Hematuria In Children Research Articles

Follow-up of children with isolated microscopic hematuria detected in a mass school urine screening test

Purpose:The isolated microscopic hematuria is the most common abnormality detected by school urinary screening, but there is no consensus about the range of investigations and long-term outcomes of isolated hematuria in children yet. This study aims to elucidate the prognosis of hematuria and the range of diagnostic studies by follow-up results. Methods:Students with isolated hematuria who were referred to the Department of Pediatrics, Asan Medical Center from Aug. 1990 to Feb. 2004 were analysed retrospectively. Cases that presented Through significant proteinuria(>250 mg/day), other symptoms of nephritis or renal dysfunction (creatinine clearance

A Review on Hematuria in Children

Asymptomatic hematuria is very common in pediatric and adolescent patients. In contrast to painless hematuria in adults, the differential diagnosis and investigative modalities in the pediatric population is vastly different. This article presents the major diseases that may cause hematuria in children and suggests an evaluation algorithm for the pediatric urologist.

The Clinical Significance of Asymptomatic Gross and Microscopic Hematuria in Children

The Clinical Significance of Asymptomatic Gross and Microscopic Hematuria in Children

Quantification of hypercalciuria with the urine calcium osmolality ratio in children

Hypercalciuria is a major risk factor for kidney stones and hematuria in children. Calcium measurements in 24-h collected urine (mg/kg/d) is still essential for the hypercalciuria diagnose but collection of 24 hour urine is difficult especially in young children. A prospective study was conducted to compare calcium/osmolality (Uca/Uosm) ratio to calcium/creatinine (Uea/Ucr) and to correlate both ratios to 24-hour urine calcium excretion (mg/kg/d) and the value of Uca/Uosm ratio for diagnosis of hypercalciuria in children. Two hundred and fifteen patients aged between 3 to 15 years (median 8 years) were included in the study. Early morning second urine samples and 24-hour collected urine samples were analyzed. The 24-hour urinary calcium excretions were significantly correlated with Uca/Ucr and Uca/Uosm ratio (r =0.67, P<0.001 and r =0.61, P<0.001 respectively). The accepted hypercalciuria level of 24-hour urine calcium of 4 mg/kg/day coincides with Uca/Ucr ratio of 0.18 mg/mg (sensitivity 90.0%, specificity 84.4%) and with Uca/Uosm ratio of 0.14 mg/l/mOsm/kg (sensitivity 90%, specificity 81.0%) in the ROC curve analysis. Positive and negative predictive values were found 98.3% and 39.1% for Uca/Uosm ratio and respectively 43.9% and 98.4% for Uca/Ucr ratio. In conclusion Uca/Uosm ratio is a good marker of hypercalciuria as well as Uca/Ucr ratio and may be used for screening of hypercalciuria.

Hematuria in Children: When to Worry

Hematuria in Children: When to Worry

The Clinical Significance of Asymptomatic Gross and Microscopic Hematuria in Children

The development of asymptomatic gross or microscopic hematuria is relatively common in children. To evaluate the clinical importance of hematuria in children and the necessity for such an evaluation using a defined diagnostic protocol. The protocol included a personal and family history, physical examination and blood pressure determination, and a set of comprehensive laboratory and radiological examinations. Of 342 children with microscopic hematuria, no cause was uncovered in 274 patients. The most common cause discovered was hypercalciuria (16%), followed by post-streptococcal glomerulonephritis (1%). Of 228 children with gross hematuria, no cause was uncovered in 86 patients. The most common cause discovered was hypercalciuria (22%). Ten patients had clinically important structural abnormalities. Fifty-three patients qualified for renal biopsy; 36 had IgA nephropathy. Our results suggest that diagnostic evaluation for potential causes of asymptomatic microscopic hematuria in children may not be necessary. Because microscopic hematuria can, rarely, be the first sign of occult renal disease, long-term follow-up is mandatory. As clinically important abnormalities of the urinary tract are commonly discovered in children with asymptomatic gross hematuria, a thorough diagnostic evaluation is warranted.

