Paediatrics 4 Microteaching: Haematuria in children Zara Gall Victoria Hopkinson Shahid Islam (Previous presentation by Satish Maddenini and Lynsey McHugh) September 2011

MCQs 1)Macroscopic haematuria is more common than microscopic haematuria in children 2)Around half of children with macroscopic haematuria will have a UTI 3)Red coloured urine can be caused by food colouring 4)Absence of RBC casts on urine microscopy excludes glomerulonephritis as the cause of haematuria 5)Cystoscopy is a first line investigation of non-glomerular haematuria in children

Causes of haematuria in children Frank (visible) haematuria Causes most concern but often benign and usually short lived Uncommon – 1:1000 visits to doctor Around 50% will have UTI Microscopic (non-visible) haematuria Prevalence of around 1.5% in children and adolesents Thus more common, but often more difficult to define Causes of urine mimicking haematuria: Dipstick (heme) positive: Haemoglobinuria, myoglobinuria, bacterial peroxidases, povidone, hypochlorite Dipstick negative, red urine: Drugs (nitrofurantoin, salicylates), foods (beetroot, food colouring), metabolites (porphyrin)

Causes of haematuria in children Microscopy positive for Eumorphic cells: Hypercalcuria Present in approx 30% of children with noninfected urine with non-glomerular haematuria Nephrolithiasis Nephrocalcinosis UTI Trauma Exercise Cystic kidney disease Tumour Haemangioma

Causes of haematuria in children Microscopy positive for Dysmorphic RBC/RBC casts Proteinuria present Poststreptococcal GN (early) IgA nephropathy Alport syndrome HSP Haemolytic uraemic syndrome Membranoproliferative GN Focal segmental GN Diffuse proliferative GN SLE Sickle cell disease or trait Hep B-associated GN Proteinuria not present Family history of haematuria Alport syndrome (if FH of hearing loss/renal failure) Thin basement membrane disease Sickle cell disease or trait No FH of haematuria IgA nephropathy Poststreptococcal GN (late)

Investigations Thorough history, examination (inc. BP check) and family history Presence of haematuria must be confirmed by both dipstick and microscopic evaluation Microscopy particularly important Are RBC present? RBC casts? Dysmorphic RBC? Hallmark of glomerular bleeding has been RBC casts +/- proteinuria But many children with glomerular or renal parenchymal disease have neither RBC casts nor proteinuria One study showed that if 10% RBC show dysmorphism, diagnosis is GN with 94% specificity and 92% sensitivity

Investigations No RBC casts/dysmorphic RBC Investigate further if Micro haematuria >5 RBC/hpf in 2 out of 3 urinalyses in asymptomatic child, or in single sample in symptomatic child Macroscopic haematuria Investigations directed towards finding non- glomerular or urological cause of haematuria Urine culture Renal USS Other Ix depending on the results of these – eg DMSA, MCUG And if these are normal Cystoscopy Esp if macroscopic haematuria RBC casts/dysmorphic RBC present ?proteinuria present Spot albumin/creatinine ratio Abnormal if >10mg/mmol in children Proteinuria confirmed Refer to a nephrologist for Ix such as: albumin, cholesterol, FBC, U+E, C3, C4, ASO, ANCA etc No proteinuria Repeat urine microscopy 3 times over 2 months If negative reassure If positive Sickle prep USS Screen for hypercalcuria If tests negative and haematuria persists Refer to nephrologist

MCQs 1)Macroscopic haematuria is more common than microscopic haematuria in children F 2)Around half of children with macroscopic haematuria will have a UTI T 3)Red coloured urine can be caused by food colouring T 4)Absence of RBC casts on urine microscopy excludes glomerulnephritis as the cause of haematuria F 5)Cystoscopy is a first line investigation of non-glomerular haematuria in children F