Hematuria in children

A 15-year-old with chest pain: An unexpected etiology

A 15-year-old female with no significant past medical history presented to the emergency department with 1 day of substernal and pleuritic chest pain, chills, cough, and hematuria. She also had swelling of the face and ankles that resolved by presentation. She was found to have elevated troponin and brain natriuretic peptide during initial workup. Electrocardiogram was normal, but there were significant pleural effusions on chest x-ray. She was strep positive and had blood pressure up to 150/90, prompting admission for cardiac monitoring and cardiology consultation. Blood pressure decreased down to 125/72 without intervention. She was afebrile with unlabored breathing and normal saturations. She was clear to auscultation bilaterally, with no abdominal distension or hepatosplenomegaly, and edema was not evident on exam. There was mild erythema to the bilateral tonsillar pillars. Initial considerations included viral myocarditis, pericarditis, and atypical nephritic syndrome. Workup revealed elevated antistreptolysin antibodies, low C3 complement, negative antineutrophil cytoplasmic antibodies, and negative flu testing. Renal sonography was unremarkable. Cardiology recommended echocardiography, which confirmed pleural effusions but revealed no cardiac abnormalities. Urinalysis revealed hematuria and mild proteinuria. Diagnosis was found to be post-streptococcal glomerulonephritis complicated by fluid overload and left ventricular strain secondary to hypertensive emergency. Post-streptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. The mechanism of disease is a proliferation and inflammation of the renal glomeruli secondary to immunologic injury, with deposition of immune complexes, neutrophils, macrophages, and C3 after complement activation. This leads to hematuria, proteinuria, and fluid overload. Edema is present in 65%–90% of patients, progressing to pulmonary involvement in severe cases. Cardiac dysfunction secondary to fluid overload is a potentially fatal outcome in the acute setting. Physicians should consider post-streptococcal glomerulonephritis for patients presenting with hypertension, cardiac/pulmonary pathology, or symptoms of acute heart failure in the context of strep infection.

A 4-year old presenting with fever and achiness

In children under the age of 5 who have abnormalities in history, physical examination, and laboratory studies indicating multi-system disease, uncovering the correct diagnosis is challenging. Here, we report the course of a 4-year-old girl who presented with a change in behavior, fever, arthralgia, arthritis, and hematuria following three recent hospitalizations for pneumonia and impetigo. Serologic findings were suggestive of a rheumatologic etiology and a renal biopsy was consistent with Membranous Lupus Nephritis Class V which helped secure the diagnosis of pediatric systemic lupus erythematosus. We review the clinical features and diagnostic criteria of early-onset systemic lupus erythematosus and discuss diagnostic considerations and prognosis.

ACR Appropriateness Criteria® Hematuria-Child

Hematuria is the presence of red blood cells in the urine, either visible to the eye (macroscopic hematuria) or as viewed under the microscope (microscopic hematuria). The clinical evaluation of children and adolescents with any form of hematuria begins with a meticulous history and thorough evaluation of the urine. The need for imaging evaluation depends on the clinical scenario in which hematuria presents, including the suspected etiology. Ultrasound and CT are the most common imaging methods used to assess hematuria in children, although other imaging modalities may be appropriate in certain instances. This review focuses on the following clinical variations of childhood hematuria: isolated hematuria (nonpainful, nontraumatic, and microscopic versus macroscopic), painful hematuria (ie, suspected nephrolithiasis or urolithiasis), and renal trauma with hematuria (microscopic versus macroscopic). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Management of Hematuria in Children

Purpose of Review

This paper provides a review of the diagnostic evaluation of both microscopic and gross hematuria, as well as an update on the pathogenesis, clinical features, and treatment strategies for several diseases of the kidneys and urinary tract in which hematuria is a prominent finding. The goal is to provide pediatric providers with a framework through which appropriate and expeditious referral to subspecialty care may be made for definitive treatment.

Recent Findings

Although there has been great heterogeneity in published treatment strategies for many causes of hematuria, the Kidney Diseases Improving Global Outcomes (KDIGO) initiative has recently set forth guidelines for glomerular diseases in particular to provide evidence-based strategies for treatment. In addition, recent advances in the understanding of molecular pathogenesis and long-term clinical outcomes for other non-glomerular diseases has led to updates in treatment strategies summarized in this review.

