HEMATURIA
BASIC COURSE OF DIAGNOSIS
Xiaoqi Xu
Renji Hospital
Shanghai Second Medical University
CONTENT
? Definition of hematuria
? Etiology
? Clinical feature
? Differential diagnosis
? Laboratory tests
? Accompanied symptoms
DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field microscopy
( > 3 RBC/HP),
Normal urine,
no red blood cell or less than three red blood cell
According to the amount of RBC in the
urine,hematuria can be classified as,
? microscopic hematuria,
normal colour with eyes
? gross hematuria,
tea-colored,cola-colored,pink or
even red
ETIOLOGY
? Diseases of the urinary system—the most
common cause
Vascular
arteriovenous malformation
arterial emboli or thrombosis
arteriovenous fistular
nutcracker syndrome
renal vein thrombosis
loin-pain hematuria syndrom
cogulation abnormality
excessive anticogulation
Glomerular
IgA nehropathy
thin basement membrane disease (incl.Alport syndrome)
other causes of primary and secondary glomerulonephritis
Interstitial
allergic interstitial nephritis
analgesic nephropathy
renal cystic diseases
acute pyelonephritis
tuberculosis
renal allograft rejection
Uroepithelium
malignancy
vigorous excise
trauma
papillary necrosis
cystitis/urethritis/prostatitis(usually caused by infection)
parasitic diseases (e.g,schistosomiasis)
nephrolithiasis or bladder calculi
Multiple sites or source unknown
hypercalciuria
hyperuricosuria
? System disorders
a,Hematological disorders
aplastic anemia leukemia
allergic purpura hemophilia
ITP (idiopathy thrombocytopenic purpura)
b,Infection
infective endocarditis
septicemia
epidemic hemorrhagic fever (Hantaan virus)
scarlet fever (?-hemolytic streptococcus)
leptospirosis (leptospire)
filariasis (Wuchereria bancrofti,Brugia malayi)
c,Connective tissue diseases
systemic lupus erythematosus (SLE)
polyarteritis nodosa
d,Cariovascular diseases
hypertensive nephropathy
chronic heart failure
renal artery sclerosis
e,Endocrine and metabolism diseases
gout
diabetes mellitus
? Diseases of adjacent organs to urinary tract
appendicitis salpingitis
carcinoma of the rectum
carcinoma of the colon
uterocervical cancer
? Drug and chemical agents
sulfanilamides anticogulation
cyclophosphamide mannitol
? miscellaneous
exercise ―idopathic‖ hematuria
CLINICAL FEATURE
? Color
depends on the amount of red blood cell
in the urine and the pH (see slide 4)
normal,light yellow,pH 6.5
? pH
acidic,more darker (brown or black)
alkaline,red
DIFFERENTIAL DIAGNOSIS
? Polluted urine,menstruation
? Drug and food,phenosulfonphtha lein (PSP),uric
acid,vegetable
? Porphyrism,porphyrin in urine (+)
? Hemoglobinuria
hemolysis
soy-like,very few RBC under the microscopy
occult blood test (+)
HEMOGLOBINURIA
RBC abnormality
? Defects of RBC membrane structure and function
(hereditary spherocytosis)
? Deficiency of enzymes (favism)
? Hemoglobinopathy (thalassemia)
? PNH
Mechanical factor (artificial heart valve),infection
or mismatched blood transfusion
LABORATORY TESTS
? Three-glass test
Method,collecting the three stages of urine of
a patient during micturition
Result,
? the initial specimen containing RBC—the urethra
? the last specimen containing RBC—the bladder
neck and trianglar area,posturethra
? all the specimens containing RBC—upper urinary
tract,bladder
? Phase-contrast microscopy
to distinguish glomerular from post glomerular
bleeding
? post glomerular bleeding,normal size and shape
of RBC
? glomerular bleeding,dysmorphic RBC
(acanthocyte)
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (non-glomerlar)
RBC MCV,92.8 um3
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (glomerlar)
ACCOMPANIED SYMPTOMS
? Hematuria with renal colic
renal stone,ureter stone
if with dysuria,miction pause or staining to void,bladder
or urethra stone
? Hematuria with urinary frequency,urgency and
dysuria
bladder or lower urinary tract (tuberculosis or tumor)
if accompanied by high spiking fever,chill and loin pain,
pyelonephritis
? Hematuria with edema and hypertension
glomerulonephritis
hypertensive nephropathy
? Hematuria with mass in the kidney
neoplasm
hereditary polycystic kidney
? Hematuria with hemorrhage in skin and
mucosa
hematological disorders
infectious diseases
? Hematuria with chyluria
filariasis
--Approaching to the patient–
(Harrison’s Principle of Internal
Medicine,14th Ed)
HEMATURIA
proteinuria (>500mg/24h)
Dysmorphic RBC or RBC casts
Pyuria,WBC casts urine culture eosinophils
serologic and hematologic
evaluation,blood culture,
anti-GBM Ab,ANCA,
complement,cryoglobulin
HBV,HCV,VDRL,HIV,
ASLO
renal biopsy
Hb electrophoresis,urine cytology,
UA of family member,24h urinary
calcium/uric acid
IVP+/-renal
ultrasound
As indicated,
retrograde
pyelography or
arteriogram of cyst
aspiration cystoscopy
CT scan
biopsy
open renal biopsy
follow
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(+)
(+)
(+)
(+) ANCA:antineutrophil cytoplasmic antibody,VDRL:venereal dis,research
laboratory,ASLO,antisteptolysin O,
IVP,intravenous pyelography
