chapter i part 3 final

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CHAPTER I

INTRODUCTION

A. BACKGROUND

Hematuria is one of the most common urinary findings that result in children

presenting to pediatric nephrologists. Hematuria can be gross (ie, the urine is overtly

bloody, smoky, or tea colored) or microscopic. It may be symptomatic or asymptomatic,

transient or persistent, and either isolated or associated with proteinuriaand other urinary

abnormalities.Macroscopic hematuria has an estimated incidence of 1. per 1!!!. "he

incidence of microscopic hematuria in schoolchildren was estimated at !.#1$when four

urine samples per child were collectedand !.%$ in girls and !.1#$ in boys when

fiveconsecutive urine specimens were analy&ed over 'years. Microscopic hematuria in

two ormore urine samples is found in 1$ to %$ ofchildren to 1' years of age.

B. PURPOSE

"he purpose is to give information to physicians in order to understand the

causing and the management of hematuria in children.

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http://emedicine.medscape.com/article/984289-overview




CHAPTER II

A. ANATOMY OF URINARY SYSTEM

"he urinary system consists of the paired kidneys and ureters and the single bladder and

urethra. "he kidneys filter the blood and manufacture urine in the process. "he systems

remaining organs provide temporary storage reservoirs or transportation channels for urine.

Picture 1 *natomy of urinary system

• "he ureters drain urine from the kidneys and conduct it by peristalsis to the bladder.

• "he urinary bladder provides temporary storage for urine.

• "he single urethra drains the bladder.

• "he triangular region of the bladder, which is delineated by three openings (two

ureteral and one urethral orifice), is called the trigone.

• In males, the urethra is appro+imately %! cm long. It has three regions the prostatic,

membranous, and spongy (penile) urethrae. It, also, has a dual function in males it

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serves as a urine conduit to the body e+terior, and it provides a passageway for semen

e-aculation. o, in males, the urethra is part of both the urinary and reproductive

systems.

• In females, the urethra is only about # cm long. "he female urethra serves only to

transport urine to the body e+terior. "he e+ternal urethral orifice, its e+ternal opening,

lies anterior to the vaginal opening.

Picture 2 *natomy of kidney

• /enal capsule is a smooth transparent membrane that tightly adheres to the e+ternal

part of the kidney

• 0idney corte+ is the superficial kidney region, which is lighter in color

• Medullary region is the region deep to the corte+ and it is a darker reddishbrown

color2 the medulla is segregated into triangular regions that have a striped or striated

appearance, also called as the medullary (renal)pyramids.

• /enal 3olumns are the areas of tissue, similar tothe corte+ is appearance, which

segregate and dip inward between the pyramids

• /enal 4elvis, located medial to the hilus2 a fairly flat, basinlike cavity that is

continuous with the ureter, which e+its from the hilus region2 the large or primary

e+tensions are called the ma-or calycesand subdivisions of the ma-or calyces are

called the minor calyces.

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*bout onefourth of the total blood flow of the body is delivered to the kidneys each

minute by the large renal arteries.

B. DEFINITION

Hematuria is blood in the urine. "wo types of blood in the urine e+ist. 5lood that can

be seen in the urine is called gross or macroscopic hematuria. 5lood that cannot be seen in

the urine, e+cept when e+amined with a microscope, is called microscopic hematuria. "he

definition of microscopic hematuria is based on urine microscopic e+amination findings of

red blood cells (/53s) of more than '678 in a fresh uncentrifuged midstream urine specimen

or more than ' /53s6highpower field (H49) in the centrifuged sediment from 1! m8 of

freshly voided midstream urine.

Picture 3 :ifference of gross and microscopic hematuria

C. EPIDEMIOLOGY

Macroscopic hematuria has an estimated incidence of 1. per 1,!!!. "he incidence of

microscopic hematuria in school children was estimated at !.#1$ when four urine samples

per child were collected and !.%$ in girls and !.1#$ in boys when five consecutive urine

specimens were analy&ed over ' years. ;verall hematuria is present in about '$ of the

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general population and #$ of school children. In the ma-ority of children, followup

urinalyses are normal. In most people, the hematuria emanates from the lower urinary tract,

especially in the conditions affecting the urethra, bladder and prostate. 8ess than 1!$ of

hematuria is caused by glomerular bleeding.

