CAUSES OF HEMATURIA AT DIFFERENT AGES

Newborn Infancy

- Congenital abnormalities of - Renal vein thrombosis

the kidney and urinary tract

• Gross hematuria with
Dr. Monina Cristina S. Cabral - Renal vascular disorder
palpable mass and HTN

- Renal cortical necrosis - Hemolytic-Uremic Syndrome

• Most common cause of

“Kidneys play a critical role in the body. Acting as the body’s filtering kidney failure in children

system, they help control water levels and eliminate wastes through - Acute infections (UTI)

urine. They also help regulate blood pressure, RBC production and the - Wilm’s Tumour
levels of calcium and minerals. When kidneys don’t develop properly,
and don’t function as they should, then kidney disease may develop.” Early Childhood Late Childhood

- Acute glomerulonephritidis - Glomerulonephritidis

SIGNS AND SYMPTOMS (PSGN or PIGN)

- IgA nephropathy

- Diverse, and may be overt or subtle

- Hemorrhagic cystitis
- Recurrent benign hematuria

- Trauma
- Hypercalciuria

Subtle Signs and Symptoms Overt Signs and Symptoms

- Henoch-Schoenlein Purpura - Trauma

with nephritis - Menstruation

- Unexplained fever
- Edema

- Anemia
• Swelling around the eyes, face,
- GI symptoms
feet and ankles
CLUES FOR CAUSES OF HEMATURIA
- Abdominal pain
- Hematuria

- Metabolic acidosis
- Dysuria
History and PE Probable Diseases
• In chronic metabolic • Burning or pain upon urination

- Hypertension
Throat infection, skin infection - Post-infectious GN
acidosis, patient no
longer manifests with - Abdominal mass

Presence of hearing loss - Alport’s Syndrome

tachypnea or - Oliguria/ polyuria

• Most common familial

Kussmaul’s breathing, • Significant decrease/ increase
nephritis, considered if
as the child has in urine output

- Frequency
there are eye abnormalities
seemingly adjusted to
as well in a male patient
the long-standing • Significant increase in the
metabolic acidosis
frequency of urination
Presence of purpuric rashes over - Henoch-Schoenlein Purpura

- Failure to thrive or growth - Incontinence

- SLE
the lower extremities
retardation • Difficulty in controlling
urination in kids mature Hypertension - Post-infectious GN
enough to use the toilet

- Nocturia
History of fever and flank pain - UTI
• Recurrence of nighttime (suprapubic pain with CVA
bedwetting in kids who have tenderness)
been dry for several months
Colicky abdominal pain - Urolithiasis

DIAGNOSTIC TESTS/ ANCILLARY PROCEDURES

HEMATURIA Probable Disease Entity Laboratory/ Ancillary Procedures

Post-infectious GN - BP monitoring

- ASO and C3
- May be gross or microscopic

- May be symptomatic or asymptomatic

UTI - Urine culture
- May be transient or persistent

Hypercalciuria - Urine calcium-creatinine ratio

• Transient hematuria caused by vigorous physical activity, fever

- May be isolated or associated with proteinuria and other urinary (preferably in the morning)

- 24 hour urine collection

abnormalities

Benign Familial Hematuria - Urine dipstick on family members

GROSS HEMATURIA
- When the blood is obvious like a clot
Renal Parenchymal Disease - Renal function panel

- Urine is bright red or tea-coloured

• BUN, creatinine, electrolytes,
albumin
MICROSCOPIC HEMATURIA Urolithiasis
- Ultrasound of KUB
- More common than gross hematuria
Cystitis

- ≥5 RBCs/ HPF in 3 out of 3 consecutive centrifuged urine specimens Post-infectious GN

obtained at least 1 week apart

1 of 4 CCCA | INSIGNIS
not all red urine is hematuria!
- History is very important, as children may have taken in the following
food and drugs, causing the red urine:
EDEMA
Food Drugs Others

- Beets
- Antipyrine
- Amorphous urates - A clinical condition characterized by an increase in interstitial fluid
- Blackberries - Benzene
“Red Diaper
- Diphenylhydantoin
Syndrome”
volume and tissue swelling

Pigments - - Common warning sign of a kidney problem in the pediatric group

Metronidazole
• Most common
- Phenolphthalein
cause in infant
• History taking is very important because edema is not always a
- Bile pigments
- Phenothiazine
- Lead poisoning
renal problem

- Hemoglobin
- Rifampicin - Serratia infection
• May also be due to malnutrition, liver problem or cardiac problem

- Myoglobin - Uric acid - Most often appear in the periorbital area, pleural cavities, abdominal
cavities, scrotum and genitalia, before progressing down to the lower
extremities

MECHANISMS OF EDEMA
PROTEINURIA - Edema is caused by any factor that:

• Reduces plasma oncotic pressure (hypoalbuminemia)

