NOVEN ZEFANYA

0961050149

WHAT IS
HEMATURIA?

Hematuria is blood in the urine. Two types of

hematuria exist. Blood that can be seen in the
urine is called gross or macroscopic
hematuria. Blood that cannot be seen in the
urine, except when examined with a
microscope, is called microscopic hematuria.

The definition of microscopic hematuria is

based on urine microscopic examination
findings of red blood cells (RBCs) of more than
5/L in a fresh uncentrifuged midstream urine
specimen or more than 5 RBCs/high-power
field (HPF) in the centrifuged sediment from
10 mL of freshly voided mid-stream urine.

Macroscopic hematuria has an estimated incidence of

1.3 per 1,000. The incidence of microscopic hematuria
in school children was estimated at 0.41% when four
urine samples per child were collected and 0.32% in
girls and 0.14% in boys when five consecutive urine
specimens were analyzed over 5 years. Overall
hematuria is present in about 5-6% of the general
population and 4% of school children. In the majority
of children, follow-up urinalyses are normal. In most
people, the hematuria emanates from the lower urinary tract, especially in the conditions affecting the
urethra, bladder and prostate. Less than 10% of
hematuria is caused by glomerular bleeding.

WHAT ARE THE

CAUSES OF
HEMATURIA?

Upper urinary tract (kidney or ureter):

Kidney disease
Abnormal blood coagulation
Sickle cell disease
Infection
Kidney stones
Obstruction, blockage or injury of the kidney or

ureter
Cancer of kidney and ureter
Benign kidney tumor
Kidney (renal) vascular disease

Lower urinary tract (bladder and urethra):

Inflammation (cystitis, urethritis)
Urinary tract infection
Bladder stone
Bladder cancer
Urethral cancer
Trauma

IgA nephropathy
FEBH
Alports Syndrome
Henoch- Schnlein purpura
Postinfectious glomerulonephritis
Rapidly progressive glomerulonephritis (RPGN)
Systemic lupus erythematosus
Membranous nephropathy
Membranoproliferative glomerulonephritis
Goodpastures disease

Tubulointerstitial
Acute pyelonephritis
Acute interstitial nephritis
Hematologic (sickle cell disease, coagulopathies

von Willebrands disease, renal vein trhombosis,

thrombocytopenia)
Tuberculosis

Urinary tract
Bacterial or viral infection
Nephrolithiasis and hypercalciuria
Structural anomalies, congenital anomalies,

polycystic disease
Trauma
Tumors
Exercise
Medication (aminoglycosides, amytriptiline,
anticonvulsants, aspirin, chlorpromazine,
coumadin, cyclophosphamide, diuretics,
penicillin, thorazine))

FACTOR

GLOMERULAR

EXTRAGLOMERULA
R

Color

Smoky, tea- or colacolored, red

Red or pink

RBC morphology

Dysmorphic

Normal

Casts

RBC, WBC

None

Clots

Absent

Present (+/-)

Proteinuria

2+

<2+

RED URINE IS NOT

ALWAYS HEMATURIA

Hemoglobinuria
Myoglobinuria
Porphyria
Food (beets, rhubarb, and sometimes food

coloring)
Drugs (phenazoypyridine, but sometimes
cascara, diphenylhydantoin, nitrofurantoin,
methyldopa, rifampicin)

 Hematuria may originate from the glomeruli, renal tubules

and interstitium, or urinary tract (including collecting

systems, ureters, bladder, and urethra). In children, the
source of bleeding is more often from glomeruli than from the
urinary tract. RBCs cross the glomerular endothelial-epithelial
barrier and enter the capillary lumen through structural
discontinuities in the capillary wall. These discontinuities
seem to be at the capillary wallmesangial cell reflections. In
most cases, proteinuria, RBC casts, and deformed
(dysmorphic) RBCs in the urine accompany hematuria caused
by any of the glomerulonephritides. The renal papillae are
susceptible to necrotic injury from microthrombi and anoxia
in patients with a hemoglobinopathy or in those exposed to
toxins. Patients with renal parenchymal lesions may have
episodes of transient microscopic or macroscopic hematuria
during systemic infections or after moderate exercise. This
may be the result of renal hemodynamic responses to
exercise or fever by undetermined mechanisms.

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. Older children may have fever, pain
and burning while urinating, urgency, and lower
belly pain. Children with kidney stones may have
belly or flank pain. Children with kidney diseases
can have a variety of symptoms, such as
weakness, high blood pressure, puffiness around
the eyes, joint swelling, abdominal pain, pale skin,
skin rashes, or seizures. Depending upon the
amount of bleeding, a clot may form in the
bladder, which may cause obstruction to the flow
of urine.

Physical

Trauma, excercise, medication intake, fever,

rash, jaundice, hypertension, swelling etc.
Laboratory
RBC casts, proteinuria, WBC, etc
Radiology
Stone, structural anomalies, masses, etc

1. History
2. Physical examination
3. Lab test
4. Reference to nephrologist/urologist

 Hematuria

is a common finding in children and

adolescents presenting to a pediatrician in a busy
practice. More often than not, parents, and sometimes
the child, reanxious and demand an immediate
diagnosis, particularly when there is gross hematuria.
Critical to the evaluation is distinguishing the difference
between the child who has asymptomatic microscopic
hematuria that often is benign and requires conservative
management and the child who has hematuria and
accompanying proteinuria, edema, hypertension, or
other symptoms suggestive of underlying renal disease.
A simple and practical approach to the child who has
hematuria should result in fewer invasive studies, a less
costly evaluation, and appropriate referral. A stepwise
approachmakes failure to identify the patient who has
serious renal disease unlikely.

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America. 2004; 31:559-73

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