Summary

As the pediatric primary care provider is often the first point of contact for children with microscopic or gross hematuria, updated knowledge as to the epidemiology and management of several of the various causes of hematuria will improve the care of children by both avoiding extraneous testing and interventions and implementing definitive care (either by expectant management and reassurance or by subspecialty referral) in a timely manner.

Child with Dysuria and/or Hematuria

Dysuria and/or hematuria are common and worrisome symptoms for most parents. Dysuria results from excessive bladder muscle contraction and peristaltic activity of the edematous and inflamed urethral mucosa. Though urinary tract infection remains the commonest cause for dysuria, non-infectious causes should also be kept in mind. Equating all cases of dysuria to urinary infection is not incorrect. Hematuria can be both macroscopic and microscopic and an important sign of genitourinary tract disease. However, systemic causes like bleeding disorder or malignancy can also present with hematuria. A thorough history and physical examination is important for arriving at a diagnosis. The investigations for both the symptoms and the urgency with which the tests are required are dictated by the patient's clinical presentation.

Urothelial papilloma: a rare cause of gross haematuria in childhood

Bladder urothelial papilloma is extremely rare in the paediatric population. It usually presents as painless gross haematuria and its diagnosis implies a high index of suspicion as other causes of haematuria predominate in this age range. We describe a 9-year-old boy with two episodes of gross haematuria occurring 1 year apart with spontaneous resolution after 2 days. Bladder ultrasound revealed an endovesical papillary lesion of 24×24 mm suggestive of bladder tumour. The diagnosis was confirmed by histopathological examination of the specimen obtained by cystoscopy with transurethral resection. After 3 years of follow-up with ultrasound and cystoscopy, there are no signs of recurrence. Due to the low prevalence of urothelial papilloma, paediatric guidelines for appropriate management and follow-up are unavailable, making this a challenging entity.

Clinical and histopathological features of asymptomaticpersistent microscopic hematuria in children

BACKGROUND/AIM

We analyzed the clinical and pathological features and prognosis of 106 children with persistent asymptomatic microscopic hematuria (PAMH) with or without mild proteinuria.

MATERIALS AND METHODS

This was a retrospective study of 106 children who were referred to our clinics from 2000 to 2013 for evaluation of PAMH.

RESULTS

Among the 106 patients, 69 (65%) were female and 37 (35%) were male. The patients were divided into two groups: 101 patients with isolated microscopic hematuria (IMH) and 5 patients with asymptomatic microscopic hematuria and mild proteinuria (AMHP). Renal biopsy was performed in all 5 children with AHMP: 2 patients had hereditary nephropathy and 2 patients had focal segmental glomerulosclerosis (FSGS). One biopsy specimen revealed nonspecific findings. Renal biopsy was performed in 9 children with IMH: 4 patients had hereditary nephropathy and 5 patients had nonspecific findings. None of the patients received any specific treatment prior to renal biopsy. During the follow-up period, none of the patients developed impaired renal function. Among all the children, only one patient with AMHP developed hypertension and 2 patients with IMH developed proteinuria.

CONCLUSION

Long-term follow-up must be done carefully for isolated microscopic hematuria and renal biopsy should be performed in selected cases.

Profound Hematuria in a Toddler Yields an Unusual Diagnosis

Herein we present a rare case of profound recurrent gross hematuria in a young child with no known predisposing event. She was eventually diagnosed with a large lymphovascular malformation of the bladder. She underwent multiple unsuccessful attempts at embolization before eventual curative partial cystectomy.

Diagnosis and management of hypercalciuria in children

PURPOSE OF REVIEW

In this review, recent advances in the epidemiology, genetics, clinical associations and management of idiopathic hypercalciuria will be discussed.

RECENT FINDINGS

A significant genetic contribution exists in the pathophysiology of hypercalciuria. Although several candidate genes and genetic alterations have been proposed, identification of precise gene(s) responsible remains elusive. Decreased bone density has been increasingly associated with hypercalciuria. Recent publications have suggested that bisphosphonates may play a role in the management in patients in whom both hypercalciuria and decreased bone density are present.

