Interactive Pediatric Hematuria Management Guide

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🔍Step 1: Suspicion and Confirmation

Pediatric patient with red, brown, or "flesh-washed" urine.

Initial Action

1. Confirm Hematuria: Use urine test strip. A positive result for "blood" must be confirmed with microscopic examination of the urinary sediment.

  • Definition of Microhematuria: Presence of > 5 red blood cells per high power field in centrifuged urine.
  • Discard False Positives: Myoglobinuria (rhabdomyolysis), hemoglobinuria (hemolysis), ingestion of food (beets, dyes) or medications (rifampicin, metronidazole).
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📋Step 2: History and Directed Physical Examination

Once hematuria is confirmed, clinical history and physical examination are crucial to guide the diagnosis.

Key Points in the History
  • Urine characteristics: Bright red color (suggests low blood flow) or brown/Coca-Cola (suggests glomerular origin)? Presence of clots (suggests extraglomerular origin)?
  • Accompanying symptoms: Fever, dysuria, frequency (UTI); edema, hypertension, oliguria (Nephritic Syndrome); flank pain (Lithiasis, Obstruction); rash, arthralgia (systemic disease).
  • Recent background: Pharyngeal or skin infection (suggests post-infectious GMN, 1-3 weeks before); intense physical exercise; trauma.
  • Family history: Deafness (Alport Syndrome), lithiasis, kidney disease, familial hematuria.
Key Points in Physical Examination
  • Blood pressure: Always measure! Hypertension is a warning sign of glomerular disease.
  • Edema: Facial (periorbital) or lower limbs.
  • Skin examination: Palpable purpura (IgA vasculitis), malar rash (Lupus).
  • Abdominal palpation: Masses (Wilms tumor, hydronephrosis), suprapubic or lumbar fossa pain.
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🔬Step 3: Glomerular Differentiation vs. Non-Glomerular and Initial Studies

The priority is to distinguish whether the bleeding comes from the glomerulus or the urinary tract. This will guide studies and management.

Are there signs of Glomerular origin?

(Brown urine, HBP, edema, significant proteinuria, blood casts in sediment)

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🩸Management of Hematuria of Glomerular Origin

The presence of HTN, edema, proteinuria and/or blood casts requires an immediate study.

Studies to be carried out

  • Blood analysis: Blood count, kidney function (urea, creatinine), electrolytes, total proteins, albumin.
  • Immunological studies: Complement C3 and C4, antistreptolysin O (ASO).
  • Urine analysis: Quantification of proteinuria (protein/creatinine ratio in isolated sample).
  • Kidney ultrasound: To assess renal morphology.

URGENT Referral Criteria to Nephrology/Hospitalization

  • Arterial hypertension.
  • Significant edema or anasarca.
  • Oliguria or anuria.
  • Elevation of creatinine (Acute Renal Failure).
  • Proteinuria in the nephrotic range (Prot/Cr Index > 2.0 mg/mg).
Management of Suspected Post-Streptococcal GMN

Typically 1-3 weeks post-pharyngotonsillitis or impetigo. It runs with low C3 and high ASO.

Management: It is supportive. There is no specific treatment for hematuria.

  • Management of HTN/Edema: Salt and fluid restriction. If necessary, diuretics.
    • Furosemide
    Oral or IV.
    Dose: 1-2 mg/kg/dose. It can be repeated every 6-8 hours. Maximum 6 mg/kg/day.
  • If there is evidence of active infection, treat with Penicillin or Amoxicillin.

Follow-up: Periodic BP and urine controls. Hematuria may persist microscopically for months. C3 normalizes in 6-8 weeks.

Other Glomerular Causes and Remission

If glomerular hematuria is recurrent (coinciding with viral infections), consider IgA nephropathy.

If there is a family history of deafness or kidney failure, consider Alport syndrome.

If there are systemic symptoms (rash, arthritis), think about Vasculitis (Schönlein-Henoch) o Lupus.

In these cases, it must REFER TO PEDIATRIC NEPHROLOGY for complete study, which may include kidney biopsy.

💧Management of Hematuria of Non-Glomerular Origin

Red/pink urine, absence of HBP/edema/significant proteinuria. The most common causes are benign.

