red urine – a mystery shaila sukthankar. haematuria common presenting symptom of renal tract...
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Red Urine – a mystery
Shaila Sukthankar
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Haematuria
Common presenting symptom of renal tract disorders
Prevalence 0.5 - 6% on population screening in children
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Haematuria - Definition
Urine microscopy
RBC > 5/uL in a fresh uncentrifuged specimen
RBC > 5 -10/high power field in a midstream sample
RBC morphology & presence of casts
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Case Presentation - May 09
5 years, male Painless gross haematuria – frequent episodes 1 week Initially red, later pink – no clots No history of
– Fever, dysuria, back/ abdo pain– rashes, joint pains– Swelling– Trauma– Bleeding diathesis– Recent medication
No family h/o renal disease/ deafness/ renal stones/ haematuria Tonsillitis 6 weeks before
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Examination
Normal vitals, BP 110/68, apyrexial
No pallor or oedema
No bruises or rash
Systems review NAD
ENT normal
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Macroscopic haematuria with no features of glomerulonephritis
Painless– IgA nephropathy– Benign familial nephropathy/ Alport’s syndrome– Exercise induced– Coagulopathy
Painful– Infection– Trauma– Malignancy
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Haematuria with features of glomerulonephritis
Primary renal diseases– IgA nephropathy– MPGN 1 and 2– Anti GBM disease
Secondary renal diseases– Postinfectious GN– HSP nephritis– SLE
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Initial Investigations
FBC, coagulation – normal Urea 6.5, creatinine 40, Albumin 46 Electrolytes, bone profile normal crp <3 Urine microscopy (X2) - <10 WCC, 50-100 RBC, no bacterial
growth, trace to 1+ proteinuria Renal USS - NAD
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Subsequent Investigations
C3 and C4 normal ANA, dsDNA negative Immunoglobulins normal ASOT 100 U/mL antiDNASe B 600 U/mL Urine calcium/ creatinine ratio 0.45 Intermittent 3+ blood on dipstick, no proteinuria and well with
normal BP over next 4 weeks
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Urine dipstick
Useful screening tool
Very sensitive
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Haematuria - Diagnosis
Do not use urine dipstick to diagnose haematuria
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12 weeks later (Aug 09)…
Recurrence of painless gross haematuria for 1 week Always towards the end of the day
– Clear in the morning– Bright red or cola coloured in the evening
Worse with exercise and vigorous activity Some discomfort with micturition No other significant positive history Urine microscopy confirmed RBCs in some but not all red urine
samples
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Causes of red or pink urine
Haemoglobinuria Myoglobinuria Porphyrins Urates (pink) Foods – beetroot, blackberries Drugs
– Rifampicin (orange)– Chloroquine, desferoxamine
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Possibilities - 1
Recurrent gross haematuria - ? Alport’s/ IgA nephropathy/ thin basement membrane disease
? Bladder pathology (polyp, interstitial cystitis) Exercise induced haematuria ? Not blood (Hburia or myoglobinuria) ? Renal AV malformation
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Management
Repeat haematology, biochemistry and immunology normal Presence of blood without RBCs on some urine samples Myoglobin screen positive on one occasion No infection MR renal angiogram (limited views) – normal Cystoscopy – NAD Family members’ urine microscopy – NAD Review by haematology – no e/o intravascular hemolysis Intermittent painless asymptomatic gross haematuria continues
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Possibilities - 2
Exercise induced haematuria – exercise test with urine microscopy before and after
Nutcracker syndrome – Repeat MR/ direct renal angiogram under GA – parents not keen for further invasive procedures/ GA
Evolving nephropathy (IgA/ Alport’s/ TBM) – no indication for biopsy as asymptomatic, normotensive, no proteinuria and normal renal function
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Nutcracker syndrome
Compression of L renal vein between the aorta and sup mesentric artery
40% of children with unexplained haematuria
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Investigations in a child with haematuria
Urine microscopy and culture Urine protein creatinine ratio FBC, coagulation U&E, creatinine, albumin Urine calcium creatinine ratio ASOT, C3 and C4 US renal tract
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Haematuria - Indications for renal biopsy
Associated proteinuria
Persistent low C3
Impaired renal function
Systemic disease with proteinuria– SLE, HSP, ANCA associated vasculitis
Family history suggestive of Alport’s syndrome
Recurrent gross haematuria of unknown aetiology with extreme parental anxieties
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Haematuria - cystoscopy
Seldom useful Consider
– Negative preliminary investigations– Suspected bladder or urethral pathology– Vascular malformations– Bladder mass on US– To lateralise the source of bleeding
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Progress – June 10 (12 months on)
Well Normally active Occasional brown urine (once in 2-3 months) Lasts for a day, resolves spontaneously Occurs with activity Occurs towards the end of the day Normotensive Parents and child opted for non-invasive observation for now
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Haematuria - Summary
In the absence of proteinuria is not usually indicative of serious pathology
Investigation are to be guided by presentation and likely diagnosis
In asymptomatic children, ensure serious conditions are not missed and guidelines for further investigations are in place if change in clinical course
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Latest update (March 11)
Well until 3 weeks before review! Febrile coryzal illness with sore throat and recurrence of haematuria Initially bright red, subsequently cola coloured Lasted for 7-10 days, progressively cleared over 2-3 days thereafter Asymptomatic (no headaches, oedema, oliguria etc) DID NOT SEE GP, COMMUNITY NURSES OR HOSPITAL
TEAM When attended clinic, back to normal self, urine NAD!! Repeat haematology, biochemistry and immunology normal.
ΔΔ??