Factors affecting spontaneous resolution of hematuria in childhood nutcracker syndrome

To identify factors affecting spontaneous resolution of hematuria in children with nutcracker syndrome, 20 patients diagnosed as having nutcracker syndrome using renal Doppler ultrasound (US) were analyzed retrospectively. Sixteen patients had microscopic hematuria, and four had gross hematuria at presentation. The mean age was 10.6 years (range 2.5-14 years). All underwent a follow-up Doppler US examination after a mean period of 1.4 years (range 0.5-3.5 years) after the first US was performed, and height and weight were measured at the time of US. At the time of follow-up US, hematuria disappeared in 15 patients and improved in 3. The peak velocity (PV) ratios of the left renal vein (LRV) at the follow-up US decreased significantly when compared to the first US examination (7.74+/-2.64 vs 3.50+/-1.09, p<0.0001), and height (147.4+/-20.1 vs 152.3+/-18.8 cm) and weight (36.1+/-10.9 vs 42.3+/-12.7 kg) increased (p<0.0001). Changes in the PV ratios of the LRV correlated positively with changes in the PV at the aortomesenteric portion (r=0.569, p=0.009). Changes in the PV at the aortomesenteric portion correlated negatively with changes in body mass index (BMI) (r=-0.543, p=0.013). Although spontaneous resolution of hematuria in children with nutcracker syndrome is obscure, our findings suggest the increase in BMI may be a possible hemodynamic factor.

Control of scabies, skin sores and haematuria in children in the Solomon Islands: another role for ivermectin.

To assess the effects of a 3-year programme aimed at controlling scabies on five small lagoon islands in the Solomon Islands by monitoring scabies, skin sores, streptococcal skin contamination, serology and haematuria in the island children. Control was achieved by treating almost all residents of each island once or twice within 2 weeks with ivermectin (160-250 microg/kg), except for children who weighed less than 15 kg and pregnant women, for whom 5% permethrin cream was used. Reintroduction of scabies was controlled by treating returning residents and visitors, whether or not they had evident scabies. Prevalence of scabies dropped from 25% to less than 1% (P < 0.001); prevalence of sores from 40% to 21% (P < 0.001); streptococcal contamination of the fingers in those with and without sores decreased significantly (P = 0.02 and 0.047, respectively) and anti-DNase B levels decreased (P = 0.002). Both the proportion of children with haematuria and its mean level fell (P = 0.002 and P < 0.001, respectively). No adverse effects of the treatments were seen. The results show that ivermectin is an effective and practical agent in the control of scabies and that control reduces the occurrence of streptococcal skin disease and possible signs of renal damage in children. Integrating community-based control of scabies and streptococcal skin disease with planned programmes for controlling filariasis and intestinal nematodes could be both practical and produce great health benefits.

Traumatic Hematuria in Children can be Evaluated as in Adults

Controversy exists regarding whether children who present with blunt abdominal trauma and microhematuria should undergo renal imaging. Adult blunt trauma victims who present without gross hematuria, shock, or significant deceleration or other major associated injuries do not require renal imaging. This study was designed to evaluate whether the criteria for imaging the renal parenchyma in adult blunt trauma victims apply to the pediatric population. We retrospectively reviewed 720 consecutive pediatric patients with suspected renal trauma to determine mechanism of injury, evaluation and treatment of subsequent injuries. Of the 720 trauma patients with hematuria (mean age 8 years) 334 underwent imaging, and 59 renal injuries were identified (grade I 32, grade II 6, grade III 8, grade IV 12, grade V 1). A total of 11 patients underwent exploration, resulting in 3 nephrectomies (grade IV 2, grade V 1). Renorrhaphy was not necessary and all other cases were managed conservatively. All patients with significant renal injuries experienced either gross hematuria, shock (systolic blood pressure less than 90 mm Hg) or a significant deceleration injury. The decision to image pediatric trauma cases based on the adult criteria of gross hematuria, shock and significant deceleration injury is appropriate. Among 720 pediatric cases of potential renal injury all would have been identified.

Blunt Traumatic Hematuria in Children. Is a Simplified Algorithm Justified?

