Current Treatment Options in Pediatrics

, Volume 4, Issue 3, pp 333–349 | Cite as

Management of Hematuria in Children

  • O. N. Ray BignallII
  • Bradley P. Dixon
Urology (P Reddy and B Vanderbrink, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Urology


Purpose of Review

This paper provides a review of the diagnostic evaluation of both microscopic and gross hematuria, as well as an update on the pathogenesis, clinical features, and treatment strategies for several diseases of the kidneys and urinary tract in which hematuria is a prominent finding. The goal is to provide pediatric providers with a framework through which appropriate and expeditious referral to subspecialty care may be made for definitive treatment.

Recent Findings

Although there has been great heterogeneity in published treatment strategies for many causes of hematuria, the Kidney Diseases Improving Global Outcomes (KDIGO) initiative has recently set forth guidelines for glomerular diseases in particular to provide evidence-based strategies for treatment. In addition, recent advances in the understanding of molecular pathogenesis and long-term clinical outcomes for other non-glomerular diseases have led to updates in treatment strategies summarized in this review.


As the pediatric primary care provider is often the first point of contact for children with microscopic or gross hematuria, updated knowledge as to the epidemiology and management of several of the various causes of hematuria will improve the care of children by both avoiding extraneous testing and interventions and implementing definitive care (either by expectant management and reassurance or by subspecialty referral) in a timely manner.


Microscopic hematuria Gross hematuria Glomerular diseases Structural renal disease 


