Hematuria copy

Hematuria

1. نمحرلا ا مسب نمحرلا ا مسب
ميحرلاميحرلا

3. HEMATURIAHEMATURIA
Dr.Samir Sally,MD
Prof. internal medicine & nephrology
Mansoura Urology & Nephrology Centre,
Mansoura University

4. 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?

5. 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

6. DefinitionDefinition
Macroscopic (gross) Hematuria
Visible (Red Urine)
Microscopic Hematuria

>3RBC/HPF from two of three urinary sediments
without a urinary tract infection, or menstruation on
microscopic evaluation

7. EvaluationEvaluation
of the patient with of the patient with
HematuriaHematuria
29/1/2014

8. It is difficult to localize the site of
bleeding by routine examination of the
patient with hematuria.
However, certain findings may be very
helpful depend on size & shape of RBCs.
For example, casts form in the
lumina of renal tubules.
Therefore, the presence of RBCs
casts localizes the site of bleeding
to the renal parenchyma.

9. HematuriaHematuria
Painful or painless
Gross or microscopic
Initial, terminal or total
Transient or persistent
Glomerular or non glomerular
Presence of clots
Azospermia
false

11. 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

14. Nutcracker syndromeNutcracker syndrome

15. 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

16. 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

17. 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 (b-hemolytic streptococcus)
leptospirosis (leptospire)
filariasis (Wuchereria bancrofti, Brugia malayi)

18. 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

19. Diseases of adjacent organs to urinary tract
appendicitis salpingitis
carcinoma of the rectum
carcinoma of the colon
uterocervical cancer
Drug and chemical agents
sulfanilamides anticoagulation
cyclophosphamide （CTX） mannitol
miscellaneous
exercise “idopathic” hematuria

23. Accompanied symptomsAccompanied symptoms
Hematuria with renal colic
renal stone, ureter stone
if with dysuria or straining 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

24. 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
Cyclic hematuria in women that is most prominent during
and shortly after menstruation, suggesting
endometriosis of the urinary tract

25. 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.

32. 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

33. NEJM, 2003
Evaluation of microscopic hematuria

35. --Approaching to the patient–
(Harrison’s Principle of Internal
Medicine,14
th
Ed)
HEMATURIA
proteinuria (>500mg/24h)
Dysmorphic RBC or RBC casts
Pyuria,WBC castsurine 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

37. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Polluted urine: menstruation
Drug and food: phenosulfonphtha lein (PSP),uric
acid, vegetable
Porphyrism: porphyrin in urine (+)
Hemoglobinuria
hemolysis
occult blood test (+)

40. MyoglobinuriaMyoglobinuria

41. HEMOGLOBINURIAHEMOGLOBINURIA
RBC abnormality
Defects of RBC membrane structure and function
(hereditary spherocytosis)
Deficiency of enzymes (favism)
Hemoglobinopathy (thalassemia)
PNH

42. Phase-contrast microscopy
to distinguish glomerular from post
glomerular bleeding
•post glomerular bleeding: normal size and shape
of RBC
•glomerular bleeding: dysmorphic RBC
(acanthocyte)

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

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

45. Glomerular HematuriaGlomerular Hematuria
RENAL
IgA nephropathy
Alport syndrome
Thin glomerular BM disease
Post infectious
MPGN
MULTI-SYSTEM
SLE nephritis
HSP nephritis
Wegener syndrome
Goodpasture syndrome
HUS
Sickle cell Disease

46. Extraglomerular HematuriaExtraglomerular Hematuria
UPPER URINARY TRACT
pyelonephritis
ATN
papillary necrosis
nephrocalcinosis
thrombosis
malformation
SCD
tumor
PCKD
LOWER URINARY TRACT
cystitis
urethritis
urolithiasis
trauma
coagulopathy
heavy excersise
UPJ obstruction
ureterocele

47. Urine CytologyUrine Cytology
The sensitivity of urine cytology for the diagnosis of
urothelial cell cancer is low, and a negative result does not
exclude patients from further testing.
It has been shown in multiple studies that the addition of
urine cytology in the primary analysis of hematuria does
not contribute to diagnosis which is usually made by
cystoscopy or imaging.

48. Urine CultureUrine Culture
The addition of cultures of urine may be
indicated if the sediment shows leukocytes.

49. Clinical Chemistry Clinical Chemistry
Important to support a nephrologic diagnosis
RFT
Coagulation profile

50. ImmunologyImmunology
Antinuclear antibody (ANA) , Anti-double stranded (ds)
antibody

C3 & C4 complement concentrations
–Low in SLE, acute post infectious
glomerulonephritis, Cryoglobulinemia
ASO titre
–High after streptococcal infection

51. SerologySerology
Hepatitis B and C, HIV serology
ANCA test for diagnosis of vascuilitis
Anti-GBM antibodies in GP syndrome
C-ANCA P-ANCA

52. CystoscopyCystoscopy
The American Urological Association best practice policy
suggests that, in patients at low risk for urothelial cancer,
cystoscopy may be avoided.
 Imaging of the bladder should preferably precede
cystoscopy, so it can aid the urologist and improve
diagnostic yield.