The Kidney Disease Outcomes Quality Initiative Guidelines of • Increases hydrostatic pressure (CHF)

the National Kidney Foundation emphasize early detection of

proteinuria and initiation of the therapies that preserve kidney functions • Increases capillary permeability (dengue, septic shock)

• Prevents lymphatic return

noRMAL URINARY PROTEIN EXCRETION

- 4 mg/m/hr
IMPORTANT FEATURES OF EDEMA
- Onset

• Rapid vs. gradual and progressive

nEPHROTIC RANGE PROTEINURIA - Distribution

- ≥40 mg/m/hr or 1000 mg/m/day

• Generalized vs. localized

- ≥2 urine protein-creatinine ratio

- Diurnal variation

- ≥3 grams/ 24 hours
• Morning vs. evening

- >50 mg/kg/day
- Pitting vs. non-pitting

- Co-existing features of primary disease

CAUSES OF PROTEINURIA
DIAGNOSTIC TESTS/ ANCILLARY PROCEDURES
Transient Orthostatic Drugs GN
Probable Disease Entity Laboratory/ Ancillary Procedures
- Exercise
- Occurs when - Chemotherapy
- Post-
- Fever px is upright
- Aminoglycosides
infectious
- BP monitoring

Post-infectious GN
- Best to get - Heavy metal - Nephrotic - ASO and C3
early morning intoxication
Syndrome

samples - CKD Post-infectious GN

- Urinalysis for hematuria or proteinuria
Nephrotic Syndrome
Tubular Reflux Diabetes Mellitus Protein
Diseases Nephropathy Overload Sx Chronic Kidney Disease - Renal function panel

- Acute - Long- - Microalbuminuria

- Hemolysis
• BUN, creatinine, electrolytes
Tubular standing - Cause diabetic - Rhabdomyo-
Necrosis recurrent UTI nephropathy in lysis
due to reflux the long term

DIAGNOSTIC TESTS/ ANCILLARY PROCEDURES
Disease Entity
HYPERTENSION
Average systolic BP and/ or diastolic BP that is ≥95th
Laboratory/ Ancillary Procedure
percentile for gender, age and height on ≥3 separate occasions

HSP
- Inspection for the presence of other systemic
SLE signs and symptoms
CAUSES OF HYPERTENSION AT DIFFERENT AGES
• Rashes, joint pains, prolonged fever
Newborn Infancy to 6 Years Old
Atypical NS - BP monitoring
- Renal artery thrombosis or embolus
- Renal artery stenosis

Renal Insufficiency - Renal function panel (BUN, creatinine) • Umbilical catheterization

- Coarctation of the aorta

- Renal vein thrombosis

- Endocrine causes

Secondary NS - Hepatitis B and C screening

-
- HIV screening • Dehydration or hyperviscosity
Medications

- Congenital renal malformation

• Steroids

- Coarctation of the aorta

• Albuterol

Nephrotic Syndrome - 24-hour urine protein or urine protein-

creatinine ratio

• Renal artery stenosis

• Pseudoephedrine
- Serum albumin and cholesterol • Bronchopulmonary dysplasia

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 6 to 10 Years Old Adolescent PRE-RENAL AKI
- Most common type

- Renal parenchymal disease - Primary (Essential HTN)

- True intravascular volume contraction

(Glomerulonephritides)
- White Coat HTN

- Renal artery stenosis

- Renal parenchymal disease
• Hemorrhage

- Primary (Essential HTN)

- Endocrine causes
• Dehydration

- Endocrine causes - Substance abuse

• Increased irreversible water losses

• Cocaine, caffeine
• Fluid space losses

• Amphetamines
- Decreased effective blood volume

• Methylphenidate • CHF

• Cardiac tamponade

• Hepatorenal syndrome

Epidemiology and Natural History - Reversible once the blood volume and hemodynamic conditions are
- High blood pressure should be considered a common long-term restored

health problem in childhood

POST-RENAL AKI
DIAGNOSTIC TESTS/ ANCILLARY PROCEDURES - More common in newborns than in older infants

- Mechanical or functional obstruction to urine flow

Probable Disease Entity Laboratory/ Ancillary Procedures • May be in the lower urinary tract e.g. PUV

Confirmation of HTN - BP measurements • May be bilateral in the upper tracts e.g. bilateral ureteropelvic
junction obstruction (rare)

Post-infectious GN - Urinalysis - Unilateral obstruction can cause acute renal failure in patients with
only one functioning kidney

Renal Malformation - Ultrasound of KUB - Reversible, as long as the cause of obstruction is removed, thereby
improving the flow of urine

Renal Artery Stenosis - Renal Doppler Ultrasound

LVH - CXR and 2D Echo RENAL PARENCYHMAL DISEASE

Co-morbidities of HTN - Lipid panel

Acute Tubular Necrosis Glomerular Lesions

- Uric acid
- From prolonged ischemia or drug- or - Post-infectious GN

toxic-mediated renal tubular injury - RPGN

(reversible)

