Haematuria in Children - draft

Overview

Definitions

Visible (macroscopic) haematuria -  is where the urine is visibly discoloured. As little as 1 mL of blood per litre of urine can produce a visible change in the urine colour (2).

Non - visible (microscopic) haematuria  - is the presence of five red blood cells/mm3 in uncentrifuged urine or 5 red blood cells per high powered field (2) usually picked up on a urine dip. Persistent microscopic haemauria is 3 (should this be 2) samples taken at last a week apart, not after exercise.

In addition, children may be symptomatic or asymptomatic and may have proteinuria or isolated haematuria without proteinuria.

Refer to the clinical guidance on Haematuria in Children (1) provided by Bristol Royal Hospital for Children for a full list of causes.

There can also be a postive urine dip caused by conditions other than blood in the urine - see before referral section.

Who to Refer

Haematuria should be confirmed by dipstick test and/or microscopy to rule out non haematuria causes.

Visible (macroscopic) Haematuria

If not due to UTI or vigorous exercise then consider immediate or 2WW referral - see red flag section below.

Non-Visible (microscopic) Haematuria

The majority of persistent microscopic haematuria is benign and resolves spontaneously.

Refer to paediatric nephrology via eRS if:

• Non- visible (microscopic) haematuria with elevated protein:creatinine ratio and/or high blood pressure. (? range)
• Non-visible (microscopic) haematuria with persistent haematuria (1+ or above on samples 2-3 weeks apart) and proteinuria (1+ or above) on dipstick test.
• Non - visible (microscopic) haematuria where proteinuria and/or hypertension develops during monitoring or Haematuria persists for 1 year (consider urine calcium/creatinine ratio and urinalysis of parents/siblings)

Referral is not required for:

• Haematuria (visible or non-visible) secondary to UTI which resolves with treatment.
• Haematuria (visible or non-visible) after vigorous exercise and no red flags and which resolves on repeat urine dip (? within 24 hours)
• Isolated non-visible (microscopic) haematuria without elevated protein:creatinine ratio or high blood pressure.
• Isolated non-visible (microscopic) haematuria/proteinuria that resolves on repeat test 2-3 weeks apart.

Red Flags

Visible (macroscopic) haematuria associated with trauma - refer to paediatric ED.

Visible (macroscopic) haematuria confirmed on dipstick test and/or microscopy where UTI or trauma has been excluded - refer to paediatric 2WW.

Palpable abdominal mass or unexplained enlarged abdominal organ (with or without haematuria)- refer to paediatric 2WW.

Before Referral

Confirm haematuria with dipstick and/or microscopy.

Non-haematuria causes of red urine include:

• Food - Beetroot, food dyes, berries containing anthocyanins like blueberries or raspberries  - dipstick negative
• Drugs- Metronidazole, nitrofurantoin, doxorubicin, rifampicin - dipstick negative.
• Metabolites - e.g. porphyrins, urate crystals, tyrosinosis
• Haemoglobin due to heamolysis - dipstick positive, microscopy negative.
• Myoglobin due to rhabdomyolysis - dipstick positive, microscopy negative

If no red flags then investigate and refer as appropriate:

• Examination - Weight and height, Temperature, Abominal exam for masses or tenderness of renal angles, External genetalia for other sources of blood,  Oedema, Skin rash, Joint swelling.
• Urine dip for protein and send for protein: creatinine ratio if positive.
• Blood pressure - see  the Henoch- Schonlein Purpura paediatric guidelines which includes an appendix on pages 10-11 with normal blood pressure measurements by sex, age and height for children.

If examination and investigations are normal then isolated asymptomatic microscopic haematuria can be monitored in primary care:

• Repeat urinalysis twice 2-3 weeks apart (without exercise).
• If positive but no other indications for referral then check urine and blood pressure every 6 months in the 1st year.
• Refer to paediatric nephrologist if: Proteinuria and/or hypertension develops during monitoring or Haematuria persists for 1 year (consider urine calcium/creatinine ratio and urinalysis of parents/siblings).

Consider requesting the following investigations if appropriate or after discussion with paediatrician:

• Bloods - FBC (and blood film if HUS suspected), U and E, LFT, uric acid, coagulation screen if history of bruising.
• Renal USS- is this appropriate or possible to request in primary care?

In addition if glomerulonephritis suspected consider (should this only on on advice of a paediatrician?):

• Urine calcium/creatinine ratio
• C3, C4
• ASO, Anti DNase B
• ANA, ANCA, Anti-double stranded DNA
• Hb electrophoresis
• Test parents for haematuria

Referral

If indicated then refer via eRS to paediatric nephrology.

There is no formal advice and guidance service for paediatric nephrology but discuss with on call team via BRCH switch if immediate or urgent concerns.

Resources

(1) Haematuria in Children provided by Bristol Royal Hospital for Children

(2) Haematuria, management and investigation in Paediatrics (scot.nhs.uk)

(3) Henoch-Schonlein Purpura (Remedy BNSSG ICB)

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