BASIC COURSE OF DIAGNOSIS
Xiaoqi Xu
Renji Hospital
Shanghai Second Medical University
CONTENT
? Definition of hematuria
? Etiology
? Clinical feature
? Differential diagnosis
? Laboratory tests
? Accompanied symptoms
DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field microscopy
( > 3 RBC/HP),
Normal urine,
no red blood cell or less than three red blood cell
According to the amount of RBC in the
urine,hematuria can be classified as,
? microscopic hematuria,
normal colour with eyes
? gross hematuria,
tea-colored,cola-colored,pink or
even red
ETIOLOGY
? Diseases of the urinary system—the most
common cause
Vascular
arteriovenous malformation
arterial emboli or thrombosis
arteriovenous fistular
nutcracker syndrome
renal vein thrombosis
loin-pain hematuria syndrom
cogulation abnormality
excessive anticogulation
Glomerular
IgA nehropathy
thin basement membrane disease (incl.Alport syndrome)
other causes of primary and secondary glomerulonephritis
Interstitial
allergic interstitial nephritis
analgesic nephropathy
renal cystic diseases
acute pyelonephritis
tuberculosis
renal allograft rejection
Uroepithelium
malignancy
vigorous excise
trauma
papillary necrosis
cystitis/urethritis/prostatitis(usually caused by infection)
parasitic diseases (e.g,schistosomiasis)
nephrolithiasis or bladder calculi
Multiple sites or source unknown
hypercalciuria
hyperuricosuria
? System disorders
a,Hematological disorders
aplastic anemia leukemia
allergic purpura hemophilia
ITP (idiopathy thrombocytopenic purpura)
b,Infection
infective endocarditis
septicemia
epidemic hemorrhagic fever (Hantaan virus)
scarlet fever (?-hemolytic streptococcus)
leptospirosis (leptospire)
filariasis (Wuchereria bancrofti,Brugia malayi)
c,Connective tissue diseases
systemic lupus erythematosus (SLE)
polyarteritis nodosa
d,Cariovascular diseases
hypertensive nephropathy
chronic heart failure
renal artery sclerosis
e,Endocrine and metabolism diseases
gout
diabetes mellitus
? Diseases of adjacent organs to urinary tract
appendicitis salpingitis
carcinoma of the rectum
carcinoma of the colon
uterocervical cancer
? Drug and chemical agents
sulfanilamides anticogulation
cyclophosphamide mannitol
? miscellaneous
exercise ―idopathic‖ hematuria
CLINICAL FEATURE
? Color
depends on the amount of red blood cell
in the urine and the pH (see slide 4)
normal,light yellow,pH 6.5
? pH
acidic,more darker (brown or black)
alkaline,red
DIFFERENTIAL DIAGNOSIS
? Polluted urine,menstruation
? Drug and food,phenosulfonphtha lein (PSP),uric
acid,vegetable
? Porphyrism,porphyrin in urine (+)
? Hemoglobinuria
hemolysis
soy-like,very few RBC under the microscopy
occult blood test (+)
HEMOGLOBINURIA
RBC abnormality
? Defects of RBC membrane structure and function
(hereditary spherocytosis)
? Deficiency of enzymes (favism)
? Hemoglobinopathy (thalassemia)
? PNH
Mechanical factor (artificial heart valve),infection
or mismatched blood transfusion
LABORATORY TESTS
? Three-glass test
Method,collecting the three stages of urine of
a patient during micturition
Result,
? the initial specimen containing RBC—the urethra
? the last specimen containing RBC—the bladder
neck and trianglar area,posturethra
? all the specimens containing RBC—upper urinary
tract,bladder
? Phase-contrast microscopy
to distinguish glomerular from post glomerular
bleeding
? post glomerular bleeding,normal size and shape
of RBC
? glomerular bleeding,dysmorphic RBC
(acanthocyte)
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (non-glomerlar)
RBC MCV,92.8 um3
EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (glomerlar)
ACCOMPANIED SYMPTOMS
? Hematuria with renal colic
renal stone,ureter stone
if with dysuria,miction pause or staining to void,bladder
or urethra stone
? Hematuria with urinary frequency,urgency and
dysuria
bladder or lower urinary tract (tuberculosis or tumor)
if accompanied by high spiking fever,chill and loin pain,
pyelonephritis
? Hematuria with edema and hypertension
glomerulonephritis
hypertensive nephropathy
? Hematuria with mass in the kidney
neoplasm
hereditary polycystic kidney
? Hematuria with hemorrhage in skin and
mucosa
hematological disorders
infectious diseases
? Hematuria with chyluria
filariasis
--Approaching to the patient–
(Harrison’s Principle of Internal
Medicine,14th Ed)
HEMATURIA
proteinuria (>500mg/24h)
Dysmorphic RBC or RBC casts
Pyuria,WBC casts urine culture eosinophils
serologic and hematologic
evaluation,blood culture,
anti-GBM Ab,ANCA,
complement,cryoglobulin
HBV,HCV,VDRL,HIV,
ASLO
renal biopsy
Hb electrophoresis,urine cytology,
UA of family member,24h urinary
calcium/uric acid
IVP+/-renal
ultrasound
As indicated,
retrograde
pyelography or
arteriogram of cyst
aspiration cystoscopy
CT scan
biopsy
open renal biopsy
follow
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(+)
(+)
(+)
(+) ANCA:antineutrophil cytoplasmic antibody,VDRL:venereal dis,research
laboratory,ASLO,antisteptolysin O,
IVP,intravenous pyelography
