Causes and diagnostic significance of macroscopic hematuria in children and young adults

Awatef Elbouaeshi; Amna Rayani; Manal Irheem; Elmukhtar Habas

doi:10.4103/LJMS.LJMS_21_17

ORIGINAL ARTICLE

Year : 2017 | Volume : 1 | Issue : 3 | Page : 72-75

Causes and diagnostic significance of macroscopic hematuria in children and young adults

Awatef Elbouaeshi¹, Amna Rayani¹, Manal Irheem¹, Elmukhtar Habas²
¹ Pediatric Hematology and Nephrology Unit, Medical Faculty, Tripoli Pediatric Hospital, Tripoli University, Tripoli, Libya
² Department of Medical, Nephrology Unit, Medical Faculty, Tripoli Central Hospital, Tripoli University, Tripoli, Libya

Date of Web Publication

26-Dec-2017

Correspondence Address:
Dr. Elmukhtar Habas
Medical Faculty, Tripoli Central Hospital, Tripoli University, Tripoli
Libya

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_21_17

Abstract

Background: Hematuria is common complaint brings patients to a physician. Macroscopic hematuria can be transient or persistent, and it may or may not associate with significant urinary system abnormalities. Objective: The objective of this study is to determine the major causes of macroscopic hematuria in ages less 20 years. Patients and Method: Descriptive case series study carrried out as a collaborative study in Tripoli during Januray 2013 - December 2014. Patients who presented with macroscopic hematuria file were studied retrospectively for gender, age, possible associated diseases as glomerulalar diseases, urinary tract infection (UTI), and others. Results: Out of 126 patients had macroscopic hematuria, 107 patients had the required data that achieved the study protocol. They were 72 cases (67.28%) males and 35 cases (32.71%), and their age ranged between (7 and 20 years). Macroscopic hematuria was more frequently reported at the age 7–13 years, and it was reported in (58.87%) due to the glomerular lesion, and in (41.12%) due to nonglomerular cause. Acute poststreptococcal glomerulonephritis (AGN) was the most common cause of macroscopic hematuria (53.27%), UTI was the second cause of macroscopic hematuria (28.97%), and renal stone was (9.34%) of total causes. Macroscopic hematuria due to trauma reported in 3 cases (6.8%), and in 5 cases (2.27%) due to IgA nephropathy. Conclusion: AGN and UTI are common causes of macroscopic hematuria. Urine microscopic examination is essential to differentiate between them before preceding to the other complicated, expensive, and invasive investigations.

Keywords: Acute glomerulonephritis, IgA nephropathy, macroscopic hematuria, urinary tract infection

How to cite this article:
Elbouaeshi A, Rayani A, Irheem M, Habas E. Causes and diagnostic significance of macroscopic hematuria in children and young adults. Libyan J Med Sci 2017;1:72-5

How to cite this URL:
Elbouaeshi A, Rayani A, Irheem M, Habas E. Causes and diagnostic significance of macroscopic hematuria in children and young adults. Libyan J Med Sci [serial online] 2017 [cited 2023 Mar 28];1:72-5. Available from: https://www.ljmsonline.com/text.asp?2017/1/3/72/221494

Introduction

Hematuria is not uncommon presenting complaint in clinical practice. It can be caused by renal, urological, and systemic diseases.^[1],[2] The presence of more than 5–10 red blood cells (RBCs)/high-power field has a significant diagnostic value.^[3],[4] Pyuria is more common in urine routine investigation than hematuria and abdominal pain.^[5] Hematuria without proteinuria does not always indicate nonglomerular origin, and glomerular bleeding is not necessary accompanied by proteinuria.^[6] It is recommended that at least two out of three urine samples analysis must have significant hematuria over 2–3 weeks before further evaluation performed.^[7],[8] Bright-red urine, visible clots, and crystals with normal-looking RBCs by microscopic examination suggest bleeding from the urinary tract rather than from the kidneys. RBC cast and dysmorphic RBCs suggest glomerular damage or disease.^[9] A positive dipstick reaction is not always indicate hematuria, because hemoglobinuria and myoglobinuria may cause positive dipstick reaction.

Hematuria may originate from the glomeruli, renal tubules, and interstitium, or other urinary tract parts.^[10] Other associated features such as hypertension, altered renal function tests, proteinuria, known previous renal problems, renal mass, and distorted RBC in the urine suggest renal origin of hematuria.^[11] Therefore, diagnostic procedures to evaluate the systemic causes of hematuria should be guided by the presence of systemic diseases features and urine macro- and micro-scopic examination findings.^[12]

Up to our knowledge, the most frequent causes of significant macroscopic hematuria was not investigated in Libya in childhood and young adults' age groups. Therefore, this study was conducted to evaluate the diagnostic significance of macroscopic hematuria.

Aim of the study

The aim of this study is to determine the diagnostic significance of macroscopic hematuria in childhood and young adults' age group.

Patients and Methods

This descriptive retrospective collaborative case series study carried out in Tripoli's Children Hospital and Tripoli Central Hospital during January 1, 2013– end of December 2014. It was conducted on all cases presented with macroscopic hematuria as main complaint.

Patients had history of dysuria, frequency, urgency, flank and/or abdominal pain, recent trauma, strenuous exercise, menstruation, or bladder catheterization, sore throat or skin infection within the past 2–4 weeks, history of drugs and toxins, family history of renal diseases, and renal stones were taken from patients follow up notes. Blood pressure and temperature measurement were also collected. Skin rash, arthritis, edema, and abdominal masses were extracted from patients review records. Laboratory investigations as, microscopic urine examination for RBCs, RBC casts, granular casts, RBCs morphology, and serum urea and creatinine levels, complete blood count, serologic testing (complement C3, C4, and antistreptolysin titer (ASOT) were collected from patients follow-up notes. Urine culture results for suspected urinary tract infection (UTI), and renal ultrasonography report were also noted from patients' follow-up records. A kidney biopsy results for 6 patients who had significant proteinuria and history of recurrent macroscopic hematuria.

