Transcript Transient hematuria

Hematuria
HAEMATURIA
 Common finding
 Incidental
 DEFINING HAEMATURIA
 Visible haematuria
 Non visible haematuria (dipstick and microscopic)
Gross hematuria:
Suspected if a red or brown color change of urine
Medications (phenazopyridine)
Ingestion of certain dyes
Myoglobinuria or hemoglobinuria
If pass clot, indicate urinary source
Causes of heme-negative red urine
Medications
Food dyes
Metabolities
Doxorubicin
Beets (in selected
patients)
Bile pigments
Chloroquine
Blackberries
Homogentisic acid
Deferoxamine
Food coloring
Melanin
Ibuprofen
Methemoglobin
Iron sorbitol
Porphyrin
Nitrofurantoin
Tyrosinosis
Phenazopyridine
Urates
Phenolphthalein
Rifampin
Microscopic hematuria:
Accidental finding from UA or urine dipstick
3 or more RBC/hpf.
No "safe" lower limit below which significant disease can be excluded
Often asymptomatic
Dx:
The urine sediment is the gold standard for the detection of microscopic hematuria
Dipsticks for heme are as sensitive as urine sediment examination,
but result in more false positive tests due to the following
A positive dipstick test must always be confirmed with microscopic examination of the urine
The evaluation should address the following three questions
1. Are there any clues from the history or physical examination that
suggest a particular diagnosis?
2. Does the hematuria represent glomerular or extraglomerular
bleeding?
3. Is the hematuria transient or persistent?
a three-tube test may also help to locate the
source of bleeding in selected cases.
Urethral: First 10-15 mL
Bladder: Final 10-30 mL
Upper urinary tract: Throughout
Goal is to quickly identify
1. Infection
2. Kidney stone
3. Malignant
Need immediate attention
History and Physical
History
Abdominal or flank pain
􀂄 Dysuria, frequency, urgency
􀂄 Trauma
􀂄 Strenuous exercise
􀂄 Menstruation
􀂄 Recent URI/ sore throat
􀂄 Skin rashes/ skin infection
􀂄 Diarrhea (especially bloody)
􀂄 Joint pains/swellings
􀂄 Medications/toxins
􀂄 h/o sickle cell disease or sickle trait

Family history
Hematuria ,
Hearing loss,
HTN,
Stones,
Renal disease,
Dialysis or transplant,
Sickle cell trait *:
Coagulopathy,
Medication Hx
Substances and Medications Affecting Urine Color
Artificial food coloring
Beets
Berries
Chloroquine (Aralen)
Furazolidone (Furoxone)
Hydroxychloroquine (Plaquenil)
Nitrofurantoin (Furadantin)
Phenazopyridine (Pyridium)
Phenolphthalein
Rifampin (Rifadin)
Information from Restrepo NC, Carey PO. Evaluating hematuria in
adults. Am Fam Physician 1989; 40(2):149-56, and Drugdex system.
Englewood: Colo.: Micromedex, Inc., 1999. Accessed Sept. 24, 1998.
Physical Exam
􀂄 Vital sign: BP, T, HR
 Skin: Rashes, evidence or trauma, bruising
􀂄 Abdomen for masses, tenderness (flank, suprapubics), bruits
􀂄 CVS: irregular irregular
􀂄 Edema (especially periorbital)
􀂄 Joint erythema, swelling, warmth
􀂄 Paleness, jaundice
􀂄 Careful inspection of external genitalia
 Prostate
•If BP is elevated, further evaluation is immediately warranted
Physical Examination Findings and Associated Causes of
Hematuria
Physical examination finding
General (systemic) examination
Cause of hematuria
Severe dehydration
Renal vein thrombosis
Peripheral edema
Nephrotic syndrome, vasculitis
Cardiovascular system
Myocardial infarction
Renal artery embolus or thrombus
Atrial fibrillation
Renal artery embolus or thrombus
Hypertension
Glomerulosclerosis with or without
proteinuria
Abdomen
Bruit
Arteriovenous fistula
Genitourinary system
Enlarged prostate
Urinary tract infection
Phimosis
Urinary tract infection
Meatal stenosis
Urinary tract infection
Clues from the history that point toward a specific diagnosis
1. Concurrent pyuria and dysuria, indicate UTI, may also occur with bladder malignancy.
2. A recent URI, raise the possibility of either post infectious glomerulonephritis or IgA
nephropathy
3. A positive family history of renal disease give suspicion of hereditary nephritis, polycystic
kidney disease, or sickle cell disease.