D. ETIOLOGY

Many substances other than red blood cells (/53s) can cause the urine to become red

in colour which needs to be distinguished, as following

• Hemoglobin (which carries o+ygen in /53) in the urine due to the breakdown of

/53

• Muscle protein (myoglobin) in urine due to the breakdown of muscle cells

• 4orphyria (a disorder caused by deficiencies of en&yms involved in the production of

heme, a chemical compund that contains iron and gives blood its red color)

• 9oods (for e+ample, beets, rhubarb, and sometimes food coloring)

• :rugs (most commonly phena&oypyridine, but sometimes cascara,

diphenylhydantoin, nitrofurantoin, methyldopa, rifampicin, chloro<uin, phenacetin,

phenotia&ines, and senna)

*natomically, hematuria must come from kidneys, ureters, bladder, or urethra. "he

most common causes of hematuria from the upper urinary tract (kidney or ureter) are

• 0idney disease

• *bnormal blood coagulation

• ickle cell disease

• Infection

• 0idney stones

• ;bstruction, blockage or in-ury of the kidney or ureter

• 3ancer of kidney and ureter

• 5enign kidney tumor

• 0idney (renal) vascular disease

"he causes of hematuria from lower urinary tract (bladder and urethra) are

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• Inflammation (cystitis, urethritis)

• =rinary tract infection

• 5ladders stone

• 5ladder cancer

•

=rethral cancer • "rauma

Picture ome causes of hematuria

Hematuria of glomerular origin usually is described as brown, teacolored, or cola

colored, whereas hematuria from thelower urinary tract (bladder and urethra) is usuallypink

or red. >lomerular disease that can cause hematuria in children are as following

• /ecurrent gross hematuria

o Ig* nephropathy

It is the disorder of kidneys where the kidneys become leaky for /53s and in

the early stages, Ig* nephropathy has no symptoms. "his disease can be silent

for years, even decades. "he first sign of Ig* nephropathy may be blood in the

urine. "he blood may appear during a cold, sore throat, or other infection. If

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the amount of blood increases, urine may turn pink or the color of tea or cola.

Ig* nephropathy is probably the most common cause of hematuria in children

o 95?H (familial benign essential hematuria)

95?H is a benign familial condition manifested as hematuria without

proteinuria and without progression to renal failure or hearing defect. :iffuse

attenuation of the >5M is usually considered the hallmark of the condition.

9rom the evidencebased research, type I@ collagen is involved in the

pathogenesis of the disorder. 4ersistent but microscopic hematuria, with

intermittent gross hematuria without any other finding, is often the usual

presentation in childhoodo *lports syndrome

*lports syndrome is characteri&ed by hematuric nephritis, hearing loss and

ocular abnormalities and has familial occurrence of progressive hematuria,

which is often missed initially because of isolated and microscopic

presentation. ensorineural hearing loss and ocular defects are commonly

associated but present later than hematuria.• HenochchAnlein purpura

H4 is the inflammation of small blood vessels, in which these vessels become

swollen and irritated. "his inflammation occurs in the skin, intestines, -oints and

kidneys. Inflamed blood vessels in the skin can leak /53s, causing a characteristic

rash called purpura. @essels in the intestines and kidneys also can swell and leak

leading to abdominal pain, altered colored stools and hematuria. H4 occurs much

more often in kids than in adults, usually between ages % and 11 years and boys get it

about twice as often as girls./enal manifestations include hematuria, proteinuria,

nephrotic syndrome, glomerulonephritis and acute renal failure.

• 4ostinfectious glomerulonephritis

4atients with acute 4I>B often present withacute onset of teacolored urine

(macroscopichematuria) consistent with glomerular bleeding,but the hematuria

occasionally may be onlymicroscopic. 4I>B isaccredited most commonly to

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pharyngitis or skininfection with >roup * betahemolytic streptococci.Microscopic

hematuriamaypersist foraslongas%years.