Compliance with Ethical Standards

Conflict of Interest

O. N. Ray Bignall II and Bradley P. Dixon declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Dodge WF, West EF, Smith EH, Bunce H. Proteinuria and hematuria in schoolchildren: epidemiology and early natural history. J Pediatr. 1976;88(2):327–47.CrossRefPubMedGoogle Scholar
  2. 2.
    Vehaskari VM, Rapola J, Koskimies O, Savilahti E, Vilska J, Hallman N. Microscopic hematuria in schoolchildren: epidemiology and clinicopathologic evaluation. J Pediatr. 1979;95(5):676–84.CrossRefPubMedGoogle Scholar
  3. 3.
    Massengill SF. Hematuria. Pediatr Rev. 2008;29(10):342–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Yap H, Lau P. Hematuria and proteinuria. Second ed. Pediatric Kidney Disease. Springer; 2016.Google Scholar
  5. 5.
    Ingelfinger JR, Davis AE, Grupe WE. Frequency and etiology of gross hematuria in a general pediatric setting. Pediatrics. 1977;59(4):557–61.PubMedGoogle Scholar
  6. 6.
    Mazouz B, Almagor M. False-positive microhematuria in dipsticks urinalysis caused by the presence of semen in urine. Clin Biochem. 2003;36(3):229–31.CrossRefPubMedGoogle Scholar
  7. 7.
    Grossfeld GD, Litwin MS, Wolf JS Jr, Hricak H, Shuler CL, Agerter DC, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—part I: definition, detection, prevalence, and etiology 1. Urology. 2001;57(4):599–603.CrossRefPubMedGoogle Scholar
  8. 8.
    Simerville JA, Maxted WC, Pahira JJ. Urinalysis: a comprehensive review. Am Fam Physician. 2005;71(6):1153–62.PubMedGoogle Scholar
  9. 9.
    Pearcy RM, Mitchell SC, Smith RL. Beetroot and red urine. Portland Press Limited; 1992.Google Scholar
  10. 10.
    Patel HP, Bissler JJ. Hematuria in children. Pediatr Clin. 2001;48(6):1519–37.CrossRefGoogle Scholar
  11. 11.
    Greenfield SP, Williot P, Kaplan D. Gross hematuria in children: a ten-year review. Urology. 2007;69(1):166–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Jackson EC. Urinary tract infections in children: knowledge updates and a salute to the future. Pediatr Rev. 2015;36(4):153–64. quiz 65–6CrossRefPubMedGoogle Scholar
  13. 13.
    Asghar M, Ahmed K, Shah S, Siddique M, Dasgupta P, Khan M. Renal vein thrombosis. Eur J Vasc Endovasc Surg. 2007;34(2):217–23.CrossRefPubMedGoogle Scholar
  14. 14.
    Siddiqui WJ, Bakar A, Aslam M, Arif H, Bianco BA, Trebelev AE, et al. Left renal vein compression syndrome: cracking the nut of clinical dilemmas–three cases and review of literature. Am J Case Rep. 2017;18:754–9.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Ananthan K, Onida S, Davies A. Nutcracker syndrome: an update on current diagnostic criteria and management guidelines. Eur J Vasc Endovasc Surg. 2017;53:886–94.CrossRefPubMedGoogle Scholar
  16. 16.
    Raghavan R, Eknoyan G. Acute interstitial nephritis—a reappraisal and update. Clin Nephrol. 2014;82(3):149–62.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    West CD. Asymptomatic hematuria and proteinuria in children: causes and appropriate diagnostic studies. J Pediatr. 1976;89(2):173–82.CrossRefPubMedGoogle Scholar
  18. 18.
    Meyers KE. Evaluation of hematuria in children. Urol Clin N Am. 2004;31(3):559–73.CrossRefGoogle Scholar
  19. 19.
    Yap H, Quek C, Shen Q, Joshi V, Chia K. Role of urinary screening programmes in children in the prevention of chronic kidney disease. Ann Acad Med Singap. 2005;34(1):3–7.PubMedGoogle Scholar
  20. 20.
    Murakami M, Yamamoto H, Ueda Y, Murakami K, Yamauchi K. Urinary screening of elementary and junior high-school children over a 13-year period in Tokyo. Pediatr Nephrol. 1991;5(1):50–3.CrossRefPubMedGoogle Scholar
  21. 21.
    Davin J-C, Coppo R. Henoch–Schönlein purpura nephritis in children. Nat Rev Nephrol. 2014;10(10):563–73.CrossRefPubMedGoogle Scholar
  22. 22.
    Lehman TJ. A practical guide to systemic lupus erythematosus. Pediatr Clin N Am. 1995;42(5):1223–38.CrossRefGoogle Scholar
  23. 23.
    Kruegel J, Rubel D, Gross O. Alport syndrome—insights from basic and clinical research. Nat Rev Nephrol. 2013;9(3):170–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Kashtan CE. Alport syndrome and thin glomerular basement membrane disease. J Am Soc Nephrol. 1998;9(9):1736–50.PubMedGoogle Scholar
  25. 25.
    Nath KA, Hebbel RP. Sickle cell disease: renal manifestations and mechanisms. Nat Rev Nephrol. 2015;11(3):161–71.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Fogazzi GB, Edefonti A, Garigali G, Giani M, Zolin A, Raimondi S, et al. Urine erythrocyte morphology in patients with microscopic haematuria caused by a glomerulopathy. Pediatr Nephrol. 2008;23(7):1093–100.CrossRefPubMedGoogle Scholar
  27. 27.
    Omoloja AA, Patel H, Ey E, Jackson E. Common renal problems in pediatric medicine. Curr Probl Pediatr Adolesc Health Care. 2007;37(5):153–94.Google Scholar
  28. 28.
