From the Guidelines
The workup for microscopic hematuria in children should begin with a thorough history and physical examination, followed by a stepwise diagnostic approach, with a focus on identifying serious conditions requiring intervention while avoiding unnecessary testing in benign cases, as most isolated microscopic hematuria in children resolves spontaneously or represents non-progressive conditions.
Initial Evaluation
The initial evaluation should include:
- Confirming persistent microscopic hematuria with at least two additional urinalyses over several weeks, as transient hematuria is common and often benign 1
- Initial laboratory evaluation, including:
- Urine culture
- Urine calcium-to-creatinine ratio
- Serum creatinine
- Blood urea nitrogen
- Complete blood count
- Complement C3 and C4 levels
Referral to Pediatric Nephrologist
If the child has proteinuria, hypertension, or abnormal renal function, refer promptly to a pediatric nephrologist 1.
Imaging Evaluation
For isolated microscopic hematuria with normal renal function, obtain a renal ultrasound to evaluate for structural abnormalities 1.
Family History and Genetic Testing
Family history is crucial as conditions like Alport syndrome, thin basement membrane nephropathy, and polycystic kidney disease have genetic components. If first-degree relatives have hematuria, consider genetic testing 1.
Dietary Modification
In cases with hypercalciuria, dietary modification with reduced sodium intake and normal calcium consumption is recommended 1.
Prognosis and Monitoring
Most children with isolated microscopic hematuria have excellent prognosis and require only periodic monitoring of blood pressure, urinalysis, and renal function 1.
Traumatic Hematuria
In cases of traumatic hematuria, the approach may differ, with a focus on identifying significant renal injuries, and imaging evaluation may be indicated in certain cases, such as macroscopic hematuria or concern for visceral trauma 1.
From the Research
Evaluation Approach
The approach to evaluating microscopic hematuria in pediatric patients involves a stepwise process to determine the underlying cause.
- The initial evaluation should include a personal and family history, physical examination, and blood pressure determination 2.
- Laboratory tests, such as urine culture, urine calcium-to-creatinine ratio, and renal and bladder sonography, may be necessary in some cases 3.
- The presence of proteinuria, hypertension, or other signs of systemic disease may require a more detailed evaluation, including renal biopsy 4, 5.
Diagnostic Considerations
The differential diagnosis of microscopic hematuria in children is extensive and includes:
- Urologic issues, such as kidney stones or structural abnormalities 6, 3
- Glomerular diseases, including disorders of the glomerular basement membrane 6
- Hematologic abnormalities 6
- Hypercalciuria, which is a common cause of microscopic hematuria in children 2, 4
- Post-streptococcal glomerulonephritis, which can cause hematuria and proteinuria 2, 4
Management
The management of microscopic hematuria in pediatric patients depends on the underlying cause and the presence of other symptoms or signs of disease.
- Children with isolated microscopic hematuria can generally be followed after baseline evaluation to rule out infection, hypercalciuria, and structural abnormalities 4, 5.
- Children with gross hematuria or those with microscopic hematuria and proteinuria require a more thorough diagnostic evaluation, including renal biopsy in some cases 2, 4.