|Year : 2017 | Volume
| Issue : 3 | Page : 72-75
Causes and diagnostic significance of macroscopic hematuria in children and young adults
Awatef Elbouaeshi1, Amna Rayani1, Manal Irheem1, Elmukhtar Habas2
1 Pediatric Hematology and Nephrology Unit, Medical Faculty, Tripoli Pediatric Hospital, Tripoli University, Tripoli, Libya
2 Department of Medical, Nephrology Unit, Medical Faculty, Tripoli Central Hospital, Tripoli University, Tripoli, Libya
|Date of Web Publication||26-Dec-2017|
Dr. Elmukhtar Habas
Medical Faculty, Tripoli Central Hospital, Tripoli University, Tripoli
Source of Support: None, Conflict of Interest: None
Background: Hematuria is common complaint brings patients to a physician. Macroscopic hematuria can be transient or persistent, and it may or may not associate with significant urinary system abnormalities. Objective: The objective of this study is to determine the major causes of macroscopic hematuria in ages less 20 years. Patients and Method: Descriptive case series study carrried out as a collaborative study in Tripoli during Januray 2013 - December 2014. Patients who presented with macroscopic hematuria file were studied retrospectively for gender, age, possible associated diseases as glomerulalar diseases, urinary tract infection (UTI), and others. Results: Out of 126 patients had macroscopic hematuria, 107 patients had the required data that achieved the study protocol. They were 72 cases (67.28%) males and 35 cases (32.71%), and their age ranged between (7 and 20 years). Macroscopic hematuria was more frequently reported at the age 7–13 years, and it was reported in (58.87%) due to the glomerular lesion, and in (41.12%) due to nonglomerular cause. Acute poststreptococcal glomerulonephritis (AGN) was the most common cause of macroscopic hematuria (53.27%), UTI was the second cause of macroscopic hematuria (28.97%), and renal stone was (9.34%) of total causes. Macroscopic hematuria due to trauma reported in 3 cases (6.8%), and in 5 cases (2.27%) due to IgA nephropathy. Conclusion: AGN and UTI are common causes of macroscopic hematuria. Urine microscopic examination is essential to differentiate between them before preceding to the other complicated, expensive, and invasive investigations.
Keywords: Acute glomerulonephritis, IgA nephropathy, macroscopic hematuria, urinary tract infection
|How to cite this article:|
Elbouaeshi A, Rayani A, Irheem M, Habas E. Causes and diagnostic significance of macroscopic hematuria in children and young adults. Libyan J Med Sci 2017;1:72-5
|How to cite this URL:|
Elbouaeshi A, Rayani A, Irheem M, Habas E. Causes and diagnostic significance of macroscopic hematuria in children and young adults. Libyan J Med Sci [serial online] 2017 [cited 2018 Aug 15];1:72-5. Available from: http://www.ljmsonline.com/text.asp?2017/1/3/72/221494
| Introduction|| |
Hematuria is not uncommon presenting complaint in clinical practice. It can be caused by renal, urological, and systemic diseases., The presence of more than 5–10 red blood cells (RBCs)/high-power field has a significant diagnostic value., Pyuria is more common in urine routine investigation than hematuria and abdominal pain. Hematuria without proteinuria does not always indicate nonglomerular origin, and glomerular bleeding is not necessary accompanied by proteinuria. It is recommended that at least two out of three urine samples analysis must have significant hematuria over 2–3 weeks before further evaluation performed., Bright-red urine, visible clots, and crystals with normal-looking RBCs by microscopic examination suggest bleeding from the urinary tract rather than from the kidneys. RBC cast and dysmorphic RBCs suggest glomerular damage or disease. A positive dipstick reaction is not always indicate hematuria, because hemoglobinuria and myoglobinuria may cause positive dipstick reaction.
Hematuria may originate from the glomeruli, renal tubules, and interstitium, or other urinary tract parts. Other associated features such as hypertension, altered renal function tests, proteinuria, known previous renal problems, renal mass, and distorted RBC in the urine suggest renal origin of hematuria. Therefore, diagnostic procedures to evaluate the systemic causes of hematuria should be guided by the presence of systemic diseases features and urine macro- and micro-scopic examination findings.
Up to our knowledge, the most frequent causes of significant macroscopic hematuria was not investigated in Libya in childhood and young adults' age groups. Therefore, this study was conducted to evaluate the diagnostic significance of macroscopic hematuria.
Aim of the study
The aim of this study is to determine the diagnostic significance of macroscopic hematuria in childhood and young adults' age group.
| Patients and Methods|| |
This descriptive retrospective collaborative case series study carried out in Tripoli's Children Hospital and Tripoli Central Hospital during January 1, 2013– end of December 2014. It was conducted on all cases presented with macroscopic hematuria as main complaint.
