Leyi Gu Renal Division, Renji Hospital HEMATURIA Leyi Gu Renal Division, Renji Hospital

CASE An otherwise healthy 48-year-old woman is found to have microscopic hematuria (5 red cells per high-power field) on a urinalysis performed by a life insurance company. No other laboratory abnormalities are identified; the serum creatinine concentration is 0.8 mg per deciliter (70.7 µmol per liter). The woman reports no symptoms and is a nonsmoker. Her blood pressure is 118/74 mm Hg, and the findings on physical examination are normal. How should she be evaluated?

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

DEFINITION More than three red blood cells are found in centrifuged urine per high-power field microscopy ( > 3 RBC/HP).

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 coagulation abnormality excessive anticoagulation

allergic interstitial nephritis Glomerular IgA nehropathy thin basement membrane disease (Alport syndrome) other causes of primary and secondary glomerulonephritis Interstitial allergic interstitial nephritis analgesic nephropathy renal cystic diseases acute pyelonephritis (急性肾盂肾炎) tuberculosis （肾结核） renal allograft rejection （移植肾排异）

Multiple sites or source unknown hypercalciuria Uroepithelium malignancy vigorous excise trauma papillary necrosis （肾乳头坏死） cystitis/urethritis/prostatitis (usually caused by infection) parasitic diseases (e.g. schistosomiasis，血吸虫病) nephrolithiasis or bladder calculi （肾结石，膀胱结石） Multiple sites or source unknown hypercalciuria

a. Hematological disorders aplastic anemia leukemia（白血病） System disorders a. Hematological disorders aplastic anemia leukemia（白血病） allergic purpura（过敏性紫癜） hemophilia（血友病） ITP (idiopathy thrombocytopenic purpura) b. Infection infective endocarditis septicemia （败血症） epidemic hemorrhagic fever (流行性出血热，Hantaan virus) scarlet fever (猩红热，-hemolytic streptococcus) leptospirosis (螺旋体病，leptospire) filariasis (丝虫病，Wuchereria bancrofti, Brugia malayi)

c. Connective tissue diseases systemic lupus erythematosus (SLE，系统性红斑狼疮) polyarteritis nodosa （结节性多动脉炎） d. Cariovascular diseases hypertensive nephropathy chronic heart failure renal artery sclerosis e. Endocrine and metabolism diseases gout （痛风） diabetes mellitus

Diseases of adjacent organs to urinary tract appendicitis （阑尾炎） salpingitis （输卵管炎） carcinoma of the rectum （直肠肿瘤） carcinoma of the colon （结肠肿瘤） uterocervical cancer Drug and chemical agents sulfanilamides （磺胺） anticoagulation cyclophosphamide （CTX） mannitol（甘露醇） miscellaneous exercise “idopathic” hematuria

Important questions to ask in patients History Has there been any signs of a UTI such as dysuria and frequency? Any suprapubic pain? Has there been any recent URI symptoms or sore throat? Has there been any type of skin rashes or sores? Any abdominal pain or colicky pain? Are the stools loose or bloody? Has there been any recent trauma? Has there been any joint pains or swellings? Is there any history of sickle cell disease or trait? Is there any family history of renal disease, transplants, or dialysis? Is there a family history of hearing deficits? What medications does the child take?

Important areas to check on the physical examination Blood Pressure Check for edema, especially around the eyes Careful inspection of the external genitalia  Look for any rashes, evidence of trauma and bruising, petechiae Exam all joints for signs of arthritis-red, warm, or swollen Feel the abdomen carefully for any masses or tenderness. Check for CVA tenderness. Try to feel for enlarged kidneys. Check for evidence of paleness or jaundice Accurately measure length and weight and plot on growth chart.

CLINICAL FEATURE Color depends on the amount of red blood cell in the urine and the pH normal: light yellow, pH 6.5 pH acidic: more darker (brown or black) alkaline: red

Red casts and red cells in urine

DIFFERENTIAL DIAGNOSIS Polluted urine: menstruation Drug and food: uric acid, vegetable Porphyrism（卟啉病）: 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)

EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST (glomerlar)

ACCOMPANIED SYMPTOMS Hematuria with renal colic renal stone, ureter stone if with dysuria, 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（丝虫病）

Evaluation of microscopic hematuria NEJM, 2003

HEMATURIA proteinuria (>500mg/24h) Dysmorphic RBC or RBC casts --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 (-) Hb electrophoresis, urine cytology, UA of family member, 24h urinary calcium/uric acid (-) As indicated: retrograde pyelography or arteriogram of cyst aspiration (+) IVP+/-renal ultrasound renal biopsy (-) (+) cystoscopy biopsy (-) CT scan ANCA:antineutrophil cytoplasmic antibody, VDRL:venereal dis. research laboratory, ASLO: antisteptolysin O, IVP: intravenous pyelography (+) open renal biopsy (-) follow

Thanks for your attention Online resource: National library of Medcine www.nlm.nih.gov/medlineplus National Kidney Foundation www.kidney.org Kidney & Urology Foundation of America www.kidneyurology.org