MICROSCOPIC HEMATURIA

HOW TO APPROACH?

Dr. Kalaivani Ganesan

Presentation:

Recognize and confirm hematuria

Site of origin (glomerular, non-glomerular [ tubules,

interstitium & urinary tract]or non-renal)

Cause of hematuria

Recognize significant disease for referral

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Introduction:

Gross (Macroscopic) hematuria

 Blood seen with the naked eye

Microscopic hematuria
 Detected by dipstick & confirmed by microscopy
 Initial determination based on examination from a
freshly voided, clean-catch urine
 No consensus to define microscopic hematuria

Microscopic hematuria:

Hematuria is defined by several parameters, common which

is the presence of 6 RBCs/ Ml of urine in a counting chamber of
2 RBCs/ hpf of urinary sediment.
Fitzwater DS, Wyatt RJ. Hematuria. Pediatr Rev 1994:15: 102 – 109.

More than 5 – 10 RBCs/ hpf is usually considered significant

W.F Dodge, E.F West, E.H Smith, H. Bruce III Proteinuria and hematuria in schoolchildren : epidemiology
and early natural history J Pediatr 1976: 88; 327-347.

It is recommended that at least two of three urinalyses indicate

microhematuria over a period of 2-3 weeks before performing
further evaluations.

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Case 1:

5 years old girl presented with AGE with severe dehydration

O/E: Signs of Dehydration +
B.P – 90/60 mmHg
U. Albumin - Nil, PC – 3 -4, RBC- Plenty.
A week later 2 urine examination was performed a week
apart as a follow-up which shows nil RBCs.
What is the diagnosis ?
a) Acute Pyelonephritis
b) Persistent Hematuria
c) Transient Hematuria
d) Contamination from external genitalia

Transient Hematuria :

 Exercise
 Febrile disorders
 Gastroenteritis with dehydration
 Contamination from external genitalia
 Trauma
 Drugs

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 Transient Vs Persistent Hematuria:

> 5 RBCs/HPF in 3 consecutive centrifuged specimens

atleast one week apart.

Differentiate glomerular from non-

glomerular:

Look for

 Shape of RBCs (normal or dysmorphic)

 Presence of RBC casts (glomerular)
 Presence of proteins (glomerular if >2+)
 Presence of white blood cells (Infection,
glomerulonephritis)
 Presence of crystals (RSD)

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 Hints:To differentiate glomerular from
non_glomerular

 History

 Physical examination

 Urinalysis

 Laboratory Testing

Common causes of Non-glomerular

hematuria

Renal Vascular Metabolic Infectious

Parenchymal Malformation
Hydronephrosis Renalvein Hypercalciuria Cystitis,
thrombosis pyelonephritis
Polycystic Sickle cell disease Hyperuricosuria Tuberculosis
kidneys

Others: Malignancy, urethrorrhagia, trauma &

coagulopathy

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Common causes - Glomerular hematuria

Primary Secondary Familial

Glomerulonephritis Glomerulonephritis

Posts infective GN Lupus nephritis Alport syndrome

IgA nephropathy Henoch-Schonlein Thin basement

purpura membrane

MPGN Hemolytic-uremic
syndrome

FSGS

Case 2:
10 years old girl presented with h/o vomiting for 3 days , her
family physician has prescribed a medication. She also gives h/o
intake of native medicines for past one year. She notices red urine
for 2 days which was painless and decreased urine output.
Further evaluvation shows:
Mild edema, B.P – 130/ 80 mm Hg, S.Cr – 2.8 mg/dL, S.K – 5.9
mEq/L Urinalyses: Albumin – 2+, pus cells- 10 – 12, RBC – field full

What is the possible diagnosis ?

a) Acute Pyelonephritis
b) RSD
c) Acute interstitialn ephritis
d) PIGN

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HISTORY:
Glomerular causes Non Glomerular causes

 Oliguria  Dysuria or Polyuria

 Recent respiratory, skin or
gastrointestinal infection
 Deafness
 Medication(NSAID,native)
 Family history of hearing loss
or renal failure
 Rash
 Joint pain/ Swelling
 Hemoptysis
 Renal colic / Abdominal pain
 Fever
 Medication exposure
 Trauma history
 Family history of sickle cell
disease, hemophilia, Von
Willibrand disease
 Strenuous excercise

PHYSICAL EXAMINATION:

GLOMERULAR CAUSES NON GLOMERULAR CAUSES

 Hypertension  Normotension
 Edema  Costovertebral angle tenderness
 Rash  Suprapubic pain
 Arthritis  Signs of Trauma
 Pallor

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 Case 3:

6 years old Mast. K was brought to the OPD with c/o passing
red urine. Urinalysis shows dysmorphic RBCs
When do we call as significant glomerular hematuria ?

a) > 10 % of dysmorphic RBCs

b) > 5 % of dysmorphic RBCs
c) 1 % of dysmorphic RBCs
d) > 20 % of dysmorphic RBCs

URINALYSIS:
GLOMERULAR CAUSES NON GLOMERULAR CAUSES
 Brown, Tea or Cola – colouerd  Bright red urine
urine  Proteinuria +/_
 Proteinuria >2+  No red blood cell casts
 Red blood cell casts  Positive nitrates or Leukocyte
 > 20 % dysmorphic RBC s
esterase

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 LABORATORY TESTING :

GLOMERULAR CAUSES NON GLOMERULAR CAUSES

 Elevated BUN / Creatinine  Normal BUN / Creatinine

 Anemia
 Abnormal complement levels
( C3, C4 )

CATEGORISATION OF
MICROHEMATURIA FOR
CLINICAL APPORACH

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 Three categories of microhematuria
have been proposed:

 Asymptomatic, Isolated microhematuria: require a follow -up

examination and stepwise evaluation

 Asymptomatic microhematuria with proteinuria: require rapid

evaluation and early referral to a nephrologist.

