Haematuria

Introduction

Microscopic haematuria is a common finding in children (>10 RBC/microlitre) and can only be detected by urinalysis as the urine colour remains normal.^{1, 2}

^Presentation

*Microscopic haematuria is common in children with nephrotic syndrome. Children with oedema plus nephrotic range proteinuria (protein-to-creatinine ³200 mg/mmol or ³3+ on dipstick) plus a low serum albumin (less than 25 g/L) should follow the nephrotic syndrome pathway (Nephrotic Syndrome Management).

History

• Previous history of haematuria
• Symptoms of infection: dysuria, frequency, pain, fever
• Systemic symptoms: fatigue, fever, oedema, rash, arthralgia, haemoptysis, epistaxis
• Recent surgery, trauma or exercise
• Family history of haematuria, proteinuria, kidney disease, renal stones, hearing loss

Examination and investigations

• Anthropometric measurements
  • Blood pressure
  • Weight
  • Height
• Examination for oedema and signs of vasculitis (e.g. rashes, aphthous ulcers, scleritis, serositis, arthritis)
• Urinalysis
• Urine MC&S and protein-to-creatinine ratio (first morning) if proteinuria on dipstick
• Urine calcium-to-creatinine ratio
• Blood tests
  • FBP
  • UEC
  • CMP
  • LFT
  • If patient has proteinuria or signs concerning for vasculitis consider CRP, ESR, C3/C4, ANA, dsDNA, ASOT and anti-DNase, and ANCA
• Renal tract ultrasound

Haematuria with any of these ‘red flag’ symptoms should be discussed with a Paediatrician or Nephrologist:

• Significant proteinuria
• Elevated serum creatinine
• Hypertension
• Fluid overload

Pre-referral management

Table 1: Management of children presenting with haematuria¹

When to refer

• Persistent microscopic haematuria (see above flowchart) or microscopic haematuria with proteinuria
  • Ensure relevant investigations are completed
  • If the initial screen and assessment are unrevealing, it is likely the patient will be returned back to their GP for ongoing monitoring (annual BP and urinalysis)
• Haematuria with any of the “red flags” should be discussed with Paediatrics or Nephrology as it may require more urgent review

How to refer

• Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service. Routine non-urgent referrals from private hospitals go to the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au).
• Urgent referrals (less than seven days) go to the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 222 to discuss referral with the on-call Renal specialist.

Essential information to include in your referral

• History, BP and clinical examination
• Results of all investigations

References

1. The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Haematuria [Internet]. Rch.org.au. 2019. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Haematuria/ [accessed 17 November 2022]
2. Boyer, G. O., Niaudet, P., Wilkie, L. Evaluation of microscopic hematuria in children [Internet]. 2020 [cited 17 Nov 2022]. Available from: https://www-uptodate-com.pklibresources.health.wa.gov.au/contents/evaluation-of-microscopic-hematuria-in-children?search=haematuria%20paediatric&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

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