Paeds · nephrology-urology-fluids-and-electrolytes
Haematuria: diagnostic approach
Also known as Blood in the urine · Red urine · Cola-coloured urine · Microscopic haematuria · Macroscopic haematuria · Glomerular haematuria · IgA nephropathy · Post-streptococcal glomerulonephritis · IgA vasculitis nephritis · Alport syndrome · Hypercalciuria
Fellowship guide to the diagnostic approach to haematuria in children, built around the glomerular versus non-glomerular fork. The page works from confirming that red or brown urine really is blood, through the colour clue and red-cell morphology, to an age-anchored differential that runs from renal vein thrombosis in the neonate through post-streptococcal glomerulonephritis, IgA nephropathy, IgA vasculitis nephritis and haemolytic uraemic syndrome in the child to lupus nephritis and Alport syndrome in the adolescent, and on to complement patterns, the indications for renal biopsy and the red flags of hypertension, oedema and an abdominal mass.
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- Brown, tea-coloured or cola-coloured urine with oedema, hypertension, oliguria or a rising creatinine is an acute nephritic emergency and needs urgent measurement of blood pressure, renal function and complement, not a delayed outpatient referral
- A child with haematuria and a blood pressure at or above the ninety-fifth centile for age, sex and height has hypertension and may be heading for a hypertensive emergency with encephalopathy, so control it in a monitored setting
- Pallor, petechiae, bruising and oliguria after a diarrhoeal illness is haemolytic uraemic syndrome until proven otherwise, with microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury
- A painless abdominal or flank mass with haematuria in a young child is a Wilms tumour or another surgical cause until imaging proves otherwise, and must never be biopsied percutaneously before a nephrology or surgical assessment
- A positive urine dipstick for blood with no red cells on microscopy is not haematuria; it points to myoglobinuria or haemoglobinuria from rhabdomyolysis or haemolysis, which can be rapidly lethal
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- Microscopic versus macroscopic haematuria and the definition of more than five red cells per high-power field
- Glomerular versus non-glomerular haematuria and the discriminating urine findings
- The age-anchored differential diagnosis of haematuria in children
- Post-streptococcal and IgA nephropathy: complement patterns, serology and biopsy
- Alport syndrome and thin basement membrane nephropathy: genetics and surveillance
- Haemolytic uraemic syndrome and the hypertensive emergency from acute nephritis
- Confirming haematuria: dipstick, microscopy and excluding myoglobinuria
- Interpreting complement, streptococcal serology and the urine calcium-to-creatinine ratio
- Red flags in a child with haematuria: hypertension, oedema, oliguria and an abdominal mass
- Long case: the child with persistent microscopic haematuria and a family history of renal failure
- Short case: assessment of the child with cola-coloured urine
- Nephrology: glomerular and non-glomerular causes of haematuria
- Recognition and investigation of the child with haematuria and hypertension
- Causes of haematuria by age and source
- Post-streptococcal glomerulonephritis, IgA nephropathy and IgA vasculitis nephritis
- Assessment of the child presenting with red or brown urine
- Evaluation of haematuria in infants and children
- Glomerulonephritis and the nephritic presentation
- Haemolytic uraemic syndrome and Alport syndrome
- Patient Care: diagnostic evaluation and stabilisation of the child with haematuria
- Medical Expert: haematuria and glomerular disease in children
Overview & Definition
Picture a six-year-old whose mother spots cola-coloured urine in the toilet, and a teenager who passes bright red urine after a long football session. Both have blood in the urine, yet the colour, the timing and company blood keeps point to completely different problems and demand different first moves. Haematuria is the presence of red blood cells in the urine, and in children its meaning is set by three things working together: whether the blood is visible, what colour it is, and whether the urine also carries protein, casts and the signs of kidney inflammation. [1] [2]
The first practical fork is not visible against invisible but visible against microscopic is only half the story. Microscopic haematuria means blood found on dipstick and confirmed as more than five red cells per high-power field on a centrifuged specimen, and it is usually picked up on a routine check. Macroscopic, or visible, haematuria means blood the family can see, and the colour they describe is immediately diagnostic of the broad source. [1]
The single trap at the door is the dipstick that lies. A urine dipstick detects haem, not intact red cells, so it turns positive for blood in the presence of free haemoglobin or myoglobin as well as whole red cells. A positive dipstick with no red cells on microscopy is therefore not haematuria at all; it points to myoglobinuria from rhabdomyolysis or haemoglobinuria from haemolysis, both of which can be rapidly dangerous. Confirming that red cells are really there, then reading their colour and their shape, is the discipline that turns an alarming symptom into a tractable problem. [1]
References12ShowHide
- [1]Kallash M; Rheault MN Approach to Persistent Microscopic Hematuria in Children. Kidney360, 2020.PMID 35369549
- [2]Vedula R; Iyengar AA Approach to Diagnosis and Management of Hematuria. Indian J Pediatr, 2020.PMID 32026313
- [3]Tu WH; Shortliffe LD Evaluation of asymptomatic, atraumatic hematuria in children and adults. Nat Rev Urol, 2010.PMID 20212514
- [4]Clark M; Aronoff S; Del Vecchio M Etiologies of asymptomatic microscopic hematuria in children - systematic review of 1092 subjects. Diagnosis (Berl), 2015.PMID 29540037
- [5]Bottini PV; Andreguetto BD; Krempser K; et al UriSed as an Alternative to Phase-Contrast Microscopy in the Differentiation between Glomerular and Non-Glomerular Hematuria. Clin Lab, 2015.PMID 26118201
- [6]Trimarchi H; Barratt J; Cattran DC; et al Oxford Classification of IgA nephropathy 2016: an update from the IgA Nephropathy Classification Working Group. Kidney Int, 2017.PMID 28341274
- [7]Iyengar A; Kamath N; Radhakrishnan J; et al Infection-Related Glomerulonephritis in Children and Adults. Semin Nephrol, 2023.PMID 38242806
- [8]Duong MD; Reidy KJ Acute Postinfectious Glomerulonephritis. Pediatr Clin North Am, 2022.PMID 36880922
- [9]Pillebout E; Sunderkötter C IgA vasculitis. Semin Immunopathol, 2021.PMID 34170395
- [10]Kashtan CE; Gross O Clinical practice recommendations for the diagnosis and management of Alport syndrome in children, adolescents, and young adults-an update for 2020. Pediatr Nephrol, 2021.PMID 33159213
- [11]MohammadKhawajah I; Shamshiri Khamene S; Mahboobipour AA; et al Investigating the Prevalence of Hypercalciuria in Children Aged 2-16 Years With Asymptomatic Microscopic Hematuria in 2020 in Tehran Children's Medical Center. Clin Case Rep, 2024.PMID 39545136
- [12]Gülhan B; Özaltın F; Fidan K; et al Management of pediatric hemolytic uremic syndrome. Turk J Pediatr, 2024.PMID 38523374