We determined whether radiographic evaluation is indicated in all children with traumatic hematuria. We retrospectively reviewed the records of 110 children from 1992 to 1999 diagnosed with blunt trauma and hematuria. It is routine practice at our emergency department to perform radiographic evaluation in all children with hematuria regardless of the degree. Each chart was evaluated for the mechanism of injury, degree of hematuria, hypotension, imaging studies, renal injury, renal anomalies, associated injuries and outcome. A total of 110 patients 1 to 18 years old (mean age 9) were identified. The most common mechanism of injury was motor vehicle accident in 37 children (34%), followed by a fall in 32 (29%). Grades I to V renal injury was present in 5, 6, 6, 6 and 1 cases, respectively (22%), while 1 (0.9%) involved ureteropelvic junction avulsion. No child had renal pedicle injury. In 9 patients renal anomalies were detected incidentally. Of the 110 patients 101 underwent radiographic evaluation, including computerized tomography in 97 (88%). The 24 patients (22%) with significant renal injury and all with incidentally diagnosed renal anomalies had 50 or greater red blood cells per high power field on urinalysis, while 1 with ureteropelvic junction avulsion presented without hematuria. Hypotension was present in only 3 patients (2.7%), who also had associated injuries, including 2 who presented with renal injury. All 3 with associated injuries. Associated injuries were identified in 11 of 25 patients (44%). The 9 patients (8%) who did not undergo radiographic imaging had negative results on repeat urinalysis with an excellent outcome. We recommend that radiological evaluation consisting of abdominal and pelvic computerized tomography should be performed only in patients with 50 or greater red blood cells on urinalysis, hypotension at presentation to the emergency room or based on the severity of mechanism of injury, for example high speed motor vehicle accident deceleration injuries. The patient who presented with ureteropelvic junction avulsion without hematuria would have undergone imaging considering the mechanism of injury and number of associated injuries.

Blunt Traumatic Hematuria in Children. Is a Simplified Algorithm Justified?

Blunt Traumatic Hematuria in Children. Is a Simplified Algorithm Justified?

THE ASSOCIATION OF AN INCREASED URINARY CALCIUM-TO- CREATININE RATIO, AND ASYMPTOMATIC GROSS AND MICROSCOPIC HEMATURIA IN CHILDREN

The role of hypercalciuria for the evaluation of unexplained asymptomatic gross and microscopic hematuria in children remains unclear, as evidenced by conflicting reports in the literature. We study the function of hypercalciuria in these patients, and determine whether routine evaluation of urine for hypercalciuria and treatment with thiazide diuretics, based on the results of a urinary calcium-to-creatinine ratio, is necessary. We also wanted to compare the yield of a urinary calcium-to-creatinine ratio in patients with gross and microscopic hematuria subgroups. Between 1991 and 1998 we treated 96 patients with microscopic hematuria (group 1) and 46 with gross hematuria (group 2). All patients had isolated unexplained hematuria. Patients with organic and anatomical causes, including urinary tract infection and other urinary symptoms, were excluded from the study. Nephrological urine and serum analyses in patients with hematuria were otherwise normal, as were all imaging studies. Group 1 included 50 males and 46 females, with a mean age of 7.6 years (range 1 to 14), and a spot urinary calcium-to-creatinine ratio was done in 79. Group 2 included 35 males and 11 females, with a mean age of 8.5 years (range 8 months to 14 years), and a spot urinary calcium-to-creatinine ratio was done in 43. A ratio of 0.2 or greater was considered hypercalciuria. The season of presentation was noted to determine any pattern. There were no seasonal variations regarding presentation. Followup of 34 patients in group 1 and 15 group 2, with a mean followup of 10.6 months (range 1 month to 8 years), was available. A total of 28 (82.3%) patients in group 1 and 15 (71.4%) group 2 had complete resolution of hematuria. However, there were 6 patients in both groups who had persistent hematuria but remained totally asymptomatic. Hydrochlorothiazide was used in only 2 patients in group 1 and 1 group 2 due to intractable hematuria on expectant management, a markedly increased urinary calcium-to-creatinine ratio and positive family history of urolithiasis. Although we cannot establish a direct cause and effect relationship, hypercalciuria is detected in a substantial number of cases of unexplained gross and microscopic hematuria. However, based on our study we do not recommend treatment with thiazide diuretics in all patients diagnosed with hypercalciuria, as hematuria resolved in a majority with observation or expectant treatment and minor dietary modification. We reserve treatment with thiazide diuretics only for those patients with intractable hematuria, a markedly increased urine calcium-to-creatinine ratio and family history of urolithiasis

