Red Urine

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Red Urine a mystery

• Shaila Sukthankar

2
Haematuria

• Common presenting symptom of renal tract
  disorders
• Prevalence 0.5 - 6 on population screening in
  children

3
Haematuria - Definition

• Urine microscopy
• RBC gt 5/uL in a fresh uncentrifuged specimen
• RBC gt 5 -10/high power field in a midstream
  sample
• RBC morphology presence of casts

4
Case Presentation - May 09

• 5 years, male
• Painless gross haematuria frequent episodes 1
  week
• Initially red, later pink no clots
• No history of
• Fever, dysuria, back/ abdo pain
• rashes, joint pains
• Swelling
• Trauma
• Bleeding diathesis
• Recent medication
• No family h/o renal disease/ deafness/ renal
  stones/ haematuria
• Tonsillitis 6 weeks before

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Examination

• Normal vitals, BP 110/68, apyrexial
• No pallor or oedema
• No bruises or rash
• Systems review NAD
• ENT normal

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Macroscopic haematuria with no features of
glomerulonephritis

• Painless
• IgA nephropathy
• Benign familial nephropathy/ Alports syndrome
• Exercise induced
• Coagulopathy
• Painful
• Infection
• Trauma
• Malignancy

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Haematuria with features of glomerulonephritis

• Primary renal diseases
• IgA nephropathy
• MPGN 1 and 2
• Anti GBM disease
• Secondary renal diseases
• Postinfectious GN
• HSP nephritis
• SLE

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Initial Investigations

• FBC, coagulation normal
• Urea 6.5, creatinine 40, Albumin 46
• Electrolytes, bone profile normal
• crp lt3
• Urine microscopy (X2) - lt10 WCC, 50-100 RBC, no
  bacterial growth, trace to 1 proteinuria
• Renal USS - NAD

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Subsequent Investigations

• C3 and C4 normal
• ANA, dsDNA negative
• Immunoglobulins normal
• ASOT 100 U/mL
• antiDNASe B 600 U/mL
• Urine calcium/ creatinine ratio 0.45
• Intermittent 3 blood on dipstick, no proteinuria
  and well with normal BP over next 4 weeks

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Urine dipstick

• Useful screening tool
• Very sensitive

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Haematuria - Diagnosis

• Do not use urine dipstick to diagnose haematuria

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12 weeks later (Aug 09)

• Recurrence of painless gross haematuria for 1
  week
• Always towards the end of the day
• Clear in the morning
• Bright red or cola coloured in the evening
• Worse with exercise and vigorous activity
• Some discomfort with micturition
• No other significant positive history
• Urine microscopy confirmed RBCs in some but not
  all red urine samples

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Causes of red or pink urine

• Haemoglobinuria
• Myoglobinuria
• Porphyrins
• Urates (pink)
• Foods beetroot, blackberries
• Drugs
• Rifampicin (orange)
• Chloroquine, desferoxamine

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Possibilities - 1

• Recurrent gross haematuria - ? Alports/ IgA
  nephropathy/ thin basement membrane disease
• ? Bladder pathology (polyp, interstitial
  cystitis)
• Exercise induced haematuria
• ? Not blood (Hburia or myoglobinuria)
• ? Renal AV malformation

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Management

• Repeat haematology, biochemistry and immunology
  normal
• Presence of blood without RBCs on some urine
  samples
• Myoglobin screen positive on one occasion
• No infection
• MR renal angiogram (limited views) normal
• Cystoscopy NAD
• Family members urine microscopy NAD
• Review by haematology no e/o intravascular
  hemolysis
• Intermittent painless asymptomatic gross
  haematuria continues

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Possibilities - 2

• Exercise induced haematuria exercise test with
  urine microscopy before and after
• Nutcracker syndrome Repeat MR/ direct renal
  angiogram under GA parents not keen for further
  invasive procedures/ GA
• Evolving nephropathy (IgA/ Alports/ TBM) no
  indication for biopsy as asymptomatic,
  normotensive, no proteinuria and normal renal
  function

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Nutcracker syndrome

• Compression of L renal vein between the aorta and
  sup mesentric artery
• 40 of children with unexplained haematuria

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Investigations in a child with haematuria

• Urine microscopy and culture
• Urine protein creatinine ratio
• FBC, coagulation
• UE, creatinine, albumin
• Urine calcium creatinine ratio
• ASOT, C3 and C4
• US renal tract

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Haematuria - Indications for renal biopsy

• Associated proteinuria
• Persistent low C3
• Impaired renal function
• Systemic disease with proteinuria
• SLE, HSP, ANCA associated vasculitis
• Family history suggestive of Alports syndrome
• Recurrent gross haematuria of unknown aetiology
  with extreme parental anxieties

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Haematuria - cystoscopy

• Seldom useful
• Consider
• Negative preliminary investigations
• Suspected bladder or urethral pathology
• Vascular malformations
• Bladder mass on US
• To lateralise the source of bleeding

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Progress June 10 (12 months on)

• Well
• Normally active
• Occasional brown urine (once in 2-3 months)
• Lasts for a day, resolves spontaneously
• Occurs with activity
• Occurs towards the end of the day
• Normotensive
• Parents and child opted for non-invasive
  observation for now

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Haematuria - Summary

• In the absence of proteinuria is not usually
  indicative of serious pathology
• Investigation are to be guided by presentation
  and likely diagnosis
• In asymptomatic children, ensure serious
  conditions are not missed and guidelines for
  further investigations are in place if change in
  clinical course

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Latest update (March 11)

• Well until 3 weeks before review!
• Febrile coryzal illness with sore throat and
  recurrence of haematuria
• Initially bright red, subsequently cola coloured
• Lasted for 7-10 days, progressively cleared over
  2-3 days thereafter
• Asymptomatic (no headaches, oedema, oliguria etc)
• DID NOT SEE GP, COMMUNITY NURSES OR HOSPITAL TEAM
• When attended clinic, back to normal self, urine
  NAD!!
• Repeat haematology, biochemistry and immunology
  normal.
• ????