Transcript HEMATURIA

HEMATURIA
Leyi Gu
Renal Division, Renji Hospital
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?
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
DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field
microscopy ( > 3 RBC/HP).
ETIOLOGY

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 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
Red casts and red cells in urine
DIFFERENTIAL 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 (+)
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
LABORATORY 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
MICROSCOPY TEST (non-glomerlar)
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (glomerlar)
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

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–
HEMATURIA
(Harrison’s Principle of Internal
Medicine,14th Ed)
proteinuria (>500mg/24h)
Dysmorphic RBC or RBC casts
(-)
Pyuria,WBC casts
(-)
(+)
urine culture
eosinophils
Hb electrophoresis, urine cytology,
UA of family member, 24h urinary
calcium/uric acid
(-)
IVP+/-renal
ultrasound
(+)
(-)
cystoscopy
(-)
CT scan
(-)
follow
(+)
As indicated:
retrograde
pyelography or
arteriogram of cyst
aspiration
(+)
serologic and hematologic
evaluation: blood culture,
anti-GBM Ab, ANCA,
complement, cryoglobulin
HBV,HCV,VDRL,HIV,
ASLO
renal biopsy
biopsy
(+)
open renal biopsy
ANCA:antineutrophil cytoplasmic
antibody, VDRL:venereal dis. research
laboratory, ASLO: antisteptolysin O,
IVP: intravenous pyelography
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