HEMATURIAHEMATURIABASIC COURSE OF DIAGNOSISBASIC COURSE OF DIAGNOSIS

Xiaoqi Xu

Renji Hospital

Shanghai Second Medical University

CONTENTCONTENT

Definition of hematuria Etiology Clinical feature Differential diagnosis Laboratory tests Accompanied symptoms

DEFINITIONDEFINITION

More than three red blood cells are found in

centrifuged urine per high-power field microscopy

( > 3 RBC/HP).

Normal urine:

no red blood cell or less than three red blood cell

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

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 cogulation abnormality excessive anticogulation

Glomerular

IgA nehropathy

thin basement membrane disease (incl.Alport syndrome)

other causes of primary and secondary glomerulonephritis

Interstitial

allergic interstitial nephritis

analgesic nephropathy

renal cystic diseases

acute pyelonephritis

tuberculosis

renal allograft rejection

Uroepithelium

malignancy

vigorous excise

trauma

papillary necrosis

cystitis/urethritis/prostatitis(usually caused by infection)

parasitic diseases (e.g. schistosomiasis)

nephrolithiasis or bladder calculi

Multiple sites or source unknown

hypercalciuria

hyperuricosuria

System disorders a. Hematological disorders

aplastic anemia leukemia allergic purpura hemophilia ITP (idiopathy thrombocytopenic purpura)

b. Infection

infective endocarditis septicemia epidemic hemorrhagic fever (Hantaan virus) scarlet fever (-hemolytic streptococcus) leptospirosis (leptospire) filariasis (Wuchereria bancrofti, Brugia malayi)

c. Connective tissue diseases systemic lupus erythematosus (SLE) polyarteritis nodosa

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

e. Endocrine and metabolism diseases gout diabetes mellitus

Diseases of adjacent organs to urinary tract appendicitis salpingitis carcinoma of the rectum carcinoma of the colon uterocervical cancer

Drug and chemical agents sulfanilamides anticogulation cyclophosphamide mannitol

miscellaneous exercise “idopathic” hematuria

CLINICAL FEATURECLINICAL FEATURE

Color

depends on the amount of red blood cell in the urine and the pH (see slide 4)

normal: light yellow, pH 6.5pH

acidic: more darker (brown or black)

alkaline: red

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Polluted urine: menstruation

Drug and food: phenosulfonphtha lein (PSP),uric

acid, vegetable

Porphyrism: 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)

RBC MCV: 92.8 um3

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, miction 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

--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

(-)

(-)

(-)

(-)

(-)

(-)

(+)

(+)

(+)

(+)

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