 Microhematuria with clinical symptoms : require emergency

evaluation and early referral to a nephrologist.
 Microhematuria with hypertension:require rapid evaluation and
referral to nephrologist
The red flag feature is the presence or absence of proteinuria

Red urine

Urinalysis No RBCs

≥5 RBCs/hpf Pigmenturia

Glomerular Hematuria Non-glomerular

BU,S Cr,SE,ASLO,C3 U C &S,BU,S Cr.,USG,S Ca,U UTI

Urine spot Pr./Cr.total protein Ca:Cr ratios ,24 h U Ca
Albumin,cholesterol
Treat as per protocol

Tests consistent with PIGN No No obvious cause Nephrolithiasis

Trauma
yes Hydronephrosis
Supportive Rx

Refer Pediatric nephrologist (F/H/O, Refer Pediatric surgeon/urologist in

HT,Hyperkalemia, hearing & visual deficits, C4,ANA consultation with a Pediatric
Azotemia Anti DsDNA,ANCA,USG& Biopsy) nephrologist

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 Hematuria
Confirm presence of blood in urine
Exclude:
-Menorrhagia,endometriosis,hematospermia
--Strenous physical exercise
Urinalysis --Fabricated or induced illness (by proxy)

Glomerular Non-Glomerular
hematuria hematuria

Investigations
Serum:Creatinine,C3,C4,ASOT /ADB,albumin
Urine protein(upcr 24h collection)

Isolated renal (glomerular) disease Multisystem disease

C3 low C3 normal C3 low C3 normal

APIGN IgAN SHP(Schonlein-Henoch purpura)

SLE
MPGN Alport,TBMN HUS(typical,atypiclal,others)
‘atypical’ HUS
Shunt nephritis Pauci immune GN Small vessel vasculitis
SBE Anti-GBM disease(Good pasture
syndrome)

Case :4

12 years old boy presented with h/o passing cola coloured urine
which was painless. Mother has also found that the child has
been having similar complaints for the past 2 yrs following each
episode of RTI . She also gives h/o similar complaints in
maternal uncle.
What is the possible diagnosis you would think ?
a) RSD.
b) IgA Nephropathy
c) Thin basement membrane & disease
d) PIGN

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 Further Evaluation:

How do we proceed ?
S. Creatinine - 0.7 mg/dl
S. Electrolytes – Normal
S. Albumin – 3.6g/ dL
S. Cholesterol – 180 mg/dl
S. C3 - Normal
Urine albumin - 2 +
Pus cells – 2 to 3
RBC – Field full
Renal biopsy - Shows IgA deposits in Mesangial matrix

Investigations:

Renal biopsy:
Indications -

Significant proteinuria (3+ or more) or nephrotic
syndrome

Gross hematuria >4wks (Microscopic >2yrs)

Abnormal renal function, Persistent HTN

Low C3 level persist beyond 12 weeks.

Serologic abnormalities (abnormal ANA or dsDNA
levels)

A family history of end stage renal disease or evidence
of Chronic renal disease

Systemic disease with significant proteinuria

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Case :5

5 years old previously well school going boy

mast. X was brought to the OPD with c/o
hematuria (passing red urine with clots),
dysuria, increased frequency of micturition ,
abdominal pain & positive family history
a) Hydronephrosis
b) RSD
c) Acute Pyelonephritis
d) HSP

Investigations :

Urinalysis
 Albumin 1+
 Pus cell 6-8/hpf
 RBC plenty

Normal RFT

Ultrasound abdomen
 LK 7.6cm. A calculus measuring 6 mm in the left renal calyx
 RK 7.8cm. Two calculus measuring 3 & 5 mm in right renal
calyx
 Bilateral normal renal echoes

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Diagnosis

24 hour urine analysis

 Calcium 5.3 mg/kg/day ( <4mg/kg/day)
 Uric acid 589 mg/1.73m2/day (<815 mg/1.73m2/day)
 Oxalate 21 mg/1.73m2/day (<52 mg/1.73m2/day)
 Citrate 121 mg/1.73m2/day (>365 mg/1.73m2/day)

Renal stone disease – Idiopathic

Hypercalciuria & Hypocitraturia

Summary

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Management:

According to cause:
 Reassurance and F/U
 Treat cystitis, pyelonephritis, AGN: As per protocol
 Supportive treatment: Diuretics, Fluid and salt
restriction, Antihypertensives
 Monitoring – BP, I/O, weight, Urine R/M
 Treat Hyperkalemia, AKI, CHF, acidosis, fluid overload,
HTN and its complications
 ACE inhibitors useful in proteinuria
 Immunosuppressive therapy: Depending on cause

Management:

 Idiopathic Hypercalciuria : Hydration,

Hydrochlorothiazide, Potassium citrate, Sodium
restriction
 ESRD: Dialysis, Renal transplantation
 Correct thrombocytopenia, anemia, coagulation factor
deficiency
 Renal vein thrombosis: Anticoagulant therapy or
thrombectomy may be needed
 Surgical correction: Calculi, PUJ obstruction, Posterior
urethral valves, Wilms tumour

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TAKE HOME MESSAGE
 Asymtomatic Microscopic Hematuria in children is rarely associated
with clinically important renal disease.

 Rarely, asymptomatic microscopichematuria can be the first sign of

occult renal disease.

 Progression to clinically significant disease will be accompanied by the

development of hypertension and/ or proteinuria.

 Long term follow-up of children with microscopic hematuria is

mandatory.

 Common clinical conditions presenting as microscopic hematuria.

 Idiopathic hypercalciuria, Resolving infection related GNP, IgA

Nephropathy and Alports Syndrome

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