According to the RBC morphology and the type of the cast, the presence or absence of white blood cells in urine microscopic examination, history of sore throat, or evidence of streptococcal infection indicators as ASOT and results of serum urea and creatinine, the origin of macroscopic hematuria was classified into glomerular and nonglomerular cause.

Statistical analysis

Statistical analysis was done using Statistical Pakage for social and Science, Version 18 (SPSS inc., Chicago III, USA) and Excel Microsoft program were used for data descriptive statistics; frequencies, percentage, and mean analysis.

Results

One hundred and seven patients out of 126 cases who had macroscopic hematuria fulfill the study protocol. They were 72 (67.28%) male and 35 (32.71%) female. Macroscopic hematuria was reported more between ages 7 and 15 years.

According to the underlying cause, patients were classified into glomerular and nonglomerular origin cause of macroscopic hematuria. Glomerular origin of macroscopic hematuria accounted for 63 cases (58.87%) whereas nonglomerular origin of macroscopic hematuria reported in 44 cases (41.12%).

Acute glomerulonephritis (AGN) was the most common cause of macroscopic hematuria of glomerular origin 57 cases (90.47%). UTI was the second cause of macroscopic hematuria in 31 patients (70.45%). Ten patients (22.72%) had macroscopic hematuria due to renal stone. Macroscopic hematuria with history of trauma was reported in 3 cases (6.8%). IgA nephropathy reported in 5 cases (7.93%) of glomerular causes [Table 1].

Table 1: Distribution of the 107 cases of gross hematuria according to the different causes

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AGN with hypertension reported in (23.36%). AGN with edema in lower limbs in (25.23%), red cell cast in urine in (48.59%), increase CRP (42.99%), low C3 (57%), increase urea and creatinine (16.12%), and increase ASOT (29.90%) of patients. Urinary RBC reported in 52 patients (48.59%) of which 81.3% had marked dysmorphic RBC [Table 2].

Table 2: Laboratory results and physical examinations

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Renal ultrasound was performed for 76 patients out of 107 patients revealed mild increases of renal echogenicity in seven patients (9.2%), four patients (5.2%) have stones with variable grades of hydronephrosis. Two patients (2.6%) with UTI and 63 patients (82.8%) had normal ultrasound finding of kidney and urinary system. Dysmorphic RBCs was reported in 81.3% of patients had glomerular origin of hematuria.

Discussion

Macroscopic hematuria can be a presenting complaint of patients has local urinary system pathological lesions or due to systemic diseases. Microscopic and macroscopic hematuria is caused by the kidneys and/or other urinary system parts as ureters, urinary bladder, prostate, urethra, and urethral meatus injuries. Routine urine examination including microscopic urine examination is usually done for most of urinary symptoms, however, there are not significant evidence to support routine screening for microscopic hematuria in general population.^[13] Either microscopic or macroscopic hematuria originates from urinary system parts, or systemic diseases need laboratory investigations, especially in adults to exclude autoimmune diseases and some hematological diseases, in addition, renal biopsy is usually done to detect the glomerular, tubular and the interstitial kidney pathological lesions as in IgA nephropathy. On the other hand, hematuria due to nonglomerular diseases in the urinary system as in ureters, urethra, and urinary bladder does not need renal biopsy, but radiological imaging techniques as ultrasound, CT and MRI urography scanning are more diagnostic.^[14]

The present study was conducted for 107 patients presented with macroscopic hematuria. Poststreptococcal AGN was the most common cause of macroscopic hematuria. The abundance of poststreptococcal AGN as a cause for macroscopic hematuria might be due to that the patients were children and they were young adults. It is well known that poststreptococcal AGN is the most common cause of glomeruli origin of hematuria in these age groups.

IgA nephropathy is due to IgA deposition in the glomerular mesangium.^[15] IgA may progress to end-stage renal disease, and IgA nephropathy is the most common cause of glomerulonephritis worldwide at late childhood and at puberty ages.^{[16],[17],[18]} IgA nephropathy is highly variable in clinical presentation and pathological changes. Clinically, IgA might be presented by asymptomatic micro and macroscopic hematuria or as rapid progressive glomerulonephritis. Acute kidney failure is not unusual in IgA nephropathy although significant number of patients is recovered spontaneously from acute renal failure. IgA nephropathy reported more in males than females (4 patients), and it was more in patients aged more than 17 years of age in the present study. This was reported by earlier conducted study.^[19]

UTI reported as a second cause of macroscopic hematuria in this study. This supported the previous reported data.^[20],[21] Youn et al.^[20] reported that UTI was the most common cause of significant hematuria followed by IgA nephropathy and then Alport's syndrome. AGN was reported much less than our results, and the IgA was more than the present study. The differences between our results and Youn et al. results might be due to early diagnosis and treatment of β-hemolytic streptococcal. A study was conducted in Egypt reported almost the same results reported by the present study.^[21] This concordance between our results and the Egyptian study results could due to the similarities of the environmental, geographical, ethnic origin, and diet habits.

Conclusion

Poststreptococcal GN and IgA nephropathy are the most common cause of macroscopic hematuria that originates from kidneys. UTI is a common cause of macroscopic hematuria that originates from other urinary tract regions. Therefore, careful examination of urine of patients presented with macroscopic hematuria for RBC morphology and cast type are necessary before other invasive investigations.

Acknowledgment

Authors would like to thank all doctors, nurses, and laboratory technicians who helped in collecting the samples and laboratory processing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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