Hematuria

HAEMATURIACommon 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 dyesMyoglobinuria or hemoglobinuria

If pass clot indicate urinary source

Causes of heme-negative red urineMedications Food dyes Metabolities

DoxorubicinBeets (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 dipstick3 or more RBChpf 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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

HAEMATURIACommon 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 dyesMyoglobinuria or hemoglobinuria

If pass clot indicate urinary source

Causes of heme-negative red urineMedications Food dyes Metabolities

DoxorubicinBeets (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 dipstick3 or more RBChpf 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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Gross hematuria

Suspected if a red or brown color change of urine

Medications (phenazopyridine)Ingestion of certain dyesMyoglobinuria or hemoglobinuria

If pass clot indicate urinary source

Causes of heme-negative red urineMedications Food dyes Metabolities

DoxorubicinBeets (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 dipstick3 or more RBChpf 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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Causes of heme-negative red urineMedications Food dyes Metabolities

DoxorubicinBeets (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 dipstick3 or more RBChpf 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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Microscopic hematuria

Accidental finding from UA or urine dipstick3 or more RBChpf 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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Urethral First 10-15 mLBladder Final 10-30 mLUpper urinary tract Throughout

a three-tube test may also help to locate the source of bleeding in selected cases

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Goal is to quickly identify

1Infection2Kidney stone3Malignant

Need immediate attention

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

History and Physical

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

History

Abdominal or flank pain1048708 Dysuria frequency urgency1048708 Trauma1048708 Strenuous exercise 1048708 Menstruation1048708 Recent URI sore throat1048708 Skin rashes skin infection1048708 Diarrhea (especially bloody)1048708 Joint painsswellings1048708 Medicationstoxins1048708 ho sickle cell disease or sickle trait

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Family history

Hematuria Hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Medication Hx

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Physical Exam

1048708 Vital sign BP T HR Skin Rashes evidence or trauma bruising1048708 Abdomen for masses tenderness (flank suprapubics) bruits1048708 CVS irregular irregular1048708 Edema (especially periorbital)1048708 Joint erythema swelling warmth1048708 Paleness jaundice1048708 Careful inspection of external genitalia ProstatebullIf BP is elevated further evaluation is immediately warranted

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Physical Examination Findings and Associated Causes of Hematuria Physical examination finding Cause of hematuria General (systemic) examination

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

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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

11Sterile pyuria with hematuria which may occur with renal

tuberculosis analgesic nephropathy and other interstitial

diseases

Clues from the history that point toward a specific diagnosis

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Glomerular or Extra Glomerular bleeding

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Glomerular

ARFprimary nephritis (post streptococcal glomerulonephritis Ig A nephropathy

Anti-GBM disease)2nd nephritis(SLE goodpasturersquos syndrome ANCA related vasculitis)Alportrsquos syndrome (hereditary nephritis)thin basement membrane nephropathy (benign familial hematuria) bull

Microscopic hematuria DDx

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

non glomerular

Renalmalignancyvascular disease (malignant hypertension AVM nutcracker syndrome renal vein thrombosis sickle cell traitdisease papillary necrosis)infection (pyelonephritis TB CMV EBV)hypercalciuriahereditary disease (polycystic kidney disease medullary sponge kidney)

Microscopic hematuria DDx

Nonrenalmalignancy (prostate ureter bladder)BPHNephrolithiasisCoagulopathyTrauma

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Rare cause of Microscopic Hematuria

Arteriovenous malformations and fistulas

Nutcracker syndrome

Loin pain-hematuria syndrome

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Arteriovenous malformations and fistulas mdash 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 mdash 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 mdash 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 Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Extraglomerular Glomerular

Color (if macroscopic)

Red or pinkRed smoky brown or Coca-Cola

Clots May be present Absent

Proteinuria lt500 mgday May be gt500 mgday

RBC morphology

Normal Dysmorphic

RBC casts Absent May be present

Extraglomerular vs Glomerular in UA

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Findings on Microscopy

FIGURE 1 Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria (phase contrast microscopy 3100 )

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 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

FIGURE 2 Dysmorphic erythrocytes from a urine specimen These cells suggest a glomerular cause of microscopic hematuria (phase contrast microscopy 3 100)

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

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Transient or persistent hematuria

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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 gt50 smoker and Hx of analgesic abuse

Transient hematuriaTransient 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

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Laboratory Tests (initial work up)

bull UA and microscopy to determine the number and morphology of RBC crystal and castsbull Consider urine Cxbull CBC PT INR electrolytes kidney functionbull Serum chemistries and serologic studies for glomerular causes of hematuria as directed by the medical historybull Repeat UA in a few days

Further urologic evaluation is warranted if more than three RBCphf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis17

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Further Work up bull Glomerular causes

Consider a refer to nephrology for further evaluation and possible renal biopsy

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

A biopsy is not usually performed for isolated glomerular hematuria (ie 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

Renal Biopsy

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Further Work up

bullNon-glomerular causes

CT renal US andor 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 hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Radiologic and other tests for the evaluation of hematuriaTest Advantages Disadvantages

Intravenous pyelogram (IVP)

Excellent visualization of the kidney collecting system and ureter

May miss bladder lesions can cause nephrotoxicity idiosyncratic reactions (110000)

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 pyelographyThe best test for examing the ureters can be combined with cystoscopy

Invasive not useful for examining other parts of the urinary collecting system

Urinary cytologySensitivity 67 percent specificity 96 percent for uroepithelial cancer

Useful only for cancer mainly of the bladder

CT scanExcellent 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

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

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)

Follow up

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

SCREENING FOR HEMATURIA

Not recommended

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Initial Evaluation of Asymptomatic Microscopic Hematuria

Thank you

Thank you