HEMATURIAHEMATURIA

Leyi Gu

Renal Division, Renji Hospital

CASECASE 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?

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

microscopic hematuria:

normal colour with eyes

gross hematuria:

tea-colored, cola-colored, pink or

even red

DEFINITIONDEFINITION

More than three red blood cells are found in

centrifuged urine per high-power field microscopy ( > 3 RBC/HP).

ETIOLOGYETIOLOGY Diseases of the urinary system—the 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

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 ( 急性肾盂肾炎 )

tuberculosis （肾结核） renal allograft rejection （移植肾排异）

Uroepithelium

malignancy

vigorous excise

trauma

papillary necrosis （肾乳头坏死） cystitis/urethritis/prostatitis (usually caused by infection)

parasitic diseases (e.g. schistosomiasis ，血吸虫病 )

nephrolithiasis or bladder calculi （肾结石，膀胱结石）

Multiple sites or source unknown

hypercalciuria

System disorders a. Hematological disorders

aplastic anemia leukemia （白血病） allergic purpura （过敏性紫癜） hemophilia （血友病） ITP (idiopathy thrombocytopenic purpura)

b. Infection

infective endocarditis septicemia （败血症） epidemic hemorrhagic fever ( 流行性出血热， Hantaan

virus) scarlet fever ( 猩红热， -hemolytic streptococcus) leptospirosis ( 螺旋体病， leptospire) filariasis ( 丝虫病， Wuchereria bancrofti, Brugia malayi)

c. Connective tissue diseases systemic lupus erythematosus (SLE ，系统性红斑狼

疮 )

polyarteritis nodosa （结节性多动脉炎）

d. Cariovascular diseases hypertensive nephropathy chronic heart failure renal artery sclerosis

e. Endocrine and metabolism diseases gout （痛风） diabetes mellitus

Diseases of adjacent organs to urinary tract appendicitis （阑尾炎） salpingitis （输卵管炎） carcinoma of the rectum （直肠肿瘤） carcinoma of the colon （结肠肿瘤） uterocervical cancer

Drug and chemical agents sulfanilamides （磺胺） anticoagulation cyclophosphamide （ CTX ） mannitol （甘露醇）

miscellaneous exercise “idopathic” hematuria

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?

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.

CLINICAL FEATURECLINICAL FEATURE

Color

depends on the amount of red blood cell in the urine and the pH

normal: light yellow, pH 6.5pH

acidic: more darker (brown or black)

alkaline: red

Red casts and red cells in urineRed casts and red cells in urine

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Polluted urine: menstruation

Drug and food: uric acid, vegetable

Porphyrism （卟啉病） : porphyrin in urine (+)

Hemoglobinuria

hemolysis

soy-like, very few RBC under the microscopy

occult blood test (+)

HEMOGLOBINURIAHEMOGLOBINURIA

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

LABORATORY TESTSLABORATORY TESTS

Three-glass test

Method: collecting the three stages of urine of

a patient during micturition

Result:

the initial specimen containing RBC—the urethra

the last specimen containing RBC—the bladder

neck and trianglar area, posturethra

all the specimens containing RBC—upper urinary

tract, bladder

Phase-contrast microscopy

to distinguish glomerular from post glomerular

bleeding

• post glomerular bleeding: normal size and shape

of RBC

• glomerular bleeding: dysmorphic RBC

(acanthocyte)

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

EXAMPLE OF PHASE-CONTRAST EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST MICROSCOPY TEST (glomerlar)(glomerlar)

ACCOMPANIED SYMPTOMSACCOMPANIED 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

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 （丝虫病）

Evaluation of

microscopic hematuria

NEJM, 2003

--Approaching to the patient–

(Harrison’s Principle of Internal Medicine,14th Ed)

HEMATURIA

proteinuria (>500mg/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

renal biopsy

Hb electrophoresis, urine cytology, UA of family member, 24h urinary calcium/uric acid

IVP+/-renal ultrasound

As indicated: retrograde pyelography or arteriogram of cyst aspiration

cystoscopy

CT scan

biopsy

open renal biopsy

follow

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(-)

(-)

(-)

(-)

(-)

(+)

(+)

(+)

(+)

(+) ANCA:antineutrophil cytoplasmic antibody, VDRL:venereal dis. research laboratory, ASLO: antisteptolysin O, IVP: intravenous pyelography

Thanks for your attentionThanks for your attention

Online resource:Online resource:National library of Medcine

www.nlm.nih.gov/medlineplusNational Kidney Foundation

www.kidney.orgKidney & Urology Foundation of America

www.kidneyurology.org