SUMMARY

Idiopathic hypercalciuria is a common disorder in children and can present with a range of clinical presentations such as hematuria, voiding dysfunction, flank pain, abdominal pain, nephrolithiasis, urinary tract infection and decreased bone mineral density. Dietary modifications are often sufficient in the management of hypercalciuria. If the symptoms persist or a rare monogenic disorder is present, consideration should be given to medical treatment with a thiazide diuretic and/or citrate therapy.

Gross hematuria in children: a ten-year review

OBJECTIVES

Gross hematuria in children is uncommon. We reviewed our experience characterizing its clinical presentation and diagnosis.

METHODS

The charts of all patients who presented for the 10-year period of 1994 through 2003 were reviewed, and 342 patients were identified. Of these 342 patients, 272 were boys (80%) and 70 (20%) were girls. At presentation, 21 patients (6%) were younger than 3 years (17 were boys and 4 were girls); 199 (58%) were 3 to 12 years old (155 were boys and 44 were girls); and 122 (36%) were 13 to 20 years old (100 were boys and 22 were girls).

RESULTS

Of the 272 male patients, 52 (19%) had benign urethrorrhagia; 48 (14%) had trauma; and 48 had a urinary tract infection (14%), and 10 of those also had urologic anomalies. Of the 342 patients, 45 (13%) had one or more congenital urologic anomalies. Of these 45 patients, 20 boys and 2 girls had vesicoureteral reflux, 10 boys had posterior urethral valves, 7 boys and 1 girl had ureteropelvic junction obstruction, 7 boys had proximal hypospadias, 2 boys and 1 girl had ureterovesical junction obstruction, 2 boys and 1 girl had ureterocele, and 1 boy had caliceal diverticulum. Also, 18 patients (5%) had stones; 3 had low-grade bladder transitional cell carcinoma; and 1 had a Wilms tumor. For 118 patients (34%; 95 boys and 23 girls), no etiology was found.

CONCLUSIONS

Gross hematuria most often had a benign cause in children and adolescents. It was more common in boys for almost all etiologic categories and ages. The extent of the urologic evaluation should depend on the clinical setting. Voiding cystourethrography is useful in those with suspicious ultrasound findings, urinary tract infection, or voiding symptoms. Cystoscopy should be reserved for the minority in whom hematuria persists or those with ambiguous imaging study findings.

Evaluation of gross hematuria

Gross hematuria in children is a common complaint that often leads patients to seek urgent care. The diagnostic evaluation can be chosen based on specific patient history and physical examination. When a patient is asymptomatic, hypercalciuria and mild forms of glomerulonephritis are common causes of gross hematuria. Although they are less common in children, special care should be taken to investigate for renal and bladder tumors.

The abnormal urinalysis

The urinalysis is one of the most commonly performed tests in pediatrics, and whether expected or incidental, abnormal findings are common. Understanding the strengths and limitations of the urinalysis allows one to maximize its use as a screening tool while avoiding expensive and unnecessary evaluations. This article reviews the significance of abnormal results on urine dipstick testing and urine microscopy. Causes of false positive and false negative results are summarized. Initial diagnostic considerations of abnormal urinalysis findings are provided where appropriate.

Diagnostic yield of parathyroid hormone testing in children evaluated for hypercalciuria

Hypercalciuria is a frequent cause of non-glomerular hematuria in pediatric patients. Because hypercalciuria can be secondary to primary hyperparathyroidism, measurement of serum parathyroid hormone (PTH) levels is often performed in children with this urinary abnormality. A retrospective chart review was performed to determine the diagnostic yield of PTH measurements when performed under these clinical circumstances. Over a 30-month period (January 1, 2001 to September 30, 2003), among 31 children who had a PTH determination, the level was elevated in 1 (3%) patient. Based on these findings and the serious nature of untreated primary hyperparathyroidism, serum PTH level should be measured in pediatric patients with newly diagnosed hypercalciuria.