Haematuria

Macroscopic Haematuria:
Seen by naked eyes, the colour of urine may vary from bright red to almost black.
Less than 0.5mL of blood in 500mL of urine causes macroscopic haematuria.

Microscopic Haematuria:
Dip stick:
- A very sensitive qualitative test Can be positive at <5 RBCs per high-power field.
- A greenish blue colour of various degrees results from reaction between
peroxidase from haemoglobin or myoglobin and a chemical indicator on the dip stick
Microscopically:
5 or more erythrocytes/ micro litre of urine in a fresh uncentrifuged midstream urine
specimen
Or More than 3 blood cells/ high power field from 10ml of freshly voided
uncentrifuged midstream urine specimen

 Positive dip sticks test needs a confirmation by a urine

microscopic test
 Positive dip sticks test, negative RBC microscopically
indicates haemogblobin or myoglobin in urine
 after UTI, idiopathic hypercalciurea is the second most
common cause of haematurea in children

Glomerular haematurea
Tea coloured urine, proteinurea > 100mg/dl (++ by dip sticks), RBC casts, deformed
urinary RBC shape
Non glomerular haematurea
Bright red urine, proteinurea <100mg/dl, WBC casts, normal urinary RBC shape,
blood clots, dysurea, burning micturition

Causes of haematuria
Glomerular hematuria
- Benign familial hematuria (Thin basement membrane disease)
- Non familial benign hematuria
- Glomerulonephritis
Postinfectious glomerulonephritis
Membranoproliferative glomerulonephritis
 membranous nephropathy
Rapidly progressive glomerulonephritis
IgA nephropathy
Lupus nephritis
Anaphylactoid purpura (Henoch-Schönlein purpura)
polyarteritis nodose
Wegner granulomatosis
- Alport syndrome
- Hemolytic-uremic syndrome
- renal vein thrombosis
- cystic renal diseas
Nonglomerular hematuria
- Fever
- Strenuous exercise
- Trauma, Foreign bodies
- Urinary tract infection
- Hypercalciuria
- urolithiasis
- Sickle cell disease/trait
- Coagulopathy
- Drugs/toxins (nonsteroidal anti-inflammatory drugs [NSAIDs], anticoagulants,
cyclophosphamide)
- Anatomic abnormalities (hydronephrosis, polycystic kidney disease, vascular
malformations)
- HyperuricosuriaGlomerular

Causes of Red coloured urine

 Red blood cells
 Haemoglobin
 myoglobin
 Certain foods (beetroot)
 Medication (nitrofurantoin, rifampicin)
 Urate crystals are commonly present in the urine of newborn babies. They
can produce a red discolouration of the nappy
 Acute porphyria
 sources other than the urinary tract (eg vaginal haemorrhage, rectal fissure ).
Important questions in History:
Pain, Colour of urine ,Fever, Oedema, Reduced Urine amount, dysurea, burning
micturition,Skin Rash, joint swelling, bloody diarrhoea or maleana, other sites of
bleeding,trauma or urinary catheterisation, strenuous excercise, passage of stones
Preceeding upper respiratory tract infection and when,
Recurrent hematurea
Drugs and herbal medicine
Family history of haematurea, stones, sickle cell diseas

important points in physical examination:

Vital signs don’t forget Bp, abdominal tenderness (supra pubic, loin), abdominal
mass, Oedema, Skin Rash, joint swelling

Investigations
For all the patients
urine analysis: proteinuria, erythrocyte morphology, casts, leucocytes

Glomerular haematuria:
FBC (full blood count)
Blood Biochemistry( urea, creatinin, electrolytes, calcium, phosphate)
C3 C4 (complements)
If symptoms suggest acute nephritis (oedema, oligurea, hypertension) add:
 urine protein/ creatinin ratio
 serum protein and albumin
 serum lipids
 throat culture
 ASO titre, Anti DNAse B
 ANA (anti nuclear anti bodies)
 Anti dstDNA (anti double stranded DNA)
 ANCA (anti neutrophil cytoplasmicc anti body) in special cases
 Consider renal biopsy if indicated
If symptoms don’t suggest acute nephritis add:
 24 hours urine protein and creatinin clearance
 Serum IGA level
 Renal ultrasound
 Test parents and siblings for haematurea
 Consider audiology and ophthalmology referral
 Consider renal biopsy if indicated

Non glomerular haematurea:

step 1
 urine culture
step 2
 Urine calcium/ creatinine ratio
 Blood Biochemistry( urea, creatinin, electrolytes, calcium, phosphate)
 Urine adenovirus culture
 Sickle cell investigations
 Ultrasound kidney, ureter, bladder and Doppler
step 3
 coagulation studies (full blood count, PT PTT)
 abdominal x-ray if urinary tract calculi are suspected
 24 hour urine calcium, uric acid, oxalate, cystein (in case of calculi)
 abdominal CT scan (in case of trauma or tumour)
 MRI, angiogram in very specific cases
 cystoscopy in very specific cases

indications for renal biopsy:

 significant proteinrea ( except in post streptococcal glomerulonephritis)
 persistant low serum C3
 unexplained azotemia
 a systemic disease with protein urea (SLE, HSP, ANCA- positive vasculitis)
 family history of a renal diseas suggestive of Alpot syndrome
 recurrent gross haematura of unknown aetiology
 persistant glomerular haematurea and parents are anxious

indications of referral to a paediatrics nephrologist

 Nephritis (glomerulonephrits, tubulointerstitial nephritis)
 Impaired renal function
 Hypertension
 Urolithiasis or nephroclcinosis
 Positive family history of a renal problem
 Recurrent gross haematurea
 persistant asymptomatic haematurea for more than 1 year
 Approach to Haematuria - Algorithm

Confirm haematuria by - dip stick positive examine for

dip sticks pigments (Hgb,
microscopic RBC negative
- microscopic exam myoglobin)
dip stick positive myoglobin)
microscopic RBCpositive

Asymptomatic haematuria
symptomaticc disappeared
-exclude excercise
-repeat twice 2 weeks follow up
apart with no excercise 6 monthly

haematuria
persisted

FBC, urea, creatinin,electrolytes, calcium,

acute nephritis C3 C4 ,urine protein/ creatinin ratio, serum
(oedema, oligurea, protein and albumin,serum lipids ,throat
hypertension) YES culture, ASO tire, Anti DNAse B ,ANA , Anti
dstDNA, ANCA in special cases
NO Consider renal biopsy if indicated

- urine RBC shape

- urine protein/ creatinin ratio

Non Glomerular Glomerular

investigate as in guidelines investigate as in guidelines

normal investigations,haematuria
intermittent or persistent

3 monthly BP and urine

analysis, creatinine annually