- Hypoxic/ ischemic acute kidney injury

Vascular Lesions
OLIGUrIa / anurIa - Nephrotoxic acute kidney injury and
tumour lysis syndrome
- HUS

- Uric acid nephropathy - HSP

Definition of oliguria Common Causes of Oliguria and Anuria

- Infants: <0.5 mL/kg/hr for 24 hours

- Older children: <500 mL/1.73 m BSA/day

Neonates Children

Pre-renal - Perinatal asphyxia

- Dehydration

Definition of Anuria - Respiratory distress - Hemorrhage

- Absence of any urine output

syndrome
- Burns

- Hemorrhage
- Third-space loss

- Sepsis or shock
• Surgery, trauma

Mechanisms of Oliguria/ Anuria - Congenital heart disease

• Nephrotic syndrome

- Elaboration of a more concentrated urine

- Dehydration
- Renal loss

- Drugs
• DM, DI

• SIADH

• Indomethacin
• Diuretics

• Decrease in oral fluid intake

• Maternal use of ACE - Shock

- Decreased renal clearance ability (acute or chronic renal failure)

inhibitors or NSAIDs - Decreased CO
• Pre-renal (hemodynamic)

• Renal (parenchymal)
Renal - Acute tubular necrosis
- Acute tubular necrosis

• Post-renal (obstructive causes)

- Exogenous toxins
- Glomerulonephritis

• Aminoglycosides
- Exogenous toxins

• Amphotericin B
• Aminoglycosides

oliguric aki - Endogenous toxins

• Amphotericin B

- 10% of newborns in the ICU

• Hgb, myoglobin
- Endogenous toxins

- 2-3% of older children requiring intensive care

• Uric acid
• Hgb, myoglobin

- 8% of patients undergoing cardiac surgery

- Congenital kidney • Uric acid

diseases
- Vascular

- Vascular
• HUS

Prevalence of AKI • Renal vein/ artery • Vasculitis

thrombosis
Pre-renal Renal Post-renal
Post-renal - Posterior urethral valves

Newborns 85% 11% 3% - Meatal stenosis

- Bilateral ureteral obstruction

Older Children 66% 33% <1% - Neurogenic bladder

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DIAGNOSTIC TESTS/ ANCILLARY PROCEDURES Causes of Urinary Urgency
- Irritation of the bladder and urethra due to chemicals in soaps and
Probable Disease Entity Laboratory/ Ancillary Procedures bubble baths

- Inflammation of the urethra and bladder

Anemia in CKD - CBC - Conditions that can obstruct urine flow

Check GFR - Renal function panel (BUN, • Kidney or bladder stones

creatinine) • Tumours

- Overactive bladder syndrome and nervous system abnormalities

Small kidneys in CKD - Ultrasound of KUB • Spinal cord injury

• Multiple sclerosis

Presence of renal dysplasia

Presence of abnormalities in
Acute Urinary Retention
the urinary tract - Complete inability to urinate despite having a full bladder

Hypocalcemia - Electrolytes
Chronic Urinary Retention
Hypophosphatemia - Generally one is able to urinate but may have a variety of difficulties
such as starting and stopping, dribbling, frequent or urgent urination
Hyperkalemia with little result and a feeling of incomplete emptying of the bladder

• Overflow incontinence

HPN in fluid overload - BP measurements • Straight catheterization is done to evacuate the urine

• Indwelling Foley catheter may be necessary to decompress the

distended urinary bladder

Urinary tract infection

URINARY SYMPTOMS - Abnormal voiding patterns in toilet-trained kids are usually
associated with UTI

- There is no one complaint specific for UTI

- Have a wide variety of causes

- Vary from mild changes in the frequency or colour of urine to serious SUMMARY
infection that can spread to the kidneys and be life-threatening

- May accompany other symptoms, which vary depending on the

underlying disease, disorder or condition

Red Flags of Kidney Disease

- Hematuria

- Proteinuria

symptoms - Edema

- Hypertension

Dysuria - Painful urination - Oliguria/ anuria

- Daytime urinary frequency

- Urinary symptoms

Pollakiuria

Urgency - Sensation that the bladder must be emptied Take Home Message
immediately - Do a detailed history

Urine retention - Inability to voluntarily or completely empty bladder - Do a thorough PE

- Formulate and confirm your initial impression

- Refer to a pediatric nephrologist

causes of dysuria - In a patient with renal disease, always consider the possibility of
- Chemotherapy
progression to ESRD

- Cystitis

- Exposure of the genital area to irritating substances or allergens

such as perfumes and soaps

- Genital herpes

- Kidney stones

- Long-term use of an indwelling bladder catheter

- Prostatitis/ epididymitis

- UTI

- Vaginitis

Causes of Pollakiuria
- No definitive cause but may have some triggers

- Non-bacterial cystitis

- Chemical urethritis

- Abnormal urine composition

- Hypercalciuria has been identified in children with pollakiuria

- Heightened bladder sensitivity in cold weather months

- Significant social or emotional stressors

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