Diagnostic approach of hematuria Presented by M.M.Taziki

Definition of hematuria Microscopic hematuria > 5 RBCs / μl ( 3 RBCs / HPF ) Gross hematuria > 2500 RBCs / μl

Causes of hematuria (1) Glomerular IGA nephropathy Postinfectious glomerulonephritis Familial glomerulonephritis RPGN MPGN Glomerulonephritis caused by systemic dz Subacute bacterial endocarditis Exercise

Causes of hematuria (2) Nonglomerular Renal (tubulointerstitial)  infection, tumor, drug-induced, familial, vascular, metabolic Extrarenal  Infection, stone, inflammation, tumor, stricture, endometriosis, BPH, congenital abnormalities

Causes of hematuria (3) Coagulopathy related Drug induced (warfarin/heparin) Secondary to systemic disease Trauma Factitious ex. Menstruation

Most common causes of hematuria by age and sex Age/sex Common causes 0-20 AGN, UTI, congenital urinary tract anomalies with obstruction 20-40 male UTI, stones, bladder tumor 40-60 female bladder tumor, stone, UTI >60 male BPH, bladder tumor, UTI >60 woman Bladder tumor, UTI

History Taking (1) ＊Past history （previous episodes, recent 　food and drug ingestion, exercise, 　instrumentation, menstruation…） ＊Dysuria ? Associated bladder irritability or flank pain ? ＊Time of hematuria  initial: urethritis, stricture, meatal stenosis  total: bladder, ureter, kidney  terminal: bladder neck or prostatic urethra

History Taking (2) ＊Associated symptoms Fever, chills, other bleeding point, dyspnea, recent URI, ＊Painless gross hematuria  consider tumor

Medical/Family and social history ＊Drug history (analgesics, NSAID, chemotherapy agents) ＊Coagulopathy ＊Family history of PCKD or Alport’s syndrome ＊Travel history: schistosomiasis

Physical Examination Vital signs, esp. BP Flank tenderness Edema Cardiac murmur Hemoptysis Suprapubic discomfort Genitourinary exam

Lab Data Urianalysis ( pH, protein, bacteria, cast ) Glomerular： RBC casts, RBC dysmorphism, hypochromic and hypocytic RBC Nonglomerular： Intact RBC, normocytic U/C, BUN, Cre, CBC Anticoagulation study Immunologic profiles

Radiologic study ＊Trauma and stone disease ＊Intravenous pyelogram (IVP) Computed tomography (CT) ＊Abdominal echo: of limited role ＊Others: retrograde urethrogram, cystogram

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Evaluation of microscopic hematuria in adults (1) Hematuria on dipstick testing  repeat dipstick test urine microscopy for erythrocytes, casts, and bacteria  Confirmation of hematuria

Evaluation of microscopic hematuria in adults (2) Assessment History, Physical examination Serum urea, electrolytes, Cre. GFR Immunology (ANCA, ANA, anti-GBM, ASO) Ultrasound for kidney and bladder Urine cytology Coagulation exam

Evaluation of microscopic hematuria in adults (3) Glomerular type hematuria  Dysmorphic RBCs with a low MCV and RBC casts  Consideration for a renal biopsy

Evaluation of microscopic hematuria in adults (4) Nonglomerular hematuria ( Isomorphic RBCs with a normal MCV) Adults > 45 y/o < 45 y/o . Urinary Ca excretion . Urinary Ca excretion . UA excretion . UA excretion . Cystoscopy . Renal biopsy . IVP . Echocolor Doppler . CT ? Angio ? . Renal biopsy

Treatment and Management (1) Gross hematuria : Note vital signs Watch out renal function, anemia, coagulopathy Consult urologist Painless gross hematuria: tumor workup

Treatment and Management (2) Microscopic hematuria Repeated followup If persistent  full urologic evaluation ( > 3 RBCs / HPF on at least 2/3 proper U/A, or a single episode of > 100 RBC / HPF )

Treatment and Management (3) Glomerulonephropathies Supportive care at ER Dialysis for severe hyperkalemia, fluid overload and uremia Antibiotics for susptected infection Steroid for RPGN

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