    •• Hernandez JD, Ellison JS, Lendvay TS. Current trends, evaluation, and management of pediatric nephrolithiasis. JAMA Pediatr. 2015;169(10):964–70. This recent review provides a comprehensive update on the epidemiology, metabolic evaluation, and management of nephrolithasis in children.CrossRefPubMedGoogle Scholar
  29. 29.
    Tasian GE, Ross ME, Song L, Sas DJ, Keren R, Denburg MR, et al. Annual incidence of nephrolithiasis among children and adults in South Carolina from 1997 to 2012. Clin J Am Soc Nephrol. 2016;11(3):488–96.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Claes DJ, Jackson E. Cystinuria: mechanisms and management. Pediatr Nephrol. 2012;27(11):2031–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Copelovitch L. Urolithiasis in children: medical approach. Pediatr Clin. 2012;59(4):881–96.CrossRefGoogle Scholar
  32. 32.
    Evan AP. Physiopathology and etiology of stone formation in the kidney and the urinary tract. Pediatr Nephrol. 2010;25(5):831–41.CrossRefPubMedGoogle Scholar
  33. 33.
    Teichman JM. Acute renal colic from ureteral calculus. N Engl J Med. 2004;350(7):684–93.CrossRefPubMedGoogle Scholar
  34. 34.
    Borghi L, Schianchi T, Meschi T, Guerra A, Allegri F, Maggiore U, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med. 2002;346(2):77–84.CrossRefPubMedGoogle Scholar
  35. 35.
    Srivastava A, Patel N. Autosomal dominant polycystic kidney disease. Am Fam Physician. 2014;90(5).Google Scholar
  36. 36.
    Malkan AD, Loh A, Bahrami A, Navid F, Coleman J, Green DM, et al. An approach to renal masses in pediatrics. Pediatrics. 2015;135(1):142–58.CrossRefPubMedGoogle Scholar
  37. 37.
    Howlader N, Noone A, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975–2010, National Cancer Institute. Bethesda, MD,, based on November 2012 SEER data submission, posted to the SEER web site, April 2013.
  38. 38.
    Fischbach BV, Trout KL, Lewis J, Luis CA, Sika M. WAGR syndrome: a clinical review of 54 cases. Pediatrics. 2005;116(4):984–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Castellino SM, McLean TW. Pediatric genitourinary tumors. Curr Opin Oncol. 2007;19(3):248–53.CrossRefPubMedGoogle Scholar
  40. 40.
    Weis SM, Cheresh DA. Tumor angiogenesis: molecular pathways and therapeutic targets. Nat Med. 2011;17(11):1359–70.CrossRefPubMedGoogle Scholar
  41. 41.
    Escobar MA. Bleeding in the patient with a malignancy. Cancer. 2012;118(2):312–20.CrossRefPubMedGoogle Scholar
  42. 42.
    O’Connor OJ, McSweeney SE, Maher MM. Imaging of hematuria. Radiol Clin N Am. 2008;46(1):113–32.CrossRefPubMedGoogle Scholar
  43. 43.
    Fallat M, Hutter J. American Academy of Pediatrics section on hematology oncology, American Academy of Pediatrics section on surgery. Preservation of fertility in pediatric and adolescent patients with cancer. Pediatrics. 2008;121(5):e1461–9.CrossRefPubMedGoogle Scholar
  44. 44.
    Becker AM. Sickle cell nephropathy: challenging the conventional wisdom. Pediatr Nephrol. 2011;26(12):2099–109.CrossRefPubMedGoogle Scholar
  45. 45.
    Pham P-TT, Pham P-CT, Wilkinson AH, Lew SQ. Renal abnormalities in sickle cell disease. Kidney Int. 2000;57(1):1–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Naik RP, Derebail VK. The spectrum of sickle hemoglobin-related nephropathy: from sickle cell disease to sickle trait. Expert Rev Hematol. 2017;10(12):1087–94.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Alves FR, FdAQ R. Revision about hearing loss in the Alport’s syndrome, analyzing the clinical, genetic and bio-molecular aspects. Rev Bras Otorrinolaringol. 2005;71(6):813–9.CrossRefGoogle Scholar
  48. 48.
    Kashtan CE. Alport syndrome and thin basement membrane nephropathy. 2001 Aug 28 [Updated 2015 Nov 25]. In: Adam MP AH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993–2018. Available from:
  49. 49.
    Mehta L, Jim B, editors. Hereditary renal diseases. Semin Nephrol; 2017: Elsevier.Google Scholar
  50. 50.
    Tarr PI, Gordon CA, Chandler WL. Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome. Lancet. 2005;365(9464):1073–86.PubMedGoogle Scholar
  51. 51.
    Garg AX, Suri RS, Barrowman N, Rehman F, Matsell D, Rosas-Arellano MP, et al. Long-term renal prognosis of diarrhea-associated hemolytic uremic syndrome: a systematic review, meta-analysis, and meta-regression. JAMA. 2003;290(10):1360–70.CrossRefPubMedGoogle Scholar
  52. 52.
    Scheiring J, Andreoli SP, Zimmerhackl LB. Treatment and outcome of Shiga-toxin-associated hemolytic uremic syndrome (HUS). Pediatr Nephrol. 2008;23(10):1749–60.CrossRefPubMedGoogle Scholar
  53. 53.
    Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin N Am. 2006;53(3):379–400.CrossRefGoogle Scholar
  54. 54.
    Boeckh M, Erard V, Zerr D, Englund J. Emerging viral infections after hematopoietic cell transplantation. Pediatr Transplant. 2005;9(s7):48–54.CrossRefPubMedGoogle Scholar
  55. 55.
    Mufson MA, Belshe RB, Horrigan TJ, Zollar LM. Cause of acute hemorrhagic cystitis in children. Am J Dis Child. 1973;126(5):605–9.PubMedGoogle Scholar