4. Unilateral flank pain radiating to the groin, suggesting ureteral obstruction due to a calculus or
blood clot, but can occasionally be seen with malignancy. Flank pain that is persistent or recurrent
can also occur in the rare loin pain hematuria syndrome.
5. Symptoms of prostatic obstruction in older men such as hesitancy and dribbling. The cellular
proliferation in BPH is associated with increased vascularity, and the new vessels can be fragile.
Clues from the history that point toward a specific diagnosis
6. Recent vigorous exercise or trauma
7. History of a bleeding disorder or bleeding from multiple sites due to
uncontrolled anticoagulant therapy.
8. Cyclic hematuria in women that is most prominent during and shortly after
menstruation, suggesting endometriosis of the urinary tract .
9. Medications that might cause nephritis (usually with other findings,
typically with renal insufficiency).
1o. Travel or residence in areas endemic for Schistosoma hematobium .
11.Sterile pyuria with hematuria, which may occur with renal tuberculosis,
analgesic nephropathy and other interstitial diseases.
Glomerular or Extra Glomerular bleeding?
Microscopic hematuria DDx
Glomerular
ARF
primary nephritis (post streptococcal glomerulonephritis, Ig A nephropathy,
Anti-GBM disease)
2nd nephritis(SLE, goodpasture’s syndrome, ANCA related vasculitis)
Alport’s syndrome (hereditary nephritis)
thin basement membrane nephropathy (benign familial hematuria)
•
Microscopic hematuria DDx
non glomerular


Renal
malignancy
vascular disease
(malignant hypertension, AVM, nutcracker syndrome, renal vein thrombosis,
sickle cell trait/disease, papillary necrosis)
infection (pyelonephritis, TB, CMV, EBV)
hypercalciuria
hereditary disease (polycystic kidney disease, medullary sponge kidney)
Nonrenal
malignancy (prostate, ureter, bladder)
BPH
Nephrolithiasis
Coagulopathy
Trauma
Rare cause of Microscopic Hematuria
Arteriovenous malformations and fistulas
Nutcracker syndrome
Loin pain-hematuria syndrome
Arteriovenous malformations and fistulas — An AV malformation (AVM) or
fistula of the urologic tract may be either congenital or acquired. The primary
presenting sign is gross hematuria, but high-output heart failure and
hypertension also may be seen . The latter is presumably due to activation of the
renin-angiotensin system resulting from ischemia distal to the AVM
Nutcracker syndrome — The nutcracker syndrome refers to compression of the left
renal vein between the aorta and proximal superior mesenteric artery. Nutcracker
syndrome can cause both microscopic and gross hematuria, primarily in children
(but also adults) in Asia . The hematuria is usually asymptomatic but may be
associated with left flank pain. Nutcracker syndrome has also been associated with
orthostatic proteinuria.
Loin pain-hematuria syndrome — The loin pain-hematuria syndrome is a poorly
defined disorder characterized by loin or flank pain that is often severe and
unrelenting, and hematuria with dysmorphic red cell features suggesting a
glomerular origin. Affected patients usually have normal kidney function.
Extraglomerular vs Glomerular in UA
Extraglomerular
Glomerular
Color (if
macroscopic)
Red or pink
Red, smoky brown, or "Coca-Cola"
Clots
May be present
Absent
Proteinuria
<500 mg/day
May be >500 mg/day
RBC morphology
Normal
Dysmorphic
RBC casts
Absent
May be present
Findings on Microscopy
Erythrocytes of uniform character are
classified as isomorphic and suggest
hematuria of lower urinary tract origin.
Microscopic clots of clumped erythrocytes
in urine are also suggestive of lower urinary
tract bleeding.
FIGURE 1. Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria. (phase contrast microscopy, 3100)
Dysmorphic erythrocytes are characterized
by an irregular outer cell membrane and
suggest hematuria of glomerular origin.
Red blood cell casts are also associated with
a glomerular cause of hematuria.
FIGURE 2. Dysmorphic erythrocytes from a
urine specimen. These cells suggest a
glomerular cause of microscopic hematuria.
(phase contrast microscopy, 3 100)
Transient or persistent hematuria
Transient hematuria
Transient microscopic hematuria is a common problem in adults
Fever, infection, trauma, and exercise are potential causes
It is reasonable to repeat an abnormal urinalysis in a few days
Exception:
Malignancy risk in older patients with transient hematuria
In older patients, even transient hematuria carries an appreciable risk of
malignancy (assuming no evidence of glomerular bleeding)
The risks includes : age >50, smoker and Hx of analgesic abuse.
