B/11. Hematuria Flashcards
Microscopic
hematuria detected by
Detected by urine dipstick
or
urine microscopy (>3-5 RBC per HPF)
Microscopic
hematuria suggests
Most commonly suggests intrinsic renal disease
(glomerular hematuria)
Macroscopic
hematuria def
Red or brown urine visible by
naked eyes
Macroscopic
hematuria source
Most commonly suggests
postrenal source in the
urinary collecting system (non-glomerular hematuria)
is red urine equal to hematuria?
NO
neg dipstick, neg urine sediment
= mimics of hematuria (drugs, food)
+dipstick, -urine sediment =
myoglobinuria (rhabodmyolysis), hemoglobinuria (hemolysis)
+dipstick, + urine sediment =
true hematuria (see DDx
Urine dipstick indicates hematuria based on
peroxidase activity;
yields positive results with both hemoglobin
and myoglobin.
Positive result must be followed up by urinalysis.
postive result of urine dipstick must be followed up by
urinalysis
Glomerular hematuria etiology
- Nephritic syndrome
- Isolated hematuria:
*transient (strenuous exercise, infections),
*persistent (IgA nephropathy, Alport syndrome,
thin basement membrane nephropathy)
transient Isolated hematuria etiologies
(strenuous
exercise, infections)
persistent Isolated hematuria etiologie
- IgA nephropathy
- Alport syndrome
- thin basement membrane
nephropathy
Nonglomerula hematuria etiologies
- Urolithiasis
- Infection: cystitis, urethritis, prostatitis
- Malignancy (especially in otherwise asymptomatic): urothelial cancer, renal cell cancer, prostate cancer, nephroblastoma
- Coagulation disorders: PLT dysfunction, hemophilia
- Urinary tract obstruction: BPH, congenital anomalies
- PCKD
- Renal papillary necrosis: sickle cell disease, acute pyelonephritis, DM, analgesics
- Trauma: to the urethra, bladder, ureter, kidney
- Drugs: cyclophosphamide, sulfonamides, warfarin, heparin
drugs causing non glomeruar hematuria/macroscopic
Drugs:
cyclophosphamide,
sulfonamides,
warfarin,
heparin
Malignancy causing macroscopic hematuria
(especially in otherwise asymptomatic):
* urothelial cancer
* renal cell cancer
* prostate cancer
* nephroblastoma
Initial evaluation of hematuria
- first step in the evaluation of patients with a positive dipstick for heme or with red or brown urine is
- to confirm the presence of hematuria by microscopic analysis of a fresh, centrifuged specimen
diagnosis of hematuria
- History: smoking, renal disease in family, sickle cell disease in family, drugs (nephrotoxic,
anticoagulants), travel history to areas endemic to Schistosoma haematobium and TB - Physical examination: urinary symptoms and systemic approach
Complete urinalysis - Urine culture (if infectious etiology suspected)
- Urine cytology (if urinary tract neoplasm suspected)
- Imaging: US, low-dose CT, cystoscopy, IV pyelography
Hematuria
Pyuria
+/- bacteriuria
+/- fever and systemic signs
suspicious for ?
what to proceed with?
*Upper UTI or
*complicated lower UTI
- Urine culture
- +/- blood culture
- +/- imaging
- Empiric AB
Young female with dysuria, urgency,
frequency, hematuria, and suprapubic pain
- Non-complicated UTI (cystitis or urethritis)
Empiric AB
Isolated painless hematuria with nondysmorphic
RBC, male patient > 35 years,
smoking history
Urinary tract
neoplasm
- Imaging (cystoscopy, US, CT)
- Urine cytology
Isolated painless hematuria in a child
Congenital
anomaly
* imaging
Hematuria presenting with acute-onset
unilateral flank pain
Urolithiasis
- Imaging (US or low-dose CT)
- Check serum Ca2+ or UA levels
Hematuria with dysmorphic RBC,
proteinuria, RBC casts
Glomerulonephritis
- Autoimmune panel
- Infectious disease panel
- Complement levels
- Hematologic evaluation
- Renal biopsy (definitive diagnosis
Women presenting with hematuria shortly
after (or during) menses
Repeat urinalysis later in the cycle (once menstrual bleeding
has ceased
Patient presenting with hematuria shortly
after vigorous exercise
Repeat confirmatory urinalysis within 4-6 weeks
Patient presenting with hematuria after
acute trauma
- Exclude active bleeding (imaging)
- Repeat confirmatory urinalysis within 4-6 weeks
Patient presenting with hematuria, anuria,
N/V, confusion, edema, dyspnea
AKI
- Rule-out pre-renal causes: check urine osmol, FeNa, BUN/Cr
- Rule-out post-renal causes: imaging with US and/or CT
- Rule-out intrinsic-renal causes Biopsy if all above are negative
- Rule-out pre-renal causes of hematuria
check urine osmol, FeNa, BUN/Cr
values for pre-renal hematuria:
urine osmol >500
FeNa < 1
BUN/Cr >20
- Rule-out post-renal causes of hematuria
imaging with US and/or CT
- Rule-out intrinsic-renal causes of hematuria
- Biopsy if all above (urine osmol, FeNa, BUN/Cr, imaging US/CT) are negative
Presence of casts in urine indicates that
hematuria/pyuria is of glomerular or renal tubular origin
hematuria with no casts is typical for
kidney stones
bladder cancer
pyuria, no casts is typical for
acute cystitis
causes of RBC casts
Glomerulonephritis,
HTN emergency
WBC casts
- Tubulointerstitial inflammation,
- acute pyelonephritis,
- transplant rejection
Granular casts
ATN ( can be muddy brown in appearance)
Fatty casts ( oval fat bodies)
Nephrotic syndrome ( associated with maltese cross sign)
Waxy casts
End stage renal disease/ CKD
Hyaline casts
- Nonspecific, can be a normal finding.
- Form via solidification of Tamm-Horsdall
mucoprotein (secreted by renal tubular cells)