  56. 56.
    Mulvey MA. Adhesion and entry of uropathogenic Escherichia coli. Cell Microbiol. 2002;4(5):257–71.CrossRefPubMedGoogle Scholar
  57. 57.
    Semeniuk H, Church D. Evaluation of the leukocyte esterase and nitrite urine dipstick screening tests for detection of bacteriuria in women with suspected uncomplicated urinary tract infections. J Clin Microbiol. 1999;37(9):3051–2.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Meglič A, Čavić M, Hren-Vencelj H, Tršinar B, Ravnik M, Kenda R. Chlamydial infection of the urinary tract in children and adolescents with hematuria. Pediatr Nephrol. 2000;15(1–2):132–3.PubMedGoogle Scholar
  59. 59.
    Gauthier M, Gouin S, Phan V, Gravel J. Association of malodorous urine with urinary tract infection in children aged 1 to 36 months. Pediatrics. 2012;129(5):885–90.CrossRefPubMedGoogle Scholar
  60. 60.
    Brandström P, Esbjörner E, Herthelius M, Swerkersson S, Jodal U, Hansson S. The Swedish reflux trial in children: III. Urinary tract infection pattern. J Urol. 2010;184(1):286–91.CrossRefPubMedGoogle Scholar
  61. 61.
    Investigators RT. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370(25):2367–76.CrossRefGoogle Scholar
  62. 62.
    Ahn S-Y, Ingulli E. Acute poststreptococcal glomerulonephritis: an update. Curr Opin Pediatr. 2008;20(2):157–62.CrossRefPubMedGoogle Scholar
  63. 63.
    Eison TM, Ault BH, Jones DP, Chesney RW, Wyatt RJ. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol. 2011;26(2):165–80.CrossRefPubMedGoogle Scholar
  64. 64.
    Kanjanabuch T, Kittikowit W, Eiam-Ong S. An update on acute postinfectious glomerulonephritis worldwide. Nat Rev Nephrol. 2009;5(5):259–69.CrossRefPubMedGoogle Scholar
  65. 65.
    Sjöholm AG. Complement components and complement activation in acute poststreptococcal glomerulonephritis. Int Arch Allergy Immunol. 1979;58(3):274–84.CrossRefGoogle Scholar
  66. 66.
    Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrol. 2008;19(10):1855–64.CrossRefPubMedGoogle Scholar
  67. 67.
    Zoch-Zwierz W, Wasilewska A, Biernacka A, Tomaszewska B, Winiecka W, Wierciński R, et al. The course of post-streptococcal glomerulonephritis depending on methods of treatment for the preceding respiratory tract infection. Wiad Lek. 2001;54(1–2):56–63.Google Scholar
  68. 68.
    Roy S, Murphy WM, Arant BS. Poststreptococcal crescenteric glomerulonephritis in children: comparison of quintuple therapy versus supportive care. J Pediatr. 1981;98(3):403–10.CrossRefPubMedGoogle Scholar
  69. 69.
    Wong W, Morris MC, Zwi J. Outcome of severe acute post-streptococcal glomerulonephritis in New Zealand children. Pediatr Nephrol. 2009;24(5):1021–6.CrossRefPubMedGoogle Scholar
  70. 70.
    Coppo R, editor. Pediatric IgA nephropathy: clinical and therapeutic perspectives. Semin Nephrol; 2008: Elsevier.Google Scholar
  71. 71.
    Yuzawa Y, Yamamoto R, Takahashi K, Katafuchi R, Tomita M, Fujigaki Y, et al. Evidence-based clinical practice guidelines for IgA nephropathy 2014. Clin Exp Nephrol. 2016;20(4):511–35.CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Tomino Y, Suzuki S, Imai H, Saito T, Kawamura T, Yorioka N, et al. Measurement of serum IgA and C3 may predict the diagnosis of patients with IgA nephropathy prior to renal biopsy. J Clin Lab Anal. 2000;14(5):220–3.CrossRefPubMedGoogle Scholar
  73. 73.
    Cattran DC, Coppo R, Cook HT, Feehally J, Roberts IS, Troyanov S, et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int. 2009;76(5):534–45.CrossRefPubMedGoogle Scholar
  74. 74.
    • Trimarchi H, Barratt J, Cattran DC, Cook HT, Coppo R, Haas M, et al. Oxford classification of IgA nephropathy 2016: an update from the IgA nephropathy classification working group. Kidney Int. 2017;91(5):1014–21. This article adds new understanding as to the implications of histopathological characteristics in IgA nephropathy, specifially the prognostic significance of crescentic disease.CrossRefPubMedGoogle Scholar
  75. 75.
    Xu K, Zhang L, Ding J, Wang S, Su B, Xiao H et al. Value of the Oxford classification of IgA nephropathy in children with Henoch–Schönlein purpura nephritis. J Nephrol. 2017:1–8.Google Scholar
  76. 76.
    •• Cattran DC, Feehally J, Cook HT, Liu ZH, Fervenza FC, Mezzano SA, et al. Kidney disease: improving global outcomes (KDIGO) glomerulonephritis work group. KDIGO clinical practice guideline for glomerulonephritis. Kidney Int Suppl. 2012;2(2):139–274. This set of practice guidelines describes the evidence-based consensus guidelines for diagnostic evaluation and treatment of several forms of glomerulonephritis with additional pediatric-focused recommendations.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Nephrology and HypertensionCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  2. 2.Renal Section, Department of PediatricsUniversity of Colorado School of MedicineAuroraUSA

Personalised recommendations