53. Investigation : Radiology Investigation : Radiology
Helical CT Urogram (preferredpreferred)
Renal US
–Defines anatomy
–Signs of glomerular disease , hydronephrosis, and renal cysts
–CT Urogram is usually preferred over US
Intravenous Pyelogram
–Suspected Nephrolithiasis
Cystoscopy
–Extraglomerular source of Hematuria
MRI Urography
–Indicated where CT Urogram is contraindicated (e.g.
Pregnancy, Children)
–Identifies urothelial cancer, Nephrolithiasis and renal tumors
http://www.ajronline.org/doi/full/10.2214/AJR.10.4198
American Journal of Roentgenology. 2010

54. Abdominal RadiographsAbdominal Radiographs
Its overall sensitivity for renal and ureteral stones
is only 45–60% in multiple studies

55. Non-contrast CTNon-contrast CT
It is now the reference standard for stone
detection, and even very-low-dose unenhanced CT
techniques with a radiation dose comparable to
that of abdominal radiographs have shown better
results

56. ADPKDADPKD

57. UltrasoundUltrasound
Ultrasound is suitable as first-line diagnostic test
In comparison with excretory urography, ultrasound
showed a higher sensitivity for bladder tumors and equal
(i.e., moderate) sensitivity for upper urinary tract tumors.
Ultrasound alone is not sensitive (19–32%) for stone
detection,

58. ADPKDADPKD

59. Excretory UrographyExcretory Urography
For hematuria, multiple studies have now shown
the superiority of CT urography over excretory
urography.
There is also a low sensitivity (< 60%) for renal
tumors smaller than 3 cm for excretory urography

60. A : IVP
B: (CT)
C: CT urography

61. MR Urography (MRU)MR Urography (MRU)
MRU has inherent advantages
in that it does not require
ionizing radiation, has a high
contrast resolution, has good
sensitivity for contrast media,
and has the possibility for
better tissue characterization
than other imaging techniques
do

62. MR Urography (MRU)MR Urography (MRU)
However, MRU is costly, technically demanding,
and not widely practiced.
Therefore, MRU expertise is available only in
specific dedicated centers.
It is good for pediatric diseases and for the
evaluation of obstructive disease.

63. Nephrological referral Nephrological referral ++ biopsy biopsy
Evidence of declining GFR (by >10ml/min at any stage within the
previous 5 years or by >5ml/min within the last 1 year)
Stage 4 or 5 CKD (eGFR <30ml/min)
 Significant proteinuria

Isolated hematuria with hypertension in those aged <40
Visible haematuria coinciding with intercurrent (usually upper
respiratory tract) infection

65. Exercise induced hematuriaExercise induced hematuria
•Gross or microscopic hematuria that occurs after strenuous exercise and resolves
with rest
•Direct trauma to the kidneys and/or bladder may be responsible for the hematuria
•Renal ischemia due to shunting of blood to exercising muscles
•Exercise-induced gross hematuria should be differentiated from two other
potential causes of red to brown urine following exercise: myoglobinuria due
to rhabdomyolysis; and march hemoglobinuria
•Evaluation is not warranted in patients under age fifty who are not at increased
risk for bladder or kidney cancer
•Evaluation for other causes of hematuria is warranted if the hematuria persists
well beyond one week

66. Henoch–Schönlein purpuraHenoch–Schönlein purpura
HSP is a systemic vasculitis (inflammation of blood
vessels) and is characterized by deposition of immune
complexes containing the antibody IgA.
Rash, arthritis, abdominal pain and hematuria

67. C/P of poststrept GNC/P of poststrept GN
In general, the latent period is 1-2 weeks after a throat
infection and 3-6 weeks after a skin infection.
Dark urine (brown-, tea-, or cola-colored)This is often
the first clinical symptom.
Dark urine is caused by hemolysis of red blood cells
that have penetrated the glomerular basement
membrane and have passed into the tubular system.

68. C/P of poststrept GNC/P of poststrept GN
The onset of puffiness of the face or eyelids is sudden. It
is usually prominent upon awakening and, if the
patient is active, tends to subside at the end of the day
In some cases, generalized edema and other features of
circulatory congestion, such as dyspnea, may be
present.
Edema is a result of a defect in renal excretion of salt
and water.

69. Gross hematuriaGross hematuria
Gross hematuria is suspected because of the presence
of red or brown urine.
The color change does not necessarily reflect the
degree of blood loss, since as little as 1 mL of blood per
liter of urine can induce a visible color change.
Gross hematuria with passage of clots almost always
indicates a lower urinary tract source.
The initial step initial step in the evaluation of patients with red
urine is centrifugation of the specimen to see if the red
or brown color is in the urine sediment or the urine
supernatant.

70. Causes of Asymptomatic Causes of Asymptomatic
Gross Hematuria by Gross Hematuria by IncidenceIncidence
Acute Cystitis (23%)Acute Cystitis (23%)
Bladder Cancer (17%)
Benign Prostatic Hyperplasia (12%)
Nephrolithiasis (10%)
Benign essential Hematuria (10%)
Prostatitis (9%)
Renal cancer (6%)
Pyelonephritis (4%)
Prostate Cancer (3%)
Urethral stricture (2%)

71. The most common risk factors for The most common risk factors for
urinary tract malignancy in AMH urinary tract malignancy in AMH
patientspatients
Age >35 years
Smoking history in which the risk correlates with the extent
of exposure
Occupational exposure to chemicals or dyes (benzenes or
aromatic amines), such as printers, painters, chemical plant
workers
History of gross hematuria
History of chronic cystitis or irritative voiding symptoms
History of pelvic irradiation
History of exposure to cyclophosphamide
History of a chronic indwelling foreign body
History of analgesic abuse, which is also associated with an
increased incidence of carcinoma of the kidney
The American Urological Association (AUA)

72. NEJM, 2003
Evaluation of microscopic hematuria

75. Thanks Thanks
29/1/2014