Hematuria in Children

Aka: Hematuria in Children, Pediatric Hematuria, Brick-Red Diaper dumping Syndrome

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II. Epidemiology: Hematuria Incidence

  1. Microscopic Hematuria
    1. School age Hematuria on single sample: 4%
    2. Hematuria on repeat sample: 0.5%
  2. Gross Hematuria
    1. More commonly found in girls
    2. Overall Incidence: 0.13%

III. Definition

  1. Gross Hematuria
    1. Pink, red or brown color visible to naked eye
    2. Confirm by dipstick and sediment exam
  2. Microscopic Hematuria significant values
    1. Urine Red Blood Cells: 0.5 - 2.4 Million/day
    2. Spun urine: 5-10 Red Blood Cells/hpf (50/ul)
    3. Confirmed on repeat Urinalysis after 1 month

IV. Differential Diagnosis of Gross Hematuria

  1. See Gross Hematuria

V. Causes (Mnemonic: ABCDEFGHI)

  1. Anatomy
    1. Ureteropelvic junction obstruction
    2. Renal Cysts (Simple, Polycystic Kidney Disease)
    3. Vaginal source of bleeding
      1. Estrogen withdrawal bleeding
        1. Occurs in newborn girls in first 5-14 days of life
        2. Onset after maternal Estrogen exposure stops with delivery
  2. Boulders
    1. Nephrolithiasis
    2. Hypercalciuria
  3. Cancer
  4. Drugs
  5. Exercise
  6. Fictitious Causes
    1. Munchausen's Syndrome
    2. Betadine contaminant
    3. Brick-Red Diaper dumping Syndrome
      1. Salmon-red color on diaper may appear to family as Gross Hematuria
      2. Diaper absorbant material reacts with urate crystals in concentrated urine to form color
      3. Benign cause and resolves with hydration
  7. Familial
  8. Foreign Body
  9. Glomerulonephritis
    1. Post-Streptococcal Glomerulonephritis
    2. Henoch-Schonlein Purpura (HSP)
    3. Systemic Lupus Erythematosus (SLE)
    4. IGA Nephropathy
    5. Alport's Syndrome
  10. Hemoglobinopathies (Sickle Cell Anemia)
  11. Hematologic disorders (Platelet disorders)
  12. Infection

VI. Family History

  1. Renal Failure
    1. Renal Transplant
    2. Dialysis
  2. Systemic Lupus Erythematosis
  3. Familial Heamturia

VII. History

  1. Abdominal Pain
  2. Bloody Diarrhea
  3. Arthralgias
  4. Vigorous Exercise
    1. Jogging
    2. Biking
    3. Snow boarding
  5. Child Abuse history
    1. Abdominal, back or Flank Pain
    2. Bruising
  6. Urinary Tract Infection, cystitis, or Hypercalciuria
    1. Dysuria
    2. Urinary Frequency
    3. Suprapubic Pain
  7. Medications
    1. Aspirin
    2. NSAIDs
    3. Antibiotics
    4. Methyldopa

VIII. Signs

  1. Blood Pressure
  2. Edema
  3. Skin rash

IX. Labs: Indicated for persistant Hematuria >1 month

  1. Repeat Urinalysis
  2. Urine Culture
  3. Urine Calcium to Creatinine Ratio (normal <0.2-0.25)
  4. Collect 24 hour Urine Collection
    1. Urine Calcium Excretion (normal <4 mg/kg/day)
  5. Urinalysis of a Family Member
  6. Chemistry panel (Chem 10)
    1. Blood Urea Nitrogen (BUN)
    2. Creatinine
    3. Serum Electrolytes
    4. Serum Glucose
    5. Serum Calcium
    6. Serum Phosphate
    7. Serum Magnesium
  7. Sickle Cell Screen
  8. Complement level (C3)
  9. Anti-streptolysin O titer (ASO Titer)
  10. Antinuclear Antibody (ANA)

X. Imaging

  1. Renal Ultrasound
  2. Bladder Ultrasound
  3. Voiding Cystourethrogram (VCUG)

XI. Diagnostic Studies

  1. Audiogram to assess for Alport's Syndrome
    1. Shows bilateral Sensorineural Hearing Loss

XII. Referral Criteria

  1. Concurrent systemic signs
    1. Pain
    2. Fever
    3. Hypertension
    4. Arthritis
  2. Elevated Renal Function testing (BUN, Creatinine)
  3. Coexistant Proteinuria
  4. Episodes of Gross Hematuria
  5. Family History
    1. Glomerulonephritis
    2. Deafness
    3. Renal Failure
    4. Renal Transplant
  6. Parental anxiety

XIII. Follow-up

  1. After negative work-up, rescreen urine every 6-12 month

XIV. References

  1. Fitzwater (1994) Pediatr Rev, 15:102-9 [PubMed]
  2. Shane (1998) Pediatr Rev, 19(6): 209-12 [PubMed]

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