1. Diagnostic approach of hematuria
Presented by M.M.Taziki

2. Definition of hematuria
Microscopic hematuria
> 5 RBCs / μl ( 3 RBCs / HPF )
Gross hematuria
> 2500 RBCs / μl

3. Causes of hematuria (1) Glomerular IGA nephropathy
Postinfectious glomerulonephritis
Familial glomerulonephritis
RPGN
MPGN
Glomerulonephritis caused by systemic dz
Subacute bacterial endocarditis
Exercise

4. Causes of hematuria (2) Nonglomerular Renal (tubulointerstitial)
 infection, tumor, drug-induced,
familial, vascular, metabolic
Extrarenal
 Infection, stone, inflammation, tumor,
stricture, endometriosis, BPH,
congenital abnormalities

5. Causes of hematuria (3) Coagulopathy related
Drug induced (warfarin/heparin)
Secondary to systemic disease
Trauma
Factitious
ex. Menstruation

6. Most common causes of hematuria by age and sex
Age/sex Common causes
AGN, UTI,
congenital urinary tract
anomalies with obstruction
20-40 male UTI, stones, bladder tumor
40-60 female bladder tumor, stone, UTI
>60 male BPH, bladder tumor, UTI
>60 woman Bladder tumor, UTI

7. History Taking (1) ＊Past history （previous episodes, recent
　food and drug ingestion, exercise,
　instrumentation, menstruation…）
＊Dysuria ?
Associated bladder irritability or flank pain ?
＊Time of hematuria
 initial: urethritis, stricture, meatal stenosis
 total: bladder, ureter, kidney
 terminal: bladder neck or prostatic urethra

8. History Taking (2) ＊Associated symptoms
Fever, chills, other bleeding point, dyspnea,
recent URI,
＊Painless gross hematuria
 consider tumor

9. Medical/Family and social history
＊Drug history (analgesics, NSAID, chemotherapy agents)
＊Coagulopathy
＊Family history of PCKD or Alport’s syndrome
＊Travel history: schistosomiasis

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

11. Lab Data Urianalysis ( pH, protein, bacteria, cast ) Glomerular：
RBC casts, RBC dysmorphism,
hypochromic and hypocytic RBC
Nonglomerular：
Intact RBC, normocytic
U/C, BUN, Cre, CBC
Anticoagulation study
Immunologic profiles

12. Radiologic study ＊Trauma and stone disease
＊Intravenous pyelogram (IVP)
Computed tomography (CT)
＊Abdominal echo: of limited role
＊Others:
retrograde urethrogram, cystogram

13. +

14. Evaluation of microscopic hematuria in adults (1)
Hematuria on dipstick testing
 repeat dipstick test
urine microscopy for erythrocytes, casts,
and bacteria
 Confirmation of hematuria

15. Evaluation of microscopic hematuria in adults (2)
Assessment
History, Physical examination
Serum urea, electrolytes, Cre.
GFR
Immunology (ANCA, ANA, anti-GBM,
ASO)
Ultrasound for kidney and bladder
Urine cytology
Coagulation exam

16. Evaluation of microscopic hematuria in adults (3)
Glomerular type hematuria
 Dysmorphic RBCs with a low MCV and
RBC casts
 Consideration for a renal biopsy

17. Evaluation of microscopic hematuria in adults (4)
Nonglomerular hematuria
( Isomorphic RBCs with a normal MCV)
Adults > 45 y/o < 45 y/o
. Urinary Ca excretion Urinary Ca excretion
. UA excretion UA excretion
. Cystoscopy Renal biopsy
. IVP
. Echocolor Doppler
. CT ? Angio ?
. Renal biopsy

18. Treatment and Management (1)
Gross hematuria :
Note vital signs
Watch out renal function, anemia, coagulopathy
Consult urologist
Painless gross hematuria: tumor workup

19. Treatment and Management (2)
Microscopic hematuria
Repeated followup
If persistent  full urologic evaluation
( > 3 RBCs / HPF on at least 2/3 proper
U/A, or a single episode of > 100 RBC /
HPF )

20. Treatment and Management (3)
Glomerulonephropathies
Supportive care at ER
Dialysis for severe hyperkalemia, fluid
overload and uremia
Antibiotics for susptected infection
Steroid for RPGN

21. Thanks for your direction !!