Sonography for the detection and follow-up of primary nonsarcomatous bladder tumors in children

Objectives. To report the use of a dedicated renal-bladder sonogram for the detection and follow-up of primary nonsarcomatous bladder tumors in children. Methods. Three children (aged 6 to 12 years) recently presented with nontraumatic gross painless hematuria. All were evaluated initially with renal-bladder sonography. Results. Two transitional cell papillomas and one inflammatory myofibroblastic tumor were easily detected initially by sonography in the 3 children. Two were treated with transurethral resection at the time of the confirmatory cystoscopy and one, with an endoscopically unresectable tumor, was treated with excisional biopsy. The use of sonography as the diagnostic tool obviated more invasive and expensive studies, as well as exposure to ionizing radiation. Conclusions. Renal-bladder sonography is the initial imaging modality of choice in the workup for nontraumatic gross painless hematuria in children. Not only is it an excellent screening tool for congenital malformations and renal calculi, it is also very sensitive for identifying primary bladder tumors in children.

A practical primary care approach to hematuria in children

Although hematuria is a common finding in the unselected population of children, the approach to evaluation is quite variable. Changes in the practice of primary care medicine in the United States mandate an approach to common office problems that is practical and realistic. This review addresses three areas: the current approach to evaluation of hematuria in children, a classification of children with hematuria into four distinct and easily identified clinical categories, and the development of an algorithm for application in the primary care setting. Each category is discussed relative to the more-common etiologies of hematuria, with recommendations for appropriate evaluation as well as suggestions of an appropriate referral to the nephrologist. An algorithm is proposed that provides a practical, systematic approach to the problem without the requirement for a specific diagnosis in every patient. The proposed classification and approach to the evaluation of children with hematuria should help simplify and clarify a potentially complex process.

Limited evaluation of microscopic hematuria in pediatrics.

The purpose was to determine the value of the standard laboratory and radiologic evaluation of microscopic hematuria in children, and to determine the prevalence of idiopathic hypercalciuria in those children referred for evaluation of unexplained microscopic hematuria. This was a retrospective study of 325 children referred from 1985 to 1994 for the evaluation of asymptomatic microscopic hematuria. The diagnostic studies reviewed included serum creatinine, blood urea nitrogen, serum electrolyte studies, serum complement concentration, antinuclear antibody, urinalysis, urine calcium to creatinine ratios, urinary protein to creatinine ratio and/or 24-hour urinary protein excretion, renal ultrasounds, intravenous pyelograms, voiding cystourethrograms, and historical information. All creatinine and electrolyte values were normal for age, and none of the biochemical tests obtained in the children with hypercalciuria was abnormal. Of the 325 patients with idiopathic microscopic hematuria, only 18 had abnormal renal ultrasound examinations and 9 voiding cystourethrograms showed low-grade reflux. Hypercalciuria was found in 29 patients. The family history was positive for urolithiasis in 16% of patients without hypercalciuria compared with 14% of patients with hypercalciuria. A positive family history of hematuria was reported in 25% of patients; 62 patients did not have hypercalciuria and 4 of the patients had hypercalciuria. Microscopic hematuria in children is a benign finding in the vast majority of children. Our data demonstrate that a renal ultrasound, voiding cystourethrogram, cystoscopy, and renal biopsy are not indicated in the work-up of microscopic hematuria, and microhematuria in the otherwise healthy child is a minimal health threat, rarely indicative of serious illness.

