Heamaturia Dr.Badi AlEnazi Consultant pediatric endocrinologest and diabetologest

Haematuria may occur as an isolated symptom or as part of a systemic disorder.

It may be visible to the naked eye (frank or macroscopic haematuria) or be detected only on microscopic analysis of the urine.

The source of the blood may be anywhere from glomerulus to urethra most cases in childhood are due to UTI or primary glomerular disease.

DDx Urinary tract infection (UTI). Glomerulonephritis (post-streptococcal, Henoch-Schonlein purpura, familial). IgA nephropathy. Acute haemorrhagic cystitis. Viral (adenovirus 11 and 21). drugs (cyclophosphamide). Calculus.

DDX Trauma. Exercise-induced. Usually after severe exercise and resolves within 48 hours. Tumours. Wilms’ tumour (uncommon presentation), bladder tumours (rare in children).

DDX Subacute bacterial endocarditis. Infections, e.g. tuberculosis, schistosomiasis. Coagulopathies. Sickle cell disease. Sickling within the renal medulla leads to local papillary infarcts.

DDX Renal vein thrombosis. Gross haematuria and palpable renal mass in a newborn infant. Factitious haematuria. As part of the Munchausen by proxy spectrum

Clinical Features The urine is usually pink or brown in colour because of the presence of the oxidized haem pigment. In post-streptococcal GMN the urine is often described as smoky.

Clinical Features If the urine is bright red with or without clots then a lower urinary tract source should be suspected. Haematuria may be an isolated finding or be associated with symptoms of a systemicdisorder, e.g. Henoch-Schbnlein purpura (rash, joint pains).

Clinical Features Hypertension and oliguria are features of acute GMN. Frequency and dysuria suggest a UTI which may be accompanied by microscopic haematuria, but presentation with frank haematuria is rare.

Clinical Features Loin pain or renal colic suggests the presence of a calculus. SBE, sickle cell disease and coagulation disorders are infrequent cause

Clinical Features ther causes of dark urine should be excluded: Bile pigments. Haemoglobinuria, myoglobinuria. Foods, e.g. beetroot. Drugs, e.g. rifampicin. Urate crystals may appear pink in the nappy of young infants

Urinary dipsticks are very sensitive and are therefore not very reliable. They are also positive for myoglobin and free haemoglobin

Urine microscopy should always be performed to confirm the presence of red cells (a fresh specimen is important since red cells lyse on standing). The presence of red cell casts indicates an intrarenal cause (either glomerular or tubular)

Urine microscopy Glomerular casts indicate a glomerular cause. Pyuria and bacteriuria point to an infective cause which should be confirmed by culture.

Urine culture will confirm a bacterial infection. CBC and coagulation tests. To exclude coagulopathies and sickle cell disease.

acute nephritis Causes of acute nephritis : Post-infectious (including streptococcus) Vasculitis (Henoch-Schönlein purpura or, rarely, SLE, Wegener's granulomatosis, microscopic polyarteritis, polyarteritis nodosa) IgA nephropathy and mesangiocapillary glomerulonephritis Anti-glomerular basement membrane disease (Goodpasture's syndrome) - very rare

acute nephritis Acute nephritis in childhood usually follows a streptococcal sore throat or skin infection. Streptococcal nephritis is a common condition in the developing world In acute nephritis, increased glomerular cellularity restricts glomerular blood flow and therefore filtration is decreased. This leads to: decreased urine output and volume overload hypertension, which may cause seizures oedema, characteristically around the eyes haematuria and proteinuria..

acute nephritis Management is by attention to both water and electrolyte balance and the use of diuretics when necessary. Rarely, there may be a rapid deterioration in renal function (rapidly progressive glomerulonephritis). This may occur with any cause of acute nephritis, but is uncommon when the cause is post-streptococcal. If left untreated, irreversible renal failure may occur over weeks or months, so renal biopsy and treatment with immunosuppression and plasma exchange should be undertaken promptly