Hematuria in Children: Model Clinical case and Viva Q&A
Clinical Case of Hematuria in Children
Clinical Case: Gross Hematuria in a 7-year-old Boy
A 7-year-old boy presents to the pediatric clinic with his mother, who reports noticing blood in her son's urine for the past two days. The urine appears bright red, and the boy complains of mild discomfort while urinating. There is no history of trauma, recent illness, or medication use.
Past Medical History:
- No significant medical conditions
- Normal growth and development
- Up-to-date on vaccinations
Family History:
- Maternal grandfather with history of kidney stones
- No known hereditary renal diseases
Physical Examination:
- Vital signs: Temperature 37°C, Heart rate 88 bpm, Respiratory rate 18/min, Blood pressure 110/70 mmHg
- General: Alert, cooperative, no acute distress
- Abdomen: Soft, non-tender, no masses or organomegaly
- Genitourinary: Normal external genitalia, no signs of trauma
- Skin: No rashes or petechiae
- Musculoskeletal: No edema or joint swelling
Initial Diagnostic Steps:
- Urinalysis: Positive for blood, protein 1+, no casts
- Urine culture: Pending
- Complete blood count: Within normal limits
- Serum creatinine and BUN: Within normal range
Based on these findings, further evaluation is needed to determine the underlying cause of hematuria in this child.
Clinical Presentations of Hematuria in Children
Varieties of Clinical Presentations of Hematuria in Children
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Asymptomatic Microscopic Hematuria
Detected incidentally during routine urinalysis, with no visible blood in urine and no other symptoms. Often transient and benign.
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Gross Hematuria with Dysuria
Visible blood in urine accompanied by pain or burning sensation during urination. May indicate urinary tract infection or bladder inflammation.
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Hematuria with Flank Pain
Blood in urine associated with severe pain in the side or back. Could suggest kidney stones or ureteropelvic junction obstruction.
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Hematuria Following Upper Respiratory Tract Infection
Occurs 1-2 weeks after a sore throat or skin infection. May indicate post-streptococcal glomerulonephritis.
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Exercise-Induced Hematuria
Blood in urine noticed after intense physical activity, often resolving with rest. Generally benign but requires evaluation to rule out other causes.
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Hematuria with Edema and Hypertension
Blood in urine accompanied by swelling (particularly around the eyes and ankles) and high blood pressure. May suggest nephrotic syndrome or acute glomerulonephritis.
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Painless Gross Hematuria
Visible blood in urine without pain or other symptoms. Can be alarming and may indicate various conditions from benign causes to more serious issues like tumors.
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Hematuria with Abdominal Mass
Blood in urine associated with a palpable abdominal mass. Warrants immediate evaluation for potential Wilms' tumor or other renal malignancies.
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Hematuria with Recent Trauma
Blood in urine following injury to the abdomen, pelvis, or genitourinary tract. May indicate renal contusion, laceration, or urethral injury.
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Hematuria with Family History of Renal Disease
Blood in urine in a child with family members affected by conditions like Alport syndrome, polycystic kidney disease, or other hereditary nephropathies.
Knowledge Check: Question and Answers for Medical Students & Professionals
This interactive quiz component covers essential viva questions and answers. It includes 30 high-yield viva questions with detailed answers.
What is the definition of hematuria in children?
Hematuria is defined as the presence of more than 5 red blood cells (RBCs) per high-power field in centrifuged urine or more than 5 RBCs/µL in uncentrifuged urine. It can be either microscopic or macroscopic (gross) hematuria.
What are the key differences between microscopic and gross hematuria?
Microscopic hematuria is only detectable through urinalysis and is not visible to the naked eye. Gross hematuria is visible and causes red or cola-colored urine. Gross hematuria tends to be more concerning and usually requires more urgent evaluation, though both types need proper investigation.
What are the most common causes of isolated hematuria in children?