REFINED MICROSCOPIC URINALYSIS FOR RED BLOOD CELL MORPHOLOGY IN THE EVALUATION OF ASYMPTOMATIC MICROSCOPIC HEMATURIA IN A PEDIATRIC POPULATION

Purpose The use of refined microscopic urinalysis for the presence of dysmorphic red blood cells (RBCs) has been evaluated in children and adults with a known source of hematuria. We examined the clinical usefulness of this study in a pediatric population with an unknown source of hematuria. Materials and Methods Children 12 years old or younger referred for evaluation of asymptomatic microscopic hematuria exhibiting 4 or more RBCs per high power field were enrolled in this study. Patients provided a first morning urine sample subjected to refined urinalysis for RBC morphology. Standard evaluation of patients was performed until a final diagnosis of the hematuria source was identified. Results A total of 44 patients completed the study. Refined urinalysis revealed pure dysmorphic RBCs in 22 patients, pure isomorphic RBCs in 8 and mixed isomorphic/dysmorphic RBCs in 14. The presence of dysmorphic RBCs correctly predicted a glomerulotubular source of hematuria in 29 of 36 patients (sensitivity 83%, specificity 81%), while the presence of isomorphic RBCs predicted a uroepithelial source of hematuria in 2 of 8 patients (sensitivity 25%, specificity 22%). Hematuria and 2+ proteinuria (100 mg./dl.) were more sensitive (100%) and specific (83%) than the presence of dysmorphic RBCs in predicting glomerulotubular hematuria. Conclusions We believe that this is a costly test offering little additional information to the evaluation of microscopic hematuria in children. A thoughtful history and physical examination with microscopic urinalysis and dipstick for proteinuria provide an equal amount of diagnostic information. We do not recommend its routine use in the evaluation of microscopic hematuria in children.

Hematuria in children: retrospective study of 128 pediatric patients

OBJECTIVE: To evaluate the diagnostic frequency of the various diseases associated with the development of hematuria in children, in a pediatric nephrology unit pertaining to a university hospital. METHODS: The clinical records of 128 children (70 male, 50 female) who presented intermittent/persistent macroscopic hematuria or persistent microscopic hematuria as the chief clinical complaint/finding, in the period of 1978-1995, were retrospectively analyzed. This evaluation was performed with special attention to the patientacute;s clinical history, physical examination, personal and family morbid history information. Patients whose investigation was not complete were not considered for analysis. The mean age on presentation was 8.2 years (5 months - 16 years) and the mean period of observation was 3.2 years (1 month-15 years). RESULTS: Macroscopic hematuria occurred in 104 patients and persistent microscopic hematuria was present in 24 patients. Urinary metabolic disturbances and urinary lithiasis, alone or in association, were diagnosed in the majority of the patients (65.5%). Hypercalciuria was the urinary metabolic disturbance (90.1%) mostly detected, either alone (73.2%) or in association with hyperuricosuria (16.9%). A positive family history of lithiasis was reported in 32.1% of the patients in which the diagnosis of lithiasis/urinary metabolic disturbance was confirmed. Glomerulopathies were diagnosed in 25% of the patients, with the predominance of post-infectious acute glomerulonephritis (11 patients, 34%). In 6 children, the etiology of hematuria was not elucidated, despite extensive investigation, including renal biopsy.CONCLUSION: The authors present an algorithm for the diagnosis of hematuria in children and suggest that in cases of isolated hematuria, presenting without clinical clues to the possible etiology, laboratory investigation should be started with the evaluation of urinary metabolic disturbances / lithiasis.