When persistent hematuria is essentially the only manifestation of
glomerular disease, one of three disorders is most likely
 IgA nephropathy, in which there is often gross hematuria, and
sometimes a positive family history but without any clear pattern of
autosomal inheritance
 Alport syndrome (hereditary nephritis), in which gross hematuria
can occur in association with a positive family history of renal failure,
and sometimes deafness or corneal abnormalities.
 Thin basement membrane nephropathy (also called thin basement
membrane disease or benign familial hematuria), in which gross
hematuria is unusual and the family history may be positive (with an
autonomic dominant pattern of inheritance) for microscopic
hematuria but not for renal failure .
Persistent hematuria
Underlying malignancy is greater in patients with persistent hematuria in
whom there is no obvious cause from the history
The primary underlying cancers are bladder, renal, and, much less often,
prostate
Risk Factors for Urothelial Carcinoma
Cigarette smoking
Occupational exposures
Aniline dyes
Aromatic amines
Benzidine
Dietary nitrites and nitrates
Analgesic abuse (e.g., phenacetin)
Chronic cystitis and bacterial infection associated with urinary calculi and
obstruction of the upper urinary tract
Urinary schistosomiasis
Cyclophosphamide (Cytoxan)
Pelvic irradiation
Information from Messing EM, Catalona W. Urothelial tumors of the urinary tract. In:
Walsh PC, ed. Campbell's Urology. 7th ed. Philadelphia: Saunders, 1998:2327-410.
Laboratory Tests (initial work up)
• UA and microscopy to determine the number and morphology of RBC, crystal and casts
• Consider urine Cx
• CBC, PT, INR, electrolytes, kidney function
• Serum chemistries and serologic studies for glomerular causes of hematuria as directed
by the medical history
• Repeat UA in a few days
Further urologic evaluation is warranted if more than three RBC/phf are
found on at least two of three properly collected urine specimens or if highgrade microscopic hematuria (more than 100 red blood cells per high-power
field) is found on a single urinalysis.17
Further Work up
• Glomerular causes:
 Consider a refer to nephrology for further evaluation and possible renal biopsy
Renal Biopsy
A biopsy is not usually performed for isolated glomerular
hematuria (i.e., no proteinuria or renal insufficiency,) since there is
no specific therapy for these conditions, unless the patient is
considering becoming a kidney donor
However, biopsy should be considered if there is evidence of
progressive disease as manifested by an elevation in the plasma
creatinine concentration, increasing protein excretion, or an
otherwise unexplained rise in blood pressure, even when the
values remain within the normal range
Further Work up
•Non-glomerular causes:
CT, renal US, and/or IVP: to search for lesions in the kidney, collecting system,
ureters, and bladder
Urine cytology: if increased risk for urothelial cancers
Consider a referral to urology for cystoscopy, especially for pt at risk of
malignancies
Radiologic and other tests for the evaluation of hematuria
Test
Advantages
Disadvantages
Intravenous pyelogram (IVP)
Excellent visualization of the
kidney, collecting system, and
ureter
May miss bladder lesions; can
cause nephrotoxicity,
idiosyncratic reactions (1/10,000)
Cystoscopy
Best way to examine the bladder,
which is not as well visualized by
IVP or ultrasound
Invasive, uncomfortable and
expensive
Ultrasound
If of good quality, as sensitive as
IVP for renal lesions, with less
morbidity and cost
Less sensitive than IVP for ureter
and bladder
Retrograde pyelography
The best test for examing the
ureters, can be combined with
cystoscopy
Invasive, not useful for
examining other parts of the
urinary collecting system
Urinary cytology
Sensitivity 67 percent, specificity
96 percent for uroepithelial
cancer
Useful only for cancer, mainly of
the bladder
CT scan
Excellent for examining the renal
parenchyma
Expensive
Angiography
Useful for gross hematuria when
other tests have not revealed the
cause; the only good test for
vascular malformations
Invasive, expensive
Follow up
The combination of negative radiologic examination(s)
( IVP, US, CT scan, cytology, and cystoscopy) is usually sufficient to exclude
malignancy in the urinary tract
However, approximately 1% of older pt with an initially negative evaluation will,
at 3 to 4 years, have a detectable urinary tract malignancy
Recommendation
Initial and then periodic urine cytology and UA should be performed in pt at
high risk for malignancy (at 6, 12, 24 and 36 months)
SCREENING FOR HEMATURIA
Not recommended
Initial Evaluation of Asymptomatic Microscopic Hematuria*
Thank you