• /apidly progressive glomerulonephritis

/4>B presentswith symptoms and signs similar to 4I>B, and although uncommon,

re<uires the urgent attention of a pediatric nephrologist. 8aboratorystudies show acute

renal failure, and renal biopsydemonstrates glomerular crescents. =ntreated/4>B can

result in endstage renal disease(?/:) in a few weeks.

• ystemic lupus erythematosus

• Membranous nephropathy

• Membranoproliferative glomerulonephritis

• >oodpastures disease

T!"#e 1.:istinguishing >romerular and ?+tragromerular Hematuria

FACTOR GLOMERULAR E$TRAGROMERULAR

C%#%r moky, tea or colacolored, red /ed or pink

RBC M%r&'%#%() :ysmorphic Bormal

C!*t* /53, C53 Bone

C#%t* *bsent 4resent (D6)Pr%tei+uri! E%D F%D

ource Hematuria. *merican *cademy of 4ediatric

5ased on location of the bleeding, e+traglomerular disease is divided into

tubulointerstitial and urinary tract

"ubulointerstitial

• *cute pyelonephritis

• *cute interstitial nephritis

• Hematologic (sickle cell disease, coagulopathies von Cillebrands disease, renal vein

thrombosis, thrombocytopenia)

• "uberculosis

=rinary tract

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• 5acterial or viral (adenoviral) infectionrelated

• Bephrolithiasis and hypercalciluria

• tructural anomalies, congenital anomalies, polycystic kidney disease

• "rauma

4elvic fractures and abdominal6chest in-urieshelp identify patients who re<uire

evaluation ofthe genitourinary tract. "he need for genitourinary tract evaluation in

pediatric trauma patientsis based as much on clinical -udgment as on thepresence of

hematuria.

• "umors

In pediatric population, Cilms tumor is one of the commonest abdominal tumor

related masses in preschool age group. Cilms tumor does not always cause signs and

symptoms, clinically children may appear healthy, or they may have abdominal

swelling, abdominal mass, fever, abdominal pain and hematuria.5ladder tumors

usually manifest with voiding difficulties or occasionally with macroscopic

hematuria.

• ?+cercise

• Medication (aminoglycosides, amytriptiline, anticonvulsants, aspirin, chlorproma&ine,

coumadin, cyclophosphamide, diuretics, penicillin, thora&ine)

E. PATHOPHYSIOLOGY

Hematuria may originate from the glomeruli,renal tubules and interstitium, or urinary

tract(including collecting systems, ureters, bladder, andurethra). In children, the source

ofbleeding is more often from glomeruli than fromthe urinary tract. /53s cross the

glomerularendothelialepithelial barrier and enter the capillary lumen through structural

discontinuities in thecapillary wall. "hese discontinuities seem to be atthe capillary wallG

mesangial cell reflections.Inmost cases, proteinuria, /53 casts, and deformed(dysmorphic)

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/53s in the urine accompany hematuria caused by any of the glomerulonephritides. "he

renal papillae are susceptible to necroticin-ury from microthrombi and ano+ia in patientswith

a hemoglobinopathy or in those e+posed toto+ins. 4atients with renal parenchymal

lesionsmay have episodes of transient microscopic ormacroscopic hematuria during systemic

infectionsor after moderate e+ercise. "his may be the resultof renal hemodynamic responses

to e+ercise orfever by undetermined mechanisms.

F. CLINICAL MANIFESTATION

Hematuria is a sign and not a disease. Hematuria is present with other symptoms.

Infants with bladder infections may have fever, be irritable, and feed poorly. ;lder children

may have fever, pain and burning while urinating, urgency, and lower belly pain. 3hildren

with kidney stones may have belly or flank pain. 3hildren with kidney diseases can have a

variety of symptoms, such as weakness, high blood pressure, puffiness around the eyes, -oint

swelling, abdominal pain, pale skin, skin rashes, or sei&ures.:epending upon the amount of

bleeding, a clot may form in the bladder, which may cause obstruction to the flow of urine.