Patients had history of dysuria, frequency, urgency, flank and/or abdominal pain, recent trauma, strenuous exercise, menstruation, or bladder catheterization, sore throat or skin infection within the past 2–4 weeks, history of drugs and toxins, family history of renal diseases, and renal stones were taken from patients follow up notes. Blood pressure and temperature measurement were also collected. Skin rash, arthritis, edema, and abdominal masses were extracted from patients review records. Laboratory investigations as, microscopic urine examination for RBCs, RBC casts, granular casts, RBCs morphology, and serum urea and creatinine levels, complete blood count, serologic testing (complement C3, C4, and antistreptolysin titer (ASOT) were collected from patients follow-up notes. Urine culture results for suspected urinary tract infection (UTI), and renal ultrasonography report were also noted from patients' follow-up records. A kidney biopsy results for 6 patients who had significant proteinuria and history of recurrent macroscopic hematuria.
According to the RBC morphology and the type of the cast, the presence or absence of white blood cells in urine microscopic examination, history of sore throat, or evidence of streptococcal infection indicators as ASOT and results of serum urea and creatinine, the origin of macroscopic hematuria was classified into glomerular and nonglomerular cause.
Statistical analysis was done using Statistical Pakage for social and Science, Version 18 (SPSS inc., Chicago III, USA) and Excel Microsoft program were used for data descriptive statistics; frequencies, percentage, and mean analysis.
| Results|| |
One hundred and seven patients out of 126 cases who had macroscopic hematuria fulfill the study protocol. They were 72 (67.28%) male and 35 (32.71%) female. Macroscopic hematuria was reported more between ages 7 and 15 years.
According to the underlying cause, patients were classified into glomerular and nonglomerular origin cause of macroscopic hematuria. Glomerular origin of macroscopic hematuria accounted for 63 cases (58.87%) whereas nonglomerular origin of macroscopic hematuria reported in 44 cases (41.12%).
Acute glomerulonephritis (AGN) was the most common cause of macroscopic hematuria of glomerular origin 57 cases (90.47%). UTI was the second cause of macroscopic hematuria in 31 patients (70.45%). Ten patients (22.72%) had macroscopic hematuria due to renal stone. Macroscopic hematuria with history of trauma was reported in 3 cases (6.8%). IgA nephropathy reported in 5 cases (7.93%) of glomerular causes [Table 1].
|Table 1: Distribution of the 107 cases of gross hematuria according to the different causes|
Click here to view
AGN with hypertension reported in (23.36%). AGN with edema in lower limbs in (25.23%), red cell cast in urine in (48.59%), increase CRP (42.99%), low C3 (57%), increase urea and creatinine (16.12%), and increase ASOT (29.90%) of patients. Urinary RBC reported in 52 patients (48.59%) of which 81.3% had marked dysmorphic RBC [Table 2].
Renal ultrasound was performed for 76 patients out of 107 patients revealed mild increases of renal echogenicity in seven patients (9.2%), four patients (5.2%) have stones with variable grades of hydronephrosis. Two patients (2.6%) with UTI and 63 patients (82.8%) had normal ultrasound finding of kidney and urinary system. Dysmorphic RBCs was reported in 81.3% of patients had glomerular origin of hematuria.
| Discussion|| |
Macroscopic hematuria can be a presenting complaint of patients has local urinary system pathological lesions or due to systemic diseases. Microscopic and macroscopic hematuria is caused by the kidneys and/or other urinary system parts as ureters, urinary bladder, prostate, urethra, and urethral meatus injuries. Routine urine examination including microscopic urine examination is usually done for most of urinary symptoms, however, there are not significant evidence to support routine screening for microscopic hematuria in general population. Either microscopic or macroscopic hematuria originates from urinary system parts, or systemic diseases need laboratory investigations, especially in adults to exclude autoimmune diseases and some hematological diseases, in addition, renal biopsy is usually done to detect the glomerular, tubular and the interstitial kidney pathological lesions as in IgA nephropathy. On the other hand, hematuria due to nonglomerular diseases in the urinary system as in ureters, urethra, and urinary bladder does not need renal biopsy, but radiological imaging techniques as ultrasound, CT and MRI urography scanning are more diagnostic.
The present study was conducted for 107 patients presented with macroscopic hematuria. Poststreptococcal AGN was the most common cause of macroscopic hematuria. The abundance of poststreptococcal AGN as a cause for macroscopic hematuria might be due to that the patients were children and they were young adults. It is well known that poststreptococcal AGN is the most common cause of glomeruli origin of hematuria in these age groups.
IgA nephropathy is due to IgA deposition in the glomerular mesangium. IgA may progress to end-stage renal disease, and IgA nephropathy is the most common cause of glomerulonephritis worldwide at late childhood and at puberty ages.,, IgA nephropathy is highly variable in clinical presentation and pathological changes. Clinically, IgA might be presented by asymptomatic micro and macroscopic hematuria or as rapid progressive glomerulonephritis. Acute kidney failure is not unusual in IgA nephropathy although significant number of patients is recovered spontaneously from acute renal failure. IgA nephropathy reported more in males than females (4 patients), and it was more in patients aged more than 17 years of age in the present study. This was reported by earlier conducted study.
