Hematuria

Hematuria – Laura Binari/Patrick Steadman

Background

  • Definition: 3 urinalyses with three or more RBC/hpf; 1 urinalysis with 100 RBC/hpf or gross hematuria (1 cc blood/L urine can induce color change)
  • Can be transient (exercise-induced, menses, trauma)
  • Hemoglobinuria: Hgb should be found only in intact RBCs, presence in urine suggests intravascular hemolysis AND fully saturated haptoglobin sites in serum
  • Myoglobinuria: should be found only in intact muscle, presence in urine suggests myonecrosis (serum haptoglobin has LOW affinity for myoglobin)
  • Concurrent pyuria/dysuria: consider urinary tract infection or bladder malignancy
  • Recent URI: think infection related glomerulonephritis, IgA, vasculitis, anti-GBM
  • Positive Family Hx of Hematuria: consider PKD, Sickle Cell Disease
  • Bleeding from other sites: think inherited/acquired bleeding disorder, anticoagulation
  • Unilateral Flank Pain: Ureteral calculus, renal malignancy, IgA Nephropathy
  • Microscopic hematuria – should be considered for CT Urography and cystoscopy
  • Malignancy Risk Factors: male sex, age > 35, smoking Hx, exposures to benzene/aromatic amine, cyclophosphamide, indwelling foreign body, pelvis irradiation, chronic UTIs, h/o heavy NSAID use, h/o urologic disorders/disease (nephrolithiasis, BPH)

 

Glomerular

Extraglomerular (Non-Glomerular Source)

Kidney

Ureter/

Bladder

Prostate/

Urethra

Other

IgA Nephropathy

IgA Vasculitis

Pyelo

Cystitis

BPH

Exercise-Induced

Lupus Nephritis

Renal Cell Carcinoma

Urothelial Malignancy

Prostate Cancer

Bleeding Diathesis

Infection-related glomerulonephritis

PKD

Nephrolithiasis

TURP

Meds (AC)

Anti-GBM Disease (Goodpasture’s)

Sickle Cell

Papillary Necrosis

Ureteral Stricture

Urethritis (STI)

Menses

ANCA-associated

Malignant HTN

Hemorrhagic Cystitis (chemo/rads)

 

TB

Schistoso-miasis

Genetic (Thin Basement Membrane Nephropathy/Alport Syndrome)

Arterial embolism

Vein thrombus

Traumatic Foley/procedure

 

 

 

 

 

Evaluation

  • Step 1: Confirm the presence of hematuria 
    • Dipstick positive heme: urinary RBCs (hematuria), free myoglobin or free hemoglobin
    • Centrifuge the urine 
        • Red sediment -> true hematuria (urinary RBCs)
        • Red supernatant +
    • Positive dipstick: myoglobulin or hemoglobin
    • Negative dipstick porphyria, Pyridium, beets, rhubarb, or ingestion of food dyes
  • Step 2: Determine if there is a GLOMERULAR or NON-GLOMERULAR source of bleeding

 

 

Glomerular

Extraglomerular

Color (if gross hematuria)

Red, Cola, Smoky

Red/Pink

Clots

Absent

Present/Absent

Proteinuria

May be > 500 mg/day

< 500 mg/day

RBC Morphology

Dysmorphic RBCs present

Normal (isomorphic)

RBC Casts

May be Present

Absent

    • Glomerular Bleeding:
        • Isolated Hematuria: Differential includes IgA Nephropathy, thin BM dx, Alport’s
        • Nephritic syndrome (new proteinuria, pyuria, HTN, edema, rise in Cr): post-infectious GN, MPGN, ANCA vasculitis, Goodpasture’s, lupus nephritis
        • Workup: anti-GMB, anti-DNase/ASO, ANA, ANCA, C3, C4, cryo, Hep B & C, HIV
        • Indications for Renal Biopsy: glomerular bleeding + risk factors for progressive disease, including albuminuria > 30 mg/day, new hypertension > 140/90 or significant elevation over baseline BP, rise in serum creatinine
    • Extraglomerular Bleeding (Imaging Section)
        • If historical clues suggest nephrolithiasis, start with non-con CT A/P
        • Gross Hematuria otherwise should be evaluated with CT A/P w/ and w/o contrast (CT urography); consult urology for cystoscopy (often done as outpatient referral)
        • If clots are passed, more likely to be secondary to lower urinary source, and if a high burden of clots poses a risk of obstruction (urologic emergency)
        • If extraglomerular bleeding with clots: hematuria catheter needs to be placed ASAP (2 valve catheter, 20-24 Fr (!); page urology if nursing unable to obtain)
    • CT Urography is more sensitive than IV pyelogram for renal masses and stones.
    • Prefer Renal and Bladder Ultrasound in pregnant patients
    • All pts w/gross hematuria that is non-glomerular in source, in whom infection has been ruled out, warrant cystoscopy. Additionally, all patients with clots need cystoscopy