G. CLINICAL E,ALUATION

P')*ic!#

4arents, and children who can understand, should be asked about recent trauma,

e+ercise, passage of urinary stones, recent respiratory or skin infections and intake of

medications like B*I: and calcium or vitamin :, or traditional medicines. It is worth

asking about family history of hematuria, hypertension, renal stones, renal failure, deafness,

coagulopathy, -aundice and hemolytic anemias. In case of se+ually active teenagers recent

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se+ual activity and any known e+posure to se+ually transmitted diseases. ;ther conditions

associated with hematuria like fever, sore throat, weight loss, failure to thrive, skin rashes,

-oint symptoms, face and leg swellings, dysuria, urinary fre<uency and urgency, back pain,

should always be checked.

"he presence or absence of hypertension orproteinuria helps to decide how

e+tensively topursue the diagnostic evaluation. 4resence of high blood pressure, low urine

output and edema prompt the clinician to think on lines of acute nephritic syndrome, while

hematuria with skin rashes or arthritis may indicate systemic lupus erythematosus or Henoch

chonlein nephritis or collagen vascular disease. However, illlook, fever, vomiting, or loin

pain may point to pyelonephritis. 4alpable abdominal masses with hematuria should be

looked for the presence of tumor, polycystic kidney, or hydronephrosis2 however, Ig*

nephropathy, thin membrane disease, *lports syndrome may present with recurrent

hematuria only. ;ther uncommon causes of recurrent gross hematuria can be 31<

nephropathy and nutcraker syndrome.

L!"%r!t%r)

9urther testing of the urine may be done to check for problems that can cause

hematuria, such as infection, kidney disease, and cancer. "he presence of white blood cells

signals a ="I. /53s that are misshapen or clumped together to form little tubes, called casts,

may indicate kidney disease. 8arge amounts of protein in the urine, called proteinuria, may

also indicate kidney disease. "he urine can also be tested for the presence of cancer cells.*

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blood test can show the presence of high levels of creatinine, a waste product of normal

muscle breakdown, which may indicate kidney disease.

/enal biopsy is reserved for the patients who haverecurrent episodes of gross

hematuria, coe+isting nephrotic syndrome, coe+isting hypertension with nephritic

component, renal insufficiency, family historysuggesting hereditary nephritis, and coe+isting

systemicsymptoms (arthritis, purpura, malar rash, hemoptysis,anemia), as well as in those in

whom nonglomerularcauses have been e+cluded.

R!-i%#%()

/enal ultrasonography can identify structural abnormalities, asymmetry, echogenicity,

renal masses, and renal vein thrombosis. *bdominal radiographs may identify radiopa<ue

stones comprised of calcium, struvite,and cystine. /adiolucent stones such as uric acid

calculiare not detected. piral helical computed tomographyscan is the most sensitive

imaging modality for detectingnephrolithiasis but delivers a high radiation dose and

ise+pensive. /adiocontrast should be used with caution inthe patient who has renal

insufficiency and rarely whenevaluating for stone disease.

3ystoscopy, an invasive and costly procedure, almostnever is indicated for

asymptomatic microscopic hematuria.It rarely discerns any underlying disease.

/habdomyosarcoma typically causes gross hematuria and voidingdysfunction. Cilms tumor

is identified best by radiographic imaging with ultrasonography.

H. MANAGEMENT

*fter it is learnt from the history, physical e+amination and lab tests that condition

does not need any immediate intervention, the parents and older children must be reassured

and advised for the stepwise plan of action. However, clues like history of recent upper

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respiratory tract infection, trauma, recent e+ercise, menstruation, sore throat, skin infection,

painful micturition, increased fre<uency, urgency, enuresis, urine color, abdominal and

costovertebral angle pain, family history hematuria, deafness, hypertension, coagulopathy,

calculi will be very helpful in appropriate management of hematuria.

