This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Hematuria Presented By: Abdulmajeed Alahmari Medical Student 2009

 Bloody urine  Gross hematuria  Microscopic hematuria ◦ 3 or more RBC’s per high power field in spun urine sediment

MedicationsFood dyesMetabolities Doxorubicin Beets (in selected patients) Bile pigments ChloroquineBlackberriesHomogentisic acid DeferoxamineFood coloringMelanin IbuprofenMethemoglobin Iron sorbitolPorphyrin NitrofurantoinTyrosinosis PhenazopyridineUrates Phenolphthalein Rifampin

Glomerular  ARF  primary nephritis (post streptococcal glomerulonephritis, Ig A nephropathy, Anti-GBM disease)  2 nd nephritis (SLE, goodpasture’s syndrome, ANCA related vasculitis)  Alport’s syndrome (hereditary nephritis)  thin basement membrane nephropathy (benign familial hematuria)

Renal Causes :  malignancy  vascular disease  sickle cell trait/disease, papillary necrosis  infection (pyelonephritis, TB, CMV, EBV)  hypercalciuria  hereditary disease (polycystic kidney disease )

Non-renal causes : malignancy (prostate, ureter, bladder) BPH Nephrolithiasis Coagulopathy Trauma

Isolated hematuria  No other urinary abnormalities  No renal insufficiency  No evidence for systemic disease

Glomerular - Benign Recurrent or Persistent Hematuria 1.Sporadic 2.Familial - IgA Nephropathy - Alport syndrome - PSAGN Non-glomerular - Idiopathic Hypercalciuria - Cystic Kidneys - Urinary Tract obstruction - Tumors - Trauma

 Thorough history and physical exam ◦ Any clues that point to particular diagnosis?  Is hematuria transient or persistent? ◦ Repeat UA in a few days to determine  Is it glomerular or extraglomerular bleeding?

 Urine is red, smoky brown or “coca- cola”  Clots absent  Proteinuria >500 mg/day  Dysmorphic RBC’s  RBC casts are present  Red or pink urine  Clots may be present  <500 mg/day proteinuria  Normal RBC  RBC casts may be present

Dysmorphic erythrocytes suggest hematuria of glomerular origin.

History Age Time of hematuria Abdominal or flank pain Dysuria, frequency, urgency Trauma Strenuous exercise Menstruation Recent URI/ sore throat Skin rashes Joint pains/swellings

Drug history (analgesics, NSAID, chemotherapy agents) Coagulopathy Family history of PCKD or Alport’s syndrome

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

 Urinalysis ( bacteria, pH, protein,, cast )  Glomerular: RBC casts, RBC dysmorphism,  Non-glomerular : Intact RBC  U/C, BUN, Cre, CBC  Anticoagulation study  Immunologic profiles

Non-glomerular causes CT, renal US, and/or 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

Thank you