. Reddish or pink urine, passage of blood clots, and eumorphic (normal sized, biconcavely shaped) erythrocytes are suggestive of a nonglomerular bleeding site.
Potential causes of hematuria in children include the following:
- Glomerular hematuria
- Thin basement membrane disease (benign familial hematuria)
- Alport syndrome
- Immunoglobulin A (IgA) nephropathy
- Hemolytic-uremic syndrome
- Postinfectious glomerulonephritis
- Membranoproliferative glomerulonephritis
- Lupus nephritis
- Anaphylactoid purpura (Henoch-Schönlein purpura)
- Nonglomerular hematuria
- Fever
- Strenuous exercise
- Mechanical trauma (masturbation)
- Menstruation
- Foreign bodies
- Urinary tract infection
- Hypercalciuria/urolithiasis
- Sickle cell disease/trait
- Coagulopathy
- Tumors
- Drugs/toxins (nonsteroidal anti-inflammatory drugs [NSAIDs], anticoagulants, cyclophosphamide, ritonavir, indinavir)
- Anatomic abnormalities (hydronephrosis, polycystic kidney disease, vascular malformations)
- Hyperuricosuria
Tu WH, Shortliffe LD. Evaluation of asymptomatic, atraumatic hematuria in children and adults. Nat Rev Urol. Apr 2010;7(4):189-94. [Medline].
Higashihara E, Nishiyama T, Horie S, et al. Hematuria: definition and screening test methods. Int J Urol. Apr 2008;15(4):281-4. [Medline].
Quigley R. Evaluation of hematuria and proteinuria: how should a pediatrician proceed?. Curr Opin Pediatr. Apr 2008;20(2):140-4. [Medline].
Diven SC, Travis LB. A practical primary care approach to hematuria in children. Pediatr Nephrol. Jan 2000;14(1):65-72. [Medline].
Dodge WF, West EF, Smith EH, Bruce Harvey 3rd. Proteinuria and hematuria in schoolchildren: epidemiology and early natural history. J Pediatr. Feb 1976;88(2):327-47. [Medline].
Crompton CH, Ward PB, Hewitt IK. The use of urinary red cell morphology to determine the source of hematuria in children. Clin Nephrol. Jan 1993;39(1):44-9. [Medline].
Cruz CC, Spitzer A. When you find protein or blood in the urine. Contemp Pediatr. 1998;15:89-109.
D'Amico G. The commonest glomerulonephritis in the world: IgA nephropathy. Q J Med. Sep 1987;64(245):709-27. [Medline].
Emancipator SN, Gallo GR, Lamm ME. IgA nephropathy: perspectives on pathogenesis and classification. Clin Nephrol. Oct 1985;24(4):161-79. [Medline].
Feld LG, Stapleton FB, Duffy L. Renal biopsy in children with asymptomatic hematuria or proteinuria: survey of pediatric nephrologists. Pediatr Nephrol. Aug 1993;7(4):441-3. [Medline].
Feld LG, Waz WR, Perez LM, Joseph DB. Hematuria. An integrated medical and surgical approach. Pediatr Clin North Am. Oct 1997;44(5):1191-210. [Medline].
Kalia A, Travis LB, Brouhard BH. The association of idiopathic hypercalciuria and asymptomatic gross hematuria in children. J Pediatr. Nov 1981;99(5):716-9. [Medline].
Kincaid-Smith P, Fairley K. The investigation of hematuria. Semin Nephrol. May 2005;25(3):127-35. [Medline].
Krieger I, Sargent DA. A postural sign in the sensory deprivation syndrome in infants. J Pediatr. Mar 1967;70(3):332-9. [Medline].
Meyers KE. Evaluation of hematuria in children. Urol Clin North Am. Aug 2004;31(3):559-73, x. [Medline].
Roy S 3rd. Hematuria. Pediatr Rev. Jun 1998;19(6):209-12; quiz 213. [Medline].
Sargent JD, Stukel TA, Kresel J, Klein RZ. Normal values for random urinary calcium to creatinine ratios in infancy. J Pediatr. Sep 1993;123(3):393-7. [Medline].
Seigel M, Lee ML. Hematuria. Semin Arthritis Rheum. 1974;3:1.
Ward JF, Kaplan GW, Mevorach R, et al. Refined microscopic urinalysis for red blood cell morphology in the evaluation of asymptomatic microscopic hematuria in a pediatric population. J Urol. Oct 1998;160(4):1492-5. [Medline].
Yadin O. Hematuria in children. Pediatr Ann. Sep 1994;23(9):474-8, 481-5. [Medline].
| Condition | Histology | History | Laboratory Data |
| Systemic lupus erythematosus | Mild glomerulitis, proliferative changes, immune complex deposition, crescents, immunoglobulin deposition | Hematuria, proteinuria, hypertension, joint pains, rashes | Abnormal C3, C4, ANA, and dsDNA levels; anemia; thrombocytopenia |
| IgA nephropathy | IgA deposition in the mesangium, glomerular sclerosis, proliferative changes, crescents in severe cases | Gross, intermittent, painless hematuria | No specific changes, although increased serum IgA levels observed in some patients |
| Henoch-Schönlein purpura | Same as IgA nephropathy | Purpura, joint pains, abdominal pain, hematuria | No specific laboratory data |
| Alport syndrome | Some thinning of basement membranes, "basket weave" changes in the glomerular basement membrane on electron microscopy | Sensorineural hearing loss, corneal abnormalities, hematuria, renal failure | No specific changes |
| Thin basement membrane disease | Average glomerular basement membranes reported to be 100-200 nm in children in this condition | Persistent microscopic or gross hematuria, significant family history | No specific changes |
| Mesangiocapillary glomerulonephritis | Glomerular lobulations, thickening of the mesangial matrix and glomerular basement membranes, crescents | Hematuria, proteinuria, hypertension | C3 levels possibly abnormal |
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