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Child Health Guideline Identifier

Haematuria

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Initial considerations

  1. Is the blood actually from urine? Vulvovaginitis, balanitis, rashes and other causes of irritation of the area around the urethra can produce false positive results. Examine child.
  2. Is this a urinary tract infection? This is a common cause of haematuria, and if confirmed usually avoids the need for further investigation of haematuria
  3. Is this microscopic or macroscopic haematuria? These suggest different sets of differential diagnoses.
  4. Is this an incidental finding? Isolated microscopic haematuria in a child with an intercurrent illness, or in an asymptomatic child is usually benign.
  5. Is this associated with proteinuria? The combination of persistent haematuria + proteinuria suggests underlying renal disease
  6. Was there a recent (days-weeks) illness? Post-infectious glomerulonephritis and IgA nephropathy can be triggered and/or aggravated by infectious illnesses.
  7. Check blood pressure in all children.

Risk factors for underlying renal tract disease

  • Haematuria with pain
  • Medical conditions associated with renal disease
  • Family history of renal calculi
  • Family history of Alport Syndrome/sensorineural deafness
  • Family history of other renal disease (specifically ask about dialysis, renal transplant)
  • Prematurity and low birth weight
  • Past history of renal insult
  • Hypertension

Children with risk factors for disease may require a lower threshold for investigation.

Microscopic haematuria

Clinical scenario Definition Recommendation
Isolated microscopic haematuria > 1+ positive on urine dipstick, no protein (< 1+), no white cells (< 1+)

No obvious source of blood (e.g. skin, UTI), no significant other signs or symptoms of underlying renal disease, otherwise well (+/- mild, incidental illness)
Repeat early morning dipstick when well
Persistent/recurrent isolated microscopic haematuria >1+ positive on repeated urine dipstick over a one month period, no protein (< 1+), no white cells (< 1+)

No obvious source of blood (e.g. skin, UTI), no significant signs or symptoms of underlying renal disease, otherwise well (+/- mild, incidental illnesses), no hypertension (check BP)
Check urine microscopy to confirm haematuria (= non-visible red cells > laboratory normal range)

If no red cells on microscopy consider haemoglobinuria (intravascular haemolysis) or myoglobinuria (in which case check serum CK and myoglobin)

If haematuria confirmed on microscopy, check early morning urine dipstick 3 or 4 times over a one year period. Confirm no protein present.
Persistent/recurrent isolated microscopic haematuria for more than 1 year As above on repeated testing for > 1 year

Check urine for hypercalciuria (request urine calcium:creatinine ratio)

Consider other baseline investigations (e.g. serum renal function)

Upper limit cut-offs for Calcium:Creatinine ratios (from Hoppe & Kemper 2010)
Age (years)              Calcium/Creatinine (mmol/mmol)
   0-1                                        2
   1-3                                        1.5
   3-5                                        1.1
   5-7                                        0.8
   >7                                         0.6

To confirm hypercalciuria in toilet trained children, 24hr urine calcium excretion is desirable, normal <0.1mmol/kg/24hr.

If Calcium:Creatinine raised, consider renal tract USS (?calculi)

If normal, recommendation: annual check for proteinuria (dipstick) and BP

Microscopic haematuria + proteinuria

Red cells >1+ positive

Protein > trace

No obvious source of blood (e.g. skin, UTI)

No significant signs and symptoms of underlying renal disease

Otherwise well (+/- mild, incidental illness)

No hypertension (check BP)

If not already done, check family history.

If no cause identified (e.g. proven UTI, skin source), recommend investigations:
    - Urine microscopy
    - Urine protein : creatinine ratio

Depending on overall clinical status, also consider:
    - Blood tests: creatinine, urea, albumin, Na, K, ANA, C3, C4, Strep serology
    - Renal tract USS

Ongoing follow up and investigation depending on clinical course.

Usually managed by General Paediatric service.

Requires follow up plan to ensure resolution or progression of renal disease.

Indications for referral to paediatric nephrology include persistent microscopic haematuria and significant proteinuria (Urine to protein to creatinine ratio >50mg/mmol) on serial specimens, and atypical clinical course

 Macroscopic haematuria

  • Haematuria visible to the eye.
  • Check for potential source of blood (skin, UTI, etc)

Fresh blood implies lower urinary tract (e.g. bladder, ureters), and a surgical cause more likely

Potential causes:

  • Cystitis (including viral - can be painful)
  • Calculi (usually but not always very painful)
  • PUJ obstruction and polycystic kidney disease can present with haematuria
Recommendations:
- Urine microscopy
- Renal tract USS
- Other investigations as indicated by presentation
- If no external or medical cause identified, refer to paediatric surgery/urology

Altered blood (darker, "Cola coloured") implies upper renal tract, and a medical cause more likely

Potential causes:

  • Glomerulonephritis
  • Other renal disease including dysplasia
Recommendations:
- Recheck family history and BP
- Urine microscopy (some but not all labs will note whether red cells are dysmorphic - more likely to be glomerular in origin)
- Bloods: creatinine, urea, albumin, Na, K, C3, C4, Strep serology, ANA
- Other investigations as indicated by presentation
- If clinically glomerulonephritis, renal USS not necessarily required: follow glomerulonephritis guideline
- If no cause identified, or atypical clinical course, consider renal tract USS and referral to paediatric services

References

  • Hoppe, B. & Kemper, M.J. (2010) Diagnostic examination of the child with urolithiasis or nephrocalcinosis. Pediatric Nephrology 25:403-413.

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Document Control

  • Date last published: 23 February 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Nephrology
  • Author(s): Tonya Kara
  • Owner: Paediatric Nephrology
  • Editor: Greg Williams
  • Review frequency: 2 years

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