UTI reported as a second cause of macroscopic hematuria in this study. This supported the previous reported data., Youn et al. reported that UTI was the most common cause of significant hematuria followed by IgA nephropathy and then Alport's syndrome. AGN was reported much less than our results, and the IgA was more than the present study. The differences between our results and Youn et al. results might be due to early diagnosis and treatment of β-hemolytic streptococcal. A study was conducted in Egypt reported almost the same results reported by the present study. This concordance between our results and the Egyptian study results could due to the similarities of the environmental, geographical, ethnic origin, and diet habits.
| Conclusion|| |
Poststreptococcal GN and IgA nephropathy are the most common cause of macroscopic hematuria that originates from kidneys. UTI is a common cause of macroscopic hematuria that originates from other urinary tract regions. Therefore, careful examination of urine of patients presented with macroscopic hematuria for RBC morphology and cast type are necessary before other invasive investigations.
Authors would like to thank all doctors, nurses, and laboratory technicians who helped in collecting the samples and laboratory processing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fairley KF, Birch DF. Hematuria: A simple method for identifying glomerular bleeding. Kidney Int 1982;21:105-8.
Shichiri M, Oowada A, Nishio Y, Tomita K, Shiigai T. Use of autoanalyser to examine urinary-red-cell morphology in the diagnosis of glomerular haematuria. Lancet 1986;2:781-2.
Dodge WF, West EF, Smith EH, Harvey B 3rd
. Proteinuria and hematuria in schoolchildren: Epidemiology and early natural history. J Pediatr 1976;88:327-47.
Fassett RG, Horgan BA, Mathew TH. Detection of glomerular bleeding by phase-contrast microscopy. Lancet 1982;1:1432-4.
Lieu TA, Grasmeder HM 3rd
, Kaplan BS. An approach to the evaluation and treatment of microscopic hematuria. Pediatr Clin North Am 1991;38:579-92.
Sharp VJ, Barnes KT, Erickson BA. Assessment of asymptomatic microscopic hematuria in adults. Am Fam Physician 2013;88:747-54.
Feld LG, Waz WR, Pérez LM, Joseph DB. Hematuria. An integrated medical and surgical approach. Pediatr Clin North Am 1997;44:1191-210.
Diven SC, Travis LB. A practical primary care approach to hematuria in children. Pediatr Nephrol 2000;14:65-72.
Tomita M, Kitamoto Y, Nakayama M, Sato T. A new morphological classification of urinary erythrocytes for differential diagnosis of glomerular hematuria. Clin Nephrol 1992;37:84-9.
Collar JE, Ladva S, Cairns TD, Cattell V. Red cell traverse through thin glomerular basement membranes. Kidney Int 2001;59:2069-72.
Yuste C, Gutierrez E, Sevillano AM, Rubio-Navarro A, Amaro-Villalobos JM, Ortiz A, et al.
Pathogenesis of glomerular haematuria. World J Nephrol 2015;4:185-95.
Benbassat J, Gergawi M, Offringa M, Drukker A. Symptomless microhaematuria in schoolchildren: Causes for variable management strategies. QJM 1996;89:845-54.
Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ, et al
. Diagnosis, evaluation and follow-up of asymptomatic Microhematuria (AMH) in adults: AUA guideline. J Urol 2012;188:2473-81.
Sarda RK, Minjas JN, Mahikwano LF. Further observations on the use of gross haematuria as an indirect screening technique for the detection of schistosoma haematobium infection in school children in Dares Salaam, Tanzania. J Trop Med Hyg 1986;89:309-12.
Lai KN, Tang SC, Schena FP, Novak J, Tomino Y, Fogo AB, et al.
IgA nephropathy. Nat Rev Dis Primers 2016;2:16001.
Glassock RJ. IgA nephropathy: Challenges and opportunities. Cleve Clin J Med 2008;75:569-76.
Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Cattran DC, Coppo R, Cook HT, Feehally J, Roberts IS, et al.
The oxford classification of IgA nephropathy: Rationale, clinicopathological correlations, and classification. Kidney Int 2009;76:534-45.
Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Coppo R, Troyanov S, Camilla R, Hogg RJ, Cattran DC, et al.
The oxford IgA nephropathy clinicopathological classification is valid for children as well as adults. Kidney Int 2010;77:921-7.
Wyatt RJ, Julian BA, Baehler RW, Stafford CC, McMorrow RG, Ferguson T, et al.
Epidemiology of IgA nephropathy in central and eastern Kentucky for the period 1975 through 1994. Central Kentucky Region of the Southeastern United States IgA Nephropathy DATABANK Project. J Am Soc Nephrol 1998;9:853-8.
Youn T, Trachtman H, Gauthier B. Clinical spectrum of gross hematuria in pediatric patients. Clin Pediatr (Phila) 2006;45:135-41.
EL-Din G, EL-Ghonemy A. Evaluation of children with macroscopic hematuria, University of Alexandria. Fac Med 1994;2:1-61.
[Table 1], [Table 2]