Initial Studies

  • Urine culture: Always, to rule out Urinary Tract Infection (UTI).
  • Calcium/Creatinine index in urine: To rule out idiopathic hypercalciuria (common cause of isolated hematuria). A value > 0.21 mg/mg is suggestive.
  • Kidney and urinary tract ultrasound: Evaluates malformations, lithiasis, tumors.
Management according to Cause

If UTI is confirmed:

Start antibiotic treatment according to local guidelines.

Amoxicillin-Clavulanate
Oral suspension (100/12.5 mg/ml), tablets.
Dosage (Cystitis): 40 mg/kg/day (amoxicillin) distributed every 8-12 hours for 3-5 days.
Cefixime
Oral suspension (100 mg/5 ml).
Dosage (Cystitis): 8 mg/kg/day distributed every 12-24 hours for 3-5 days.

Reevaluate with control urine culture if the clinic requires it.

If Hypercalciuria is confirmed:

Treatment is mainly dietary.

  • Increase fluid intake.
  • Normosodic diet (avoid excess salt).
  • Do not restrict calcium from the diet.

Follow-up: Control in 3-6 months. Hematuria is usually intermittent. Refer to nephrology if it is associated with lithiasis or is very recurrent.

If the studies are negative (Unidentified cause):

It is a Persistent Isolated Microscopic Hematuria. It is the most frequent situation.

Management:

  1. Confirm persistence in 2-3 samples in the following weeks/months.
  2. Carry out a family study (test strip for parents and siblings).
  3. Reevaluation in consultation every 6-12 months with urine strip and TA measurement.

Criteria for Referral to Nephrology (in non-glomerular hematuria)

  • Recurrent macroscopic hematuria.
  • Appearance of proteinuria, HTN or edema during follow-up.
  • Family history of significant kidney disease.
  • Anomalies on ultrasound (complex lithiasis, malformations).

Referral to Pediatric Urology

  • If anatomical cause is suspected (meal stenosis, polyps).
  • Kidney or urinary tract trauma.
  • Bladder or kidney tumor.

Recommendations for Parents and Caregivers

Seeing blood in your child's urine can be alarming, but in many cases the cause is not serious. Here's a guide on what to do and what not to do.

👍WHAT TO DO (TWO)

  • Keep calm: Most of the time, hematuria in children has a good prognosis. A small amount of blood can stain the urine very strikingly.
  • Consult the pediatrician: It is always the first step. Don't assume the cause. The doctor will perform the necessary tests for a correct diagnosis.
  • Follow medical instructions: Perform requested tests and give medications (such as antibiotics for an infection) as prescribed.
  • Promote hydration: Encourage your child to drink plenty of water, especially if hypercalciuria is suspected or to help "clean" the urinary tract.
  • Observe other symptoms: Tell the doctor if your child has fever, pain when urinating, pain in the abdomen or back, swelling (especially of the face or feet), or skin lesions.

👎WHAT NOT TO DO (DON'Ts)

  • Do not medicate on your own: Do not give anti-inflammatories (such as ibuprofen) without consulting, as some may affect kidney function.
  • Do not restrict liquids: Unless specifically directed by your doctor (such as in cases of kidney failure or significant edema).
  • Do not assume that it is "something temporary": Although many causes are benign, it always requires an initial medical evaluation to rule out serious problems.
  • Do not force strange diets: Do not restrict calcium or salt in your diet unless clearly directed by your pediatrician or nephrologist.

Final Evaluation: What have we learned?

Answer these questions to reinforce the key concepts of the guide.

1. What is the essential first step when suspecting hematuria in a child?

2. What set of signs and symptoms most strongly indicates hematuria of glomerular origin?

3. In a child with isolated, persistent microscopic hematuria and with normal initial studies (urine culture, ultrasound, Ca/Cr), what is the most appropriate behavior?

4. When is referral to an emergency department or pediatric nephrology a priority?

5. What is the recommended initial management for idiopathic hypercalciuria diagnosed as a cause of hematuria?

See Correct Answers

1. c) Confirm the presence of red blood cells with a urinary sediment.

2. b) Hypertension, edema and proteinuria.

3. c) Periodic monitoring (every 6-12 months) with urine strip and TA measurement.

4. b) If hematuria is accompanied by HTN, edema or alteration of kidney function.

5. c) Increased fluid intake and a normosodic diet (without excess salt).

Bibliography and References