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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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
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less costly evaluation, and appropriatereferral. * stepwise approachmakes failure to identify
thepatient who has serious renal disease unlikely.
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. *shraf, M. et al. Hematuria in 3hildren. International Journal of Clinical Pediatrics.
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#. 8unn, *. and 9orbes. ". *. Hematuria and 4roteinuria in 3hildhood. Paediatrics and
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