The most common causes include: 1) Idiopathic hypercalciuria (15-30%), 2) IgA nephropathy, 3) Thin basement membrane nephropathy, 4) Post-infectious glomerulonephritis, 5) Exercise-induced hematuria, and 6) Urinary tract infection.
What is the significance of timing of hematuria during urination?
Initial hematuria suggests anterior urethral pathology, terminal hematuria suggests bladder or posterior urethral causes, and total hematuria throughout urination suggests kidney or upper urinary tract pathology.
What key historical information should be obtained when evaluating a child with hematuria?
Key history includes: family history of kidney disease or hematuria, recent infections, medication use, trauma, exercise history, associated symptoms (edema, joint pain, rash), prior urologic problems, and dietary history. The pattern and timing of hematuria onset are also crucial.
How do you differentiate glomerular from non-glomerular hematuria?
Glomerular hematuria typically presents with dysmorphic RBCs, RBC casts, and significant proteinuria. It may be accompanied by hypertension and edema. Non-glomerular hematuria shows normal-shaped RBCs, no casts, minimal/no proteinuria, and may be painful.
What is the significance of proteinuria accompanying hematuria?
The presence of significant proteinuria with hematuria suggests glomerular disease and is more concerning than isolated hematuria. Proteinuria >1g/day or protein:creatinine ratio >0.5-1.0 indicates significant glomerular involvement and requires prompt nephrology evaluation.
What is IgA nephropathy and how does it typically present in children?
IgA nephropathy is the most common chronic glomerulonephritis worldwide. It typically presents with episodic gross hematuria following upper respiratory infections (synpharyngitic hematuria). Diagnosis requires kidney biopsy showing mesangial IgA deposits.
How should hypercalciuria be evaluated in a child with hematuria?
Evaluation includes: 24-hour urine calcium (>4mg/kg/day is abnormal), spot urine calcium-to-creatinine ratio (>0.21 in children >2 years is abnormal), serum calcium, PTH, and vitamin D levels. Family history and dietary calcium intake should be assessed.
What are the indications for immediate referral to pediatric nephrology in a child with hematuria?
Immediate referral is indicated for: 1) Gross hematuria with significant proteinuria, 2) Acute kidney injury, 3) Hypertension, 4) Decreased C3 complement, 5) Systemic symptoms suggesting vasculitis, and 6) Family history of progressive kidney disease.
What is the role of imaging in evaluating pediatric hematuria?
Initial imaging typically includes renal ultrasound to evaluate for structural abnormalities, stones, masses, or hydronephrosis. CT or MRI may be needed for suspected tumors or vascular malformations. Imaging choice depends on clinical presentation and suspected etiology.
What is Alport syndrome and what are its characteristic features?
Alport syndrome is a hereditary condition affecting type IV collagen in basement membranes. Features include progressive hematuria, proteinuria, hearing loss, and eye abnormalities. X-linked inheritance is most common, affecting males more severely. Early diagnosis is crucial for management.
How do you evaluate exercise-induced hematuria in children?
Exercise-induced hematuria typically resolves within 48-72 hours of rest. Evaluation includes detailed exercise history, timing of hematuria, and ruling out other causes. If hematuria persists after rest, further investigation is needed. It's important to distinguish from more serious conditions.
What is the significance of RBC morphology in urinalysis?
RBC morphology helps distinguish glomerular from non-glomerular hematuria. Dysmorphic RBCs (>80%) suggest glomerular origin, while isomorphic RBCs suggest lower urinary tract or non-glomerular causes. Phase contrast microscopy is ideal for this assessment.
How do you manage asymptomatic microscopic hematuria in children?
Management includes: 1) Initial basic workup (urinalysis, urine calcium/creatinine ratio, blood pressure), 2) Regular monitoring every 3-6 months, 3) Family history assessment, 4) Renal ultrasound if persistent. More extensive workup if additional symptoms develop or hematuria worsens.
What are the common causes of acute post-infectious glomerulonephritis in children?