:ipstick test and microscopic urinalysis should be repeated weekly within % weeks

after the initial specimen. If the hematuria resolves, no further tests are needed. If hematuria

persists, with more than ' /53s6H49 and no evidence of hypertension, edema, oliguria, or

proteinuriaon at least two of three consecutive samples, determination of the serum creatinine

levels and ultrasonography for the presence or absence of stones, tumors, hydronephrosis,

structural anomalies, renal parenchymal dysplasia, medical renal disease, inflammation of the

bladder, bladder polyps, and posterior urethral valves, should be performed. "he cost

effectiveness of renal ultrasonography for evaluation of an asymptomatic child with

microscopic hematuria is e<uivocal though. If there is no proteinuria, no /53 casts, no

edema and oliguria, no hypertension, normal serum creatinine along with normal renal and

bladder ultrasonography, reassurance to parents and patient with regular followup is advised.

However, parents and sibling urine should be tested with dipsticks, to rule in6out the familial

causes of hematuria. >oing for detailed investigations including invasive renal biopsy is still

debatable in asymptomatic hematuria2 however, for prognosis, insurance purposes and

genetic counseling, renal biopsy has been recommended by some researchers.

I. ALGORITHM OF HEMATURIA

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ource ?valuation of Hematuria in 3hildren. =rologic 3linics of Borth *merica

CHAPTER III

CONCLUSION

Hematuria is a common finding in children and adolescents presenting to a

pediatrician in a busy practice.Moreoften than not, parents, and sometimes the child,

rean+ious and demand an immediate diagnosis, particularly when there is gross hematuria.

3ritical to the evaluationis distinguishing the difference between the child whohas

asymptomatic microscopic hematuria that often isbenign and re<uires conservative

management and thechild who has hematuria and accompanying proteinuria,edema,

hypertension, or other symptoms suggestive ofunderlying renal disease. * simple and

practical approachto the child who has hematuria should result in fewerinvasive studies, a

15



less costly evaluation, and appropriatereferral. * stepwise approachmakes failure to identify

thepatient who has serious renal disease unlikely.

REFERENCES

1. Meyers, 0. ?. 3. ?valuation of Hematuria in 3hildren. Urologic Clinics of North

America. %!!#2 1''

%. Massengill, . 9. Hematuria. American Academy of Pediatrics. %!!J2 % #%J.

. *shraf, M. et al. Hematuria in 3hildren. International Journal of Clinical Pediatrics.

%!12 %(%)'1!.

#. 8unn, *. and 9orbes. ". *. Hematuria and 4roteinuria in 3hildhood. Paediatrics and

Child Health. %!1%2 %%(J)1'%1.'. 3harleston, K (?d). Hematuria: Blood in Urine. Maryland Bational Institute of

:iabetes and :igestive and 0idney :isease.

. Hedge. . and 0rishnan. /. Approach to A Childwith Hematuria. L;nline. *vailable

on http66www.welshpaediatrics.org.uk6approachchildhaematuria

. Mattoo. ". 0. Patient Information: Blood in the Urine (Hematuria in chlidren

(Beyond the Basics. L;nline. *vailable onhttp66www.uptodate.com6contents6blood

intheurinehematuriainchildrenbeyondthebasicsNviewOprint

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http://www.welshpaediatrics.org.uk/approach-child-haematuria

http://www.uptodate.com/contents/blood-in-the-urine-hematuria-in-children-beyond-the-basics?view=print


http://www.welshpaediatrics.org.uk/approach-child-haematuria





J. 5lood in =rine. L;nline. "he Merck Manual Home Health Handbook. *vailable

onhttp66www.merckmanuals.com6home6kidneyPandPurinaryPtractPdisorders6sympto

msPofPkidneyPandPurinaryPtractPdisorders6urinePbloodPin.html

. >ulati. . Hematuria. %!1 L;nline. *vailable

onhttp66emedicine.medscape.com6article6J1JJoverview

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http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/symptoms_of_kidney_and_urinary_tract_disorders/urine_blood_in.html






chapter i part 3 final

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