Haematuria prof mohamed sobh

Urology & Nephrology Center, Mansoura University,

Egypt

HAEMATURIA

By

Mohamad A. Sobh, MD, FACP

Prof. of NephrologyUrology & Nephrology Center

Mansoura UniversityEgypt


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Definitions:

Normally the number of RBCs in urine

should not be more than 5 RBCs/ high

power field on microscopic examination

of fresh centrifuged urine sample.

So, haematuria is defined as a secretion of

more than 5 RBCs/ HPF in urine.

Haematuria


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Transient microscopic haematuria is

relatively common. Up to 40% of adults

between ages of 18 and 33 may have

microscopic haematuria at least once, and

up to 16% may have it in two or more

occasions.

Therefore, an extensive workup is not

indicated except in high-risk patients, > 50

years of age and those patients with other

clinical or urinary abnormalities.


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Initial is usually urethral.

Terminal hematuria is usually prostatic or

bladder origen.

Total hematuria is either bladder, ureteral

or renal origen.

Gross or Microscopic.

Painfull or painless.

Symptomatic or Asymptomatic.

Patterns Of Haematuria


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Transient haematuria

• Exercise ( ‘ joggers ’ nephritis ’ ).

• Menstruation..

• Viral illnesses.

• Trauma


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In gross hematuria, urine looks red if alkaline,

but brown or coca-cola like if urine is acidic

due to denaturation of the hemoglobin.


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False positive test for haematuria:

Haemoglobinuria.

Myoglobinuria.

Ascorbic acid.

False negative test for hematuria:

Highly diluted urine.


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Differential Diagnosis of Haematuria:A- First, haematuria should be differentiated from

other causes of red or brownish urine:

Haemoglobinuria (haemolysis)

Myoglobinuria (muscle damage)

Porphyrins (in porphyria)

Bile (in jaundice)

Melanin (in melanoma)

Alkaptonuria,

Food dyes.

Drugs as PAS or phenylphthalein.


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Dipsticks (Hemastix) will be positive

with haematuria, haemoglobinuria and

with myoglobinuria but negative with

other causes e.g. porphyrins bile

melanin, alkaptonuria, food dyes and

drugs as PAS or phenylphthalein.

Microscopy will show RBC’s only

with haematuria.


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B-Haematuria could be glomerular (because of

glomerular disease, sometimes called medical); or

non glomerular (sometimes called surgical).

Glomerular haematuria could be differentiated

from non glomerular haematuria by:

1. The shape of RBCs in urine are small and

dysmorphic in cases with glomerular haematuria

while it will be normal in case of non glomerular

haematuria.


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2. Proteinuria is present in most cases of glomerular hematuria but not in cases of non glomerular hematuria.

3. Casts, especially red cell casts are seen in glomerular haematuria.

4. Blood clots indicate non-glomerular bleeding and can be associated with pain & colic.


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(in dipsticks test reaction occurs between orthotolidine andhaemoglobin or myoglobin).


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Causes of HaematuriaI. Haematuria of renal origin: Glomerular haematuria

Renal infection and tubulointerstitial diseases.

Renal neoplastic diseases:

Hereditary renal diseases

Coagulation defect

Stone disease.

Renal vascular disease

Exertional haematuria.

II. Haematuria of ureteral origin:

III. Haematuria of bladder origin:

IV. Haematuria of urethral origin.


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Haematuria of renal origin:

a.Glomerular haematuria: Either primary

glomerular disease (e.g. IgA nephropathy,

mesangial proliferative

glomerulonephritis or crescentic

glomerulonephritis); or secondary glomerulonephritis i.e. renal involvement is a part of systemic disease (e.g.post-strephococcalglomerulonephritis, Henoch-Schönleinpurpura, SLE, polyarteritis nodosa).