Common causes include Group A beta-hemolytic Streptococcus (most common), other bacterial infections, viral infections (hepatitis B, HIV), and parasitic infections. Typically presents 1-3 weeks after infection with hematuria, edema, and hypertension.
What is the role of complement studies in evaluating hematuria?
Low C3 complement suggests post-infectious glomerulonephritis, lupus nephritis, or membranoproliferative glomerulonephritis. Normal complement with hematuria may indicate IgA nephropathy or thin basement membrane disease.
How do you differentiate between UTI and glomerulonephritis in a child with hematuria?
UTI typically presents with dysuria, frequency, and pyuria on urinalysis. Glomerulonephritis shows RBC casts, significant proteinuria, and possible hypertension/edema. Culture is positive in UTI. Timing and associated symptoms help differentiate.
What are the indications for kidney biopsy in pediatric hematuria?
Indications include: 1) Persistent significant proteinuria, 2) Declining kidney function, 3) Persistent low complement levels, 4) Family history of progressive kidney disease, 5) Need for definitive diagnosis for treatment planning.
How do you evaluate a child with combined hematuria and proteinuria?
Evaluation includes: complete urinalysis, protein/creatinine ratio, serum creatinine, complement levels, ANA, anti-dsDNA, ANCA, blood pressure monitoring, and renal ultrasound. Early nephrology referral is usually indicated.
What is nutcracker syndrome and how does it present?
Nutcracker syndrome occurs when the left renal vein is compressed between the aorta and superior mesenteric artery. It presents with left-sided hematuria, flank pain, and occasionally varicocele in males. Diagnosis often requires CT/MRI or venography.
What are the common medications that can cause hematuria in children?
Common medications include: anticoagulants, cyclophosphamide (hemorrhagic cystitis), penicillins (interstitial nephritis), NSAIDs, and rifampin. Careful medication history and timing of hematuria onset are important for diagnosis.
How should persistent asymptomatic microscopic hematuria be monitored long-term?
Monitoring includes: regular urinalysis every 3-6 months, annual blood pressure checks, periodic assessment of renal function, and protein/creatinine ratio. Family should be educated about red flags requiring immediate evaluation.
What is the significance of family history in pediatric hematuria?
Family history may indicate inherited conditions like Alport syndrome, thin basement membrane disease, or polycystic kidney disease. It helps guide genetic testing and determines screening needs for family members.
How do you evaluate hematuria in a child with recent trauma?
Evaluation includes: detailed trauma history, vital signs, physical exam for abdominal/flank tenderness, CT with contrast if significant trauma, serial hematocrit monitoring, and observation for urinary retention or decreasing urine output.
What is the approach to hematuria in a child with sickle cell disease?
Approach includes ruling out papillary necrosis, renal medullary carcinoma, and urinary tract infection. Assessment of hydration status and hemoglobin levels is crucial. Imaging may be needed to evaluate for structural changes.
What are the red flags in the physical examination of a child with hematuria?
Red flags include: hypertension, edema, rash (suggesting vasculitis), joint swelling, abdominal mass, costovertebral angle tenderness, and signs of systemic illness. These findings require urgent evaluation.
How do you differentiate between hematuria and other causes of red/brown urine?
Differential includes myoglobinuria, hemoglobinuria, medications (rifampin), foods (beets), and porphyria. Urinalysis with microscopy confirms true hematuria. Urine dipstick positive for blood but no RBCs suggests other causes.
What is the role of genetic testing in pediatric hematuria?
Genetic testing is indicated for: suspected Alport syndrome, family history of hereditary nephritis, early-onset hematuria with hearing loss, and cases with strong family history of kidney disease. Results guide management and family counseling.
What are the long-term complications of untreated glomerular hematuria?
Potential complications include chronic kidney disease, hypertension, proteinuria, and end-stage renal disease. The risk depends on underlying cause, with conditions like Alport syndrome having higher risk of progression.
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