Haematuria: Approach in Children
Guideline to the approach to haematuria in children
Lead Authors: Dr Shaegan Irusen & Dr Christel du Buisson
Acknowledgements: Dr PJ Sinclair, Dr P Nourse, Dr P Gajjar, Prof M McCulloch
Summary algorithm
Introduction
Clinical presentation
Examination and assessment
Differential diagnosis
Investigations
Management guided by suspected diagnosis
Referral criteria
Summary algorithm
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Introduction
Haematuria is defined as the presence of red blood cells, haemoglobin or myoglobin in urine. It is a common presenting symptom of renal & urinary tract disorders.
Clinical presentation
- Symptoms: fever, lethargy, abdominal pain, dysuria & frequency
- Ask about patterns of bleeding
- Urine colour (e.g. Coke colour = myoglobin)
- Pharyngitis, skin infection/rash, arthralgia, myalgia or haemoptysis
- Any history of trauma (incl. urethral catheterisation) – discuss with urology
- Bleeding tendency or bruising
- Any ingested food pigments
- Travel history: bilharzia, malaria or TB contact
- Family history: haematuria or kidney stones
- For Neonates: Central line insertion (e.g. UAC & UVC) can predispose renal vein & artery thrombosis
Examination and Assessment
- Check ABC for signs of imminent collapse
- Pallor/oedema
- Signs of dehydration (dry mucus membranes, decreased skin turgor etc.) and/or poor perfusion (capillary refill >3 sec, weak pulses etc.)
- Proptosis
- Epistaxis, septal perforation, saddle nose (Wegners Granulomatosis)
- Blood pressure, signs of fluid overload & congestive cardiac failure
- Abdominal mass
- Abdominal/flank pain
- Malar/discoid rash or impetigo
- Arthralgia
- Purpura/petechiae
- Petechial rash behind thighs/buttocks (?Henoch Schonlein Purpura)
- Urethral injury (discuss with urology)
Differential Diagnosis
Investigations
- Should be done in children with a positive history & symptoms of nephritis or features suggestive of autoimmune disease (e.g. rash, arthralgia, petechial rash on legs, thighs. buttocks)
Urgent tests:
- Full blood count, Electrolytes, Urea & Creatinine
- Type and Screen & Coagulation screen
- Urine Culture, urine protein: creatinine ratio
- Serum & urine myoglobin, creatinine kinase (CK)
Tests to consider if patient is in EC >24hours:
- C3/C4 fractions
- ASOT
- Anti-DNAse
- ANA
- ANCA
- Renal ultrasound
Management guided by suspected diagnosis:
Refer to a Paediatric Inpatient Unit:
- Episodic Macroscopic haematuria
- Family history
- Stones
- Decreased hearing or visual acuity
- Palpable kidney or bladder mass
- Hypertension
- Features of nephritic or nephrotic (proteinuria and oedema) syndrome
- Renal impairment
- Bruising/ petechiae or bleeding from other sites
Discuss with urology team:
- Any history of trauma
- Abnormal anatomy
- Abnormal cytology
Referral criteria:
Paediatric Outpatient referral: only if ISOLATED asymptomatic haematuria
Refer to a Paediatric Inpatient Unit:
- Episodic Macroscopic haematuria
- Family history
- Stones
- Decreased hearing or visual acuity
- Palpable kidney or bladder mass
- Hypertension
- Features of nephritic or nephrotic (proteinuria & oedema) syndrome
- Renal impairment
- Bruising/ petechiae or bleeding from other sites
Refer to urology team:
- Any history of trauma
- Abnormal anatomy
- Abnormal cytology
References
1. Wallis LA, Reynolds TA. AFEM Handbook of Acute and Emergency Care. South Africa: Oxford University Press; 2013.
2. Motala C, Davidson A, Figaji A, Levin M, editors. Handbook of Paediatrics. 7th edition. South Africa: Oxford University Press; 2012.