Hematuria

Diagnostic approach Diagnostic approach of hematuriaof hematuria

Presented by Ri 陳柏璋

Definition of hematuriaDefinition of hematuria

Microscopic hematuria

> 5 RBCs / μl ( 3 RBCs / HPF )

Gross hematuria

> 2500 RBCs / μl

Causes of hematuria (1)Causes of hematuria (1)

Glomerular IGA nephropathy Postinfectious glomerulonephritis Familial glomerulonephritis RPGN MPGN Glomerulonephritis caused by systemic dz Subacute bacterial endocarditis Exercise

Causes of hematuria (2)Causes of hematuria (2)

Nonglomerular Renal (tubulointerstitial) infection, tumor, drug-induced, familial, vascular, metabolic Extrarenal Infection, stone, inflammation, tumor, stricture, endometriosis, BPH, congenital abnormalities

Causes of hematuria (3)Causes of hematuria (3)

Coagulopathy related Drug induced (warfarin/heparin) Secondary to systemic diseaseTraumaFactitious ex. Menstruation

Most common causes of hematurMost common causes of hematuria by age and sexia by age and sex

Age/sex Common causes0-20 AGN, UTI, congenital urinary tract anomalies with obstruction20-40 male UTI, stones, bladder tumor40-60 female bladder tumor, stone, UTI>60 male BPH, bladder tumor, UTI>60 woman Bladder tumor, UTI

History Taking (1)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

History Taking (2)History Taking (2)

＊ Associated symptoms

Fever, chills, other bleeding point, dyspnea,

recent URI,

＊ Painless gross hematuria

consider tumor

Medical/Family and social Medical/Family and social historyhistory

＊ Drug history (analgesics, NSAID, chemotherapy agents)

＊ Coagulopathy

＊ Family history of PCKD or Alport’s syndrome

＊ Travel history: schistosomiasis

Physical ExaminationPhysical Examination

Vital signs, esp. BP and BTFlank tendernessEdemaCardiac murmurHemoptysisSuprapubic discomfortGenitourinary exam

Lab DataLab DataUrianalysis ( pH, protein, bacteria, cast ) Glomerular： RBC casts, RBC dysmorphism, hypochromic and hypocytic RBC Nonglomerular： Intact RBC, normocyticU/C, BUN, Cre, CBCAnticoagulation studyImmunologic profiles

Radiologic studyRadiologic study

＊ Trauma and stone disease

＊ Intravenous pyelogram (IVP)

Computed tomography (CT)

＊ Abdominal echo: of limited role

＊ Others:

retrograde urethrogram, cystogram

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Evaluation of microscopic heEvaluation of microscopic hematuria in adults (1)maturia in adults (1)

Hematuria on dipstick testing repeat dipstick test urine microscopy for erythrocytes, casts, and bacteria Confirmation of hematuria

Evaluation of microscopic heEvaluation of microscopic hematuria in adults (2)maturia 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

Evaluation of microscopic heEvaluation of microscopic hematuria in adults (3)maturia in adults (3)

Glomerular type hematuria

Dysmorphic RBCs with a low MCV and RBC casts Consideration for a renal biopsy

Evaluation of microscopic heEvaluation of microscopic hematuria in adults (4)maturia 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

Treatment and Management Treatment and Management (1)(1)

Gross hematuria : Note vital signs Severe: three-way, large-bore Foley to prevent acute urinary retention by blood clot Watch out renal function, anemia, coagul

opathy