Hematuria

Question 1

American Urological Association defines microscopic hematuria as

Answer 1

3 RBCs/high power field on microscopic examination of the centrifuged urine specimen in 2/3 freshly voided, clean catch, midstream urine samples

Question 2

Risk groups for hematuria

Answer 2

#1 is old men
#2: young women
#3: kids

Question 3

Mickey Mouse Ears

Answer 3

Red cells that pass through the glomerulus are deformed “dysmorphic”

Question 4

RBC casts

Answer 4

If find in urine represent significant disease at the glomerular level.

Question 5

Anything that disrupts the uroepithelium such as irration, inflammation, or invasion can lead to

Answer 5

normal appearing RBCs in the urine.
Malignancy, renal stones, trauma, infection and medications. Tumors, renal cysts, infarction , and AV malformations can also cause bld loss to urine space.

Question 6

Hypercalciuria common cause of hematuria in

Answer 6

children, rare in adults.

Question 7

Polycystic kidney disease

Answer 7

Family history of renal failure and cerebral aneurysms

Question 8

Hearing loss and renal failure in male members of family

Answer 8

Alport’s disease

Question 9

Family history without hearing loss or renal failure

Answer 9

Can suggest thin basement membrane disease (benign familial hematuria)

Question 10

Type IV collagen mutation, a tendency to form kidney stones in

Answer 10

Alports, and thin bm disease

Question 11

Recent Strenuous Exercise**

Answer 11

Can produce transient hematuria by traumatic and non-traumatic mechanisms.
Increased glomerular permeability may result from ischemic damage to the nephron as blood is shunted to exercising muscle or from an increased perfusion pressure secondary to efferent arteriolar vasoconstriction.

Question 12

Can cause red pigmenturia

Answer 12

Bilirubin, myoglobin, hemoglobin, porphyrins

Question 13

Foods

Answer 13

Rhubarb, blackberries, blueberries, paprika, beets, fava beans, artificial food colorings

Question 14

Drugs that cause red pigmenturia

Answer 14

Rifampin, Phenazopyridine, Adriamycin, Desferoxamine

Question 15

Fever, arthritis, rash may suggest

Answer 15

Glomerulonephritis associated with CT like Lupus.

Question 16

Hematuria or cola-colored urine following URI

Answer 16

IgA nephritis, HSP (systemic variant of IgA nephritis)

Question 17

Absence of constitutional symptoms does NOT rule out glomerulonephritis

Answer 17

Many primary renal diseases manifest with ONLY hematuria and/or proteinuria

Question 18

Renal capsular distension from inflammation (pyelonephritis) or hematoma (trauma) can result in CVA tenderness

Answer 18

Bleeding or infection in renal cyst can also cause CVA tenderness.

Question 19

CVA tenderness causes:

Answer 19

• Pyelonephritis
• Hematoma
• Renal cyst bleeding or
• Infection

Question 20

Glomerular source of bleeding

Answer 20

Microscopic hematuria. Blood equally dispersed thru urine stream and does NOT clot (usually).

Question 21

Hematuria or clots at beginning of urine stream, initial hematuria

Answer 21

Symptoms of URETHRAL cause

Question 22

Terminal hematuria

Answer 22

At end of urine stream, may occur with a prostatic, bladder, or trigonal cause of hematuria.

Question 23

Diagnosis of hematuria:

Answer 23

Urinalysis BEFORE imaging.

-Dipstick

Question 24

Sensitivity of dipstick to detect hematuria at a concentration of MORE than 3 RBCs/HPF is

Answer 24

MORE than 90%

Question 25

False negative can result from

Answer 25

Vitamin C ingestion, urine pH lower than 5.1 or dipstick that has prolonged exposure to air

Question 26

False positive

Answer 26

• Contamination with menstrual blood
• Myoglobinuria**
• Bacterial peroxidases

Question 27

All positive dipstick results and all negative results with high index of suspicion should undergo microscopy

Answer 27

Evaluate within 1 hour b/c casts will begin to break down and RBCs may lyse, can refrigerate.

Question 28

Dysmorphic red cells and rbc casts

Answer 28

Glomerular source bleeding

-do not need evaluation for urologic disease

Question 29

RBCs from NON-glomerular source

Answer 29

more closely resemble peripheral blood on microscopy, with isomorphic rbcs and absence of casts

Question 30

3 tube test

Answer 30

Hematuria in:
1st sample: urethral source
end of urine stream: lesion at bladder trigone
Equivalent in all 3 samples: renal, ureteral, and diffuse bladder lesions

Question 31

Renal parenchymal disease

Answer 31

Proteinuria, typically HIGHER than 500 to 1000 mg/day along with hematuria.

Question 32

**Pathognomonic for parenchymal disease

Answer 32

Abnormal RBC morphology (dysmorphic RBCs) and the presence of RBC casts.

Question 33

Presence of >80% dysmorphic rbcs in sample

Answer 33

Glomerular source

Question 34

Less than 20% dysmorphic

Answer 34

Urologic source

Question 35

RBC cast

Answer 35

MPGN, acute glomerulonephritis like Post-strep GN and RPGN may all have RBC casts in urine.

Question 36

Hematuria without glomerulonephritis can see in

Answer 36

• Acute allergic interstitial nephritis
• Chronic interstitial nephritis
• Papillary necrosis
• Pyelonephritis
• RBCs in these disorders are more commonly free RBCs, no associated in casts, and may not be the pre-dominant abnormal finding on the urinalysis.

Question 37

**Risk factors for significant disease in patients with Microscopic Hematuria:

Answer 37

• Smoking history
• Occupational exposure to chemicals or dyes (benzenes, aromatic amines)
• Age older 40
• Hx urologic disorder/dz
• Hz of irritative voiding symptoms
• Hx UTI
• Analgesic abuse
• Hx pelvic irradiation

Question 38

If a patient has a dipstick + for heme but no RBCs are seen on microscopic examination, consider the diagnosis of

Answer 38

Rhabdomyolysis.