Hematuria means blood in urine. Significant hematuria is defined as more than 5 red blood cells/HPF of a standard urinary sediment. The site of bleeding can be from kidneys / pelvicalyceal system / ureters / urinary bladder or urethra. Rarely hematuria is due to coagulation disorder.

The colour of the urine can give clue to the site of hematuria eg. Cola coloured urine - glomerular bleeding especially with proteinuria > 2+ and puffiness of eyes. Bright red colour especially if at the end of urination is due to bleeding from urinary bladder or urethra. Every pink / red / brown coloured urine need not be due to blood in urine. Ingestion of coloured sweets, beet root, drugs, hemoglobin or myoglobin can cause red urine and history is very important before investigating further.

Investigations of hematuria:

Urine

• color
 
• dipstick to detect blood / benzedine test (+ve with Hb / myoglobin and proteinuria)
 
• microscopy of urine for RBC's
 
• Wright's stain / phase contrast microscopy / Coulter counter can detect source of bleeding from glomerular or non glomerular source

Clinical clues from history and physical examination

Dysuria, loin pain, colic -	Hypercalcuria, stone ;
joint pain, skin rash -	SLE, HSP
Bleeding tendency -;	Coagulation disorders, platelet deficiency ;
Family history of hematuria -	Benign familial, Alport's syndrome, stones
Purpura -	HSP
Edema, Hypertension -;	Glomerulonephritis
Anemia, Splenomegaly -	Sickle Cell Disease
Renal angle tenderness -	Urinary tract infection
Renal mass -	Wilm's tumor, Polycystic kidney disease, hydronephrosis
Deafness -	Alport's syndrome
Painful hematuria -	Stones, UTI, hypercalciuria

Investigations should be phased in such a way as to rule out common causes.

Phase I

• Acute post infections glomerulonephritis- ASO titre, serum C3 level, HBsAg
 
• Acute pyelonephritis - Urine Culture, Colony Count
 
• Hypercalciuria - Urinary Calcium/Creatinine ratio, 24 hours urinary calcium excretion
 
• Ultrasonography to rule out stones, tumors, hydronephrosis, cystic kidney disease

If urine examination reveals < 5 RBC's / HPF on monthly examination, then urine examination should be repeated at least 3 times before it is considered normal.

Phase II

If hematuria is persistent in school age, then the following should be done:

• Family members should be screened for hematuria
 
• ANA, Antidss DNA, C3 levels
 
• Renal function tests
 
• Audiometry for nerve deafness
 
• Renal biopsy to rule out IgA nephropathy. If biopsy is normal then in case of positive family history, it is familial benign nephropathy

Indications for renal biopsy (Light immunoflourescent and electron microscopy)

• Asymptomatic hematuria for more than 1 year
 
• Hematuria with positive family history
 
• Hematuria + moderate to severe proteinuria, hypertension or elevated BUN, S.creatinine lasting for 2-3 weeks (atypical features in acute post streptococcal GN)
 
• Deafness +
 
• +ve serology for hepatitis B or SLE

* Alport's syndrome can be diagnosed only if EM is done. IgA nephropathy can be diagnosed only if IF is done. If EM and IF is not possible, Light microscopy alone can give final diagnosis in all condition except Alport's syndrome and IgA nephropathy

Intermittent hematuria in an active child
Always rule out exercise induced hematuria (after active sports or school activity, RBC's appear in urine and disappear if child is rested. IVP / Cystoscopy -are rarely required for diagnosis of hematuria Microscopic hematuria of long standing usually does not cause anemia, hence does not need hematinics

Salient Features of selected diseases with hematuria

Post streptococcal glomerulonephritis: Refer to Acute Glomerulonephritis

Renal stones& hypercalciuria: Refer to Renal Stones

Urinary tract Infections: Refer to UTI

Alport's Syndrome - It is a triad of persistent hematuria, deafness, familial disease along with eye anomalies which progresses to chronic renal failure especially in males. It is inherited as sex linked recessive / autosomal recessive / autosomal dominant condition. No treatment is available except renal transplant when the child to progresses to ESRD.

IgA nephropathy - It is a non-familial disease of unknown etiology. It presents with persistent microscopic and rarely macro hematuria. In majority of cases, it does not progress to ESRD in pediatric age. But 15% cases of IgA nephropathy in adults end in ESRD. Rarely nephrotic syndrome and hypertension is encountered after many years of onset.

Familial benign hematuria- It also presents with persistent microscopic hematuria and needs to be differentiated from Alport's syndrome since the prognosis is good in Familial benign hematuria whilst chronic renal failure occurs in Alport's syndrome. Final diagnosis is based on audiometry and kidney biopsy on EM.

Last created on 6-11-2000
Last updated on 01-07-2007