PRIMARY EWING'S SARCOMA OF THE BLADDER ASSOCIATED WITH AN ELEVATED ANTINUCLEAR ANTIBODY TITER

Lower urinary tract malignancy is an uncommon cause of hematuria in children. The most common pediatric bladder malignancies are rhabdomyosarcoma, leiomyosarcoma and transitional cell carcinoma. To our knowledge primary Ewing's sarcoma of the bladder has not been previously reported in any age group. We report a case of primary Ewing's sarcoma of the bladder associated with elevated antinuclear antibody titer. CASE REPORT A previously healthy 15-year-old white girl presented for evaluation of painless gross hematuria and clot urinary retention. Physical examination was normal and medical history was unremarkable. Urinalysis revealed numerous isomorphic erythrocytes but no pyuria or bacteriuria. Creatinine, serum electrolytes, liver function tests, alkaline phosphatase, lactate dehydrogenase, hematocrit and coagulation studies were normal. An antinuclear antibody titer that was obtained to rule out nephrological hematuria was elevated at 1:10,240 (normal up to 1:15). Excretory urogram showed normal kidneys and an unremarkable upper urinary tract. However, a filling defect was noted in the bladder. Cystoscopic examination revealed a 2 x 2 cm. bleeding, sessile globular tumor with focal areas of necrosis and no papillary features. The lesion was at the right anterolateral bladder wall. Transurethral resection was incomplete and biopsy specimens were not consistent with transitional cell carcinoma. Immunohistochemical and electron microscopy studies revealed small round blue malignant cells (fig. 1). Staging chest, abdomen and pelvis computerized tomography (CT) failed to reveal intra-abdominal or retroperitoneal pathology.

Djenkol beans as a cause of hematuria in children.

Djenkolism is djenkol bean poisoning, characterized by acute renal failure, urinary obstruction and spasmodic pain. The effects of djenkol bean consumption on the urinary tract without overt symptoms and long-term outcome are not established. This paper examines the association between djenkol bean ingestion and urine abnormalities in school children. 609 school children aged 7-11 years in five urban Hat-Yai schools were interviewed, and had their urine analyzed. All children included in the study had normal blood pressure for age, no illness (including respiratory tract symptoms) and were not taking medication. 78% of the children had a history of eating djenkol bean and of these 31% had done so in the past 24 h. Children with hematuria were almost four times (crude odds ratio = 3.7) as likely to have a history of eating djenkol beans as those with normal urine. Crystaluria and pyuria were not significantly more common among those eating the beans. The risk of having hematuria did not change with increasing consumption, or time since last eaten, or type of preparation even after adjustment for sex and age. Djenkol bean consumption may be defined as one of the probable causes of hematuria in the area where the djenkol tree grows.

Hematuria in children and adolescents with insulin-dependent diabetes mellitus

Hematuria is not described as a common finding in diabetic nephropathy, and may suggest nondiabetic renal disease. We reviewed the records of 59 children and adolescents with insulin-dependent diabetes mellitus referred to the Children's Kidney Center from 1983 to 1992. Fifty-two patients had clinical and/or biopsy evidence of diabetic nephropathy; 18 52 (35%) had microscopic hematuria at the time of referral. Patients with hematuria on presentation were referred for: hypertension (61%), proteinuria (61%), and decreased glomerular filtration rate (GFR) (11%). For patients without hematuria on presentation, reasons for referral included hypertension (79%), proteinuria (56%), and decreased GFR (3%). When comparing patients with and without hematuria, those with hematuria had a significantly longer duration of diabetes (12.8 ± 3.1 versus 10.8 ± 3.7 years, p < 0.05). The groups did not differ significantly with regard to age (18.3 ± 1.8 versus 17.1 ± 2.9 years), height (162.2 ± 10.4 versus 159.3 ± 11.3 cm), weight (63.9 ± 10.9 versus 59.4 ± 14.8 kg), systolic blood pressure (137.2 ± 11.9 versus 133.2 ± 13.2 mm Hg), diastolic blood pressure (85.6 ± 7.6 versus 83.9 ± 13.4 mm Hg), serum creatinine (1.0 ± 0.18 versus 1.0 ± 0.43 mg/dL), blood urea nitrogen (15 ± 5 versus 13 ± 4 mg/dL), glomerular filtration rate (117 ± 34 versus 117 ± 46 mL/min/1.73 m 2), 24-h urine protein (2311 ± 3862 versus 570 ± 476 mg/day), or microalbuminuria (75 ± 41 versus 34 ± 35 μg/min). We detected a significant association between retinopathy and microscopic hematuria (sensitivity 47%, specificity 82%, p < 0.05), but no association between labstix proteinuria or sex and hematuria. We conclude that microscopic hematuria is a common finding in children and adolescents at presentation of diabetic nephropathy.