What is the treatment for microscopic hematuria in a 13-year-old?

Management of Microscopic Hematuria in a 13-Year-Old

For a 13-year-old with microscopic hematuria, the initial approach should focus on determining the cause through targeted evaluation, with most cases requiring clinical follow-up rather than extensive intervention, as isolated microscopic hematuria in children is often benign and rarely requires specific treatment. 1

Initial Evaluation

• Confirm true microscopic hematuria by verifying ≥5 red blood cells per high-power field in 2-3 consecutive urine specimens, as dipstick positivity alone is insufficient 1
• Investigate factitious causes of "hematuria" such as food substances or medications that may color the urine without actual red blood cells 1
• Assess for proteinuria, which if present (>2+ by dipstick) suggests glomerular disease and requires more extensive evaluation 1
• Evaluate for hypercalciuria with a spot urine calcium-to-creatinine ratio, as this is a common cause of microscopic hematuria in children 1
• Obtain urine culture to rule out urinary tract infection, which would direct care differently 1

Clinical Assessment

• Obtain thorough history focusing on:

  • Family history of stone disease, hearing loss, or familial renal disease 1
  • History of trauma, recent viral illness, or hypertension 1, 2
  • Medication use that could affect urine color 1

• Physical examination should assess for:

  • Height and weight to evaluate growth 1
  • Blood pressure to screen for hypertension 1, 2
  • Presence of edema, rashes, or arthritis that might suggest systemic disease 1

Laboratory Testing

• Basic laboratory screening should include:
  • Urinalysis with microscopic examination to assess for dysmorphic RBCs or red cell casts (suggesting glomerular source) 1, 2
  • Serum creatinine and blood urea nitrogen to assess kidney function 1
  • Complete blood count with platelets 1

Diagnostic Algorithm Based on Initial Findings

For Isolated Microscopic Hematuria Without Proteinuria:

• Clinical follow-up is recommended without immediate imaging, as these patients are unlikely to have clinically significant renal disease 1
• Family screening may be useful to identify benign familial hematuria, including thin basement membrane nephropathy 1

For Microscopic Hematuria With Proteinuria or Other Concerning Features:

• More extensive evaluation is warranted, including:
  • Renal ultrasound to assess kidney size and structure 1
  • Consideration of audiogram and slit lamp examination if Alport syndrome is suspected 1
  • Advanced medical assessment for glomerulonephritis and vasculitis if suggested by clinical findings 1
  • Possible nephrology referral for consideration of renal biopsy 1, 3

Common Causes in Children

• Thin basement membrane nephropathy (most common cause of persistent microscopic hematuria) 1, 3
• IgA nephropathy (Berger disease) 1, 3
• Idiopathic hypercalciuria 1, 3
• Postinfectious glomerulonephritis 4, 3

Follow-up Recommendations

• For persistent unexplained microscopic hematuria without proteinuria:
  • Periodic urinalysis to monitor for development of proteinuria 2
  • Blood pressure monitoring 2
  • Consider renal ultrasound if hematuria persists to evaluate for occult anatomic abnormalities, though yield is low 1

Important Caveats

• Isolated microscopic hematuria in children has a much lower risk of significant urologic disease compared to adults, particularly those over 40 1
• The presence of dysmorphic red blood cells and red cell casts strongly suggests glomerular disease and warrants nephrology referral 2, 4
• CT imaging is not appropriate in the initial evaluation of isolated microscopic hematuria without proteinuria in children 1
• Most children with isolated microscopic hematuria have a benign course and do not require extensive workup 1, 5