HEMATURIA

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HEMATURIA

• Leyi Gu
• Renal Division, Renji Hospital

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CASE

• An otherwise healthy 48-year-old woman
  is found to have microscopic hematuria (5 red
  cells per high-power field) on a urinalysis
  performed by a life insurance company. No other
  laboratory abnormalities are identified the
  serum creatinine concentration is 0.8 mg per
  deciliter (70.7 µmol per liter). The woman
  reports no symptoms and is a nonsmoker. Her blood
  pressure is 118/74 mm Hg, and the findings on
  physical examination are normal. How should she
  be evaluated?

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According to the amount of RBC in the urine,
hematuria can be classified as

• microscopic hematuria
• normal colour with eyes
• gross hematuria
• tea-colored, cola-colored, pink or
• even red

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DEFINITION

• More than three red blood cells are found in
• centrifuged urine per high-power field microscopy
  ( gt 3 RBC/HP).

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ETIOLOGY

• Diseases of the urinary systemthe most common
  cause
• Vascular
• arteriovenous malformation
• arterial emboli or thrombosis
• arteriovenous fistular
• nutcracker syndrome
• renal vein thrombosis
• loin-pain hematuria syndrom
• coagulation abnormality
• excessive anticoagulation

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• Glomerular
• IgA nehropathy
• thin basement membrane disease (Alport
  syndrome)
• other causes of primary and secondary
  glomerulonephritis
• Interstitial
• allergic interstitial nephritis
• analgesic nephropathy
• renal cystic diseases
• acute pyelonephritis (??????)
• tuberculosis (???)
• renal allograft rejection (?????)

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• Uroepithelium
• malignancy
• vigorous excise
• trauma
• papillary necrosis (?????)
• cystitis/urethritis/prostatitis (usually
  caused by infection)
• parasitic diseases (e.g. schistosomiasis,????)
  
• nephrolithiasis or bladder calculi (???,????)
• Multiple sites or source unknown
• hypercalciuria

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• System disorders
• a. Hematological disorders
• aplastic anemia
  leukemia(???)
• allergic purpura(?????) hemophilia(???)
• ITP (idiopathy thrombocytopenic purpura)
• b. Infection
• infective endocarditis
• septicemia (???)
• epidemic hemorrhagic fever (??????,Hantaan
  virus)
• scarlet fever (???,?-hemolytic
  streptococcus)
• leptospirosis (????,leptospire)
• filariasis (???,Wuchereria bancrofti,
  Brugia malayi)

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• c. Connective tissue diseases
• systemic lupus erythematosus (SLE,???????)
• polyarteritis nodosa (???????)
• d. Cariovascular diseases
• hypertensive nephropathy
• chronic heart failure
• renal artery sclerosis
• e. Endocrine and metabolism diseases
• gout (??)
• diabetes mellitus

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• Diseases of adjacent organs to urinary tract
• appendicitis (???) salpingitis (????)
• carcinoma of the rectum (????)
• carcinoma of the colon (????)
• uterocervical cancer
• Drug and chemical agents
• sulfanilamides (??) anticoagulation
• cyclophosphamide (CTX) mannitol(???)
• miscellaneous
• exercise idopathic hematuria

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• Important questions to ask in patients History
• Has there been any signs of a UTI such as dysuria
  and frequency? Any suprapubic pain?
• Has there been any recent URI symptoms or sore
  throat?
• Has there been any type of skin rashes or sores?
• Any abdominal pain or colicky pain?
• Are the stools loose or bloody?
• Has there been any recent trauma?
• Has there been any joint pains or swellings?
• Is there any history of sickle cell disease or
  trait?
• Is there any family history of renal disease,
  transplants, or dialysis? Is there a family
  history of hearing deficits?
• What medications does the child take?

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• Important areas to check on the physical
  examination
• Blood Pressure
• Check for edema, especially around the eyes
• Careful inspection of the external genitalia 
• Look for any rashes, evidence of trauma and
  bruising, petechiae
• Exam all joints for signs of arthritis-red, warm,
  or swollen
• Feel the abdomen carefully for any masses or
  tenderness. Check for CVA tenderness. Try to feel
  for enlarged kidneys.
• Check for evidence of paleness or jaundice
• Accurately measure length and weight and plot on
  growth chart.

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CLINICAL FEATURE

• Color
• depends on the amount of red blood cell in the
  urine and the pH
• normal light yellow, pH 6.5
• pH
• acidic more darker (brown or black)
• alkaline red

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Red casts and red cells in urine
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DIFFERENTIAL DIAGNOSIS

• Polluted urine menstruation
• Drug and food uric acid, vegetable
• Porphyrism(???) porphyrin in urine ()
• Hemoglobinuria
• hemolysis
• soy-like, very few RBC under the microscopy
• occult blood test ()

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HEMOGLOBINURIA

• RBC abnormality
• Defects of RBC membrane structure and function
  (hereditary spherocytosis)
• Deficiency of enzymes (favism)
• Hemoglobinopathy (thalassemia)
• PNH
• Mechanical factor (artificial heart valve),
  infection
• or mismatched blood transfusion

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LABORATORY TESTS

• Three-glass test
• Method collecting the three stages of urine of
• a patient during micturition
• Result
• the initial specimen containing RBCthe urethra
• the last specimen containing RBCthe bladder
• neck and trianglar area, posturethra
• all the specimens containing RBCupper urinary
• tract, bladder

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• Phase-contrast microscopy
• to distinguish glomerular from post
  glomerular bleeding
• post glomerular bleeding normal size and shape
  of RBC
• glomerular bleeding dysmorphic RBC (acanthocyte)

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EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST
(non-glomerlar)
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EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST
(glomerlar)
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ACCOMPANIED SYMPTOMS

• Hematuria with renal colic
• renal stone, ureter stone
• if with dysuria, pause or staining to void
  bladder or urethra stone
• Hematuria with urinary frequency, urgency and
  dysuria
• bladder or lower urinary tract (tuberculosis
  or tumor)
• if accompanied by high spiking fever, chill
  and loin pain pyelonephritis

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• Hematuria with edema and hypertension
• glomerulonephritis
• hypertensive nephropathy
• Hematuria with mass in the kidney
• neoplasm
• hereditary polycystic kidney
• Hematuria with hemorrhage in skin and mucosa
• hematological disorders
• infectious diseases
• Hematuria with chyluria
• filariasis(???)

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Evaluation of microscopic hematuria
NEJM, 2003
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--Approaching to the patient (Harrisons
Principle of Internal Medicine,14th Ed)
HEMATURIA
proteinuria (gt500mg/24h) Dysmorphic RBC or RBC
casts
(-)
()
()
Pyuria,WBC casts
urine culture eosinophils
serologic and hematologic evaluation blood
culture, anti-GBM Ab, ANCA, complement,
cryoglobulin HBV,HCV,VDRL,HIV, ASLO
(-)
Hb electrophoresis, urine cytology, UA of family
member, 24h urinary calcium/uric acid
As indicated retrograde pyelography or
arteriogram of cyst aspiration
(-)
()
IVP/-renal ultrasound
renal biopsy
(-)
()
cystoscopy
biopsy
(-)
ANCAantineutrophil cytoplasmic antibody,
VDRLvenereal dis. research laboratory, ASLO
antisteptolysin O, IVP intravenous pyelography
CT scan
()
open renal biopsy
(-)
follow
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Thanks for your attention

• Online resource
• National library of Medcine
• www.nlm.nih.gov/medlineplus
• National Kidney Foundation
• www.kidney.org
• Kidney Urology Foundation of America
• www.kidneyurology.org