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b.Renal infection and tubulointerstitialdiseases: Pyelonephritis, renal papillary necrosis, tuberculosis, and toxic nephropathies.

c.Stone disease.

d.Renal neoplastic diseases: Renal cell carcinoma, transitional cell carcinoma of the renal pelvis and others.

e.Hereditary renal diseases: Medularly, sponge kidney, polycystic kidney disease, Alport’s syndrome, and thin basement membrane disease.


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f. Coagulation defect: use of

anticoagulant, liver disease and

thrombocytopaenia.

g. Renal vascular disease: Renal

infarction, renal vein thrombosis or

malignant hypertension.

h. Exertional haematuria.


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II. Haematuria of ureteral origin:

a. Malignancy.

b. Nephrolithiasis.

c. Ureteral inflammatory conditionsecondary to nearby inflammatione.g. diverticulitis, appendicitis orsalpingitis.

d. Ureteral trauma e.g. duringureteroscopy.

e. Ureteral varices, aneurysms, orarteriovenous malformation.


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III. Haematuria of bladder origin:

a. Infection: schistosoma, viral or bacterial

cystitis.

b. Neoplasma.

c. Foreign body in the bladder e.g.

stones.

d. Trauma: During instrumentation or

accidental.

e. Drug: e.g. cyclophosphamide induced

haemorrhagic cystitis.


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Cyclical haematuria in ♀ suggests

endometriosis of the urinary tract


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IV. Hematuria of urethral (or

associated structures) origen:

a. Urethritis, foreign body or

local trauma to the urethra.

b. Prostate: Acute prostatitis,

benign prostatic hypertrophy.


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1. First exclude haemoglobinuria andmyoglobinuria since both of them canalso cause positive dipstick test forhaematuria. This is done by microscopicexamination of fresh urine sample. In caseof haematuria, RBCs could be seen whilein the other two conditions no RBC’s couldbe seen.

Investigations of a case of haematuria


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In case of myoglobinuria, clinical

examination may show manifestations of

muscle disease and the examination of

urine by immunoelectrophoresis may show

myoglobin.

In case of haemoglobinuria, manifestations

of haemolysis may be evident


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2. Examination of urine for:

Proteinuria.

Casts.

Pus.

Bacteria (specific and non specific)

Culture (Ordinary and special)

PCR (TB-DNA)


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3. Ultasound, plain X-ray, I.V.P. (if

serum creatinine is normal), and

possibly angiography, for the

diagnosis of surgical diseases e.g.

stone, malignancy, infection, or

malformations.


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4. RBCs in urine could be examined for its

shape to differentiate glomerular (small,

distorted) from non glomerular causes

(by phase contrast microscopy).

5. Kidney function tests.

6. Specific investigations for diagnosis of

systemic disease causing haematuria

e.g. SLE.

7. Kidney biopsy for glomerular

haematuria.


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Microscopic haematuria and the risk of ESRD

• A recent longitudinal study of 1.2 million young individuals

(aged 16 – 25) presenting for military service found an initial 0.3%

prevalence of persistent microscopic haematuria (with normal SCr and

proteinuria <200mg/day).

• Males were affected twice as commonly as females.

• During 21 years ’ follow-up, ESRD developed in 0.7% of those with (and

0.045% of those without) initial microscopic haematuria.

• This gave an adjusted hazard ratio of 18.5.

• The mean age of ESRD treatment was earlier (34 vs 38) in the haematuria

cohort and attributed mainly to glomerular disease.

• While the relevant advisory bodies do not presently advocate population

screening, these recent data have led to a call for selected screening of

younger patients so that they can be followed up more closely for the

development of overt renal disease.

* Vivante A, Afek A, Frenkel-Nir Y, et al . (2011). Persistent asymptomatic

isolated microscopic hematuria in adolescents and young adults and risk for

end-stage renal disease. JAMA .


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1. Treatment of the cause.

2. Haemostatic e.g.:

Cyclokapron.

Vitamin K

DDAVP

Frish frozen plasma.

3. Haematenics and blood transfusion.

Treatment Of Haematuria


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Haematuria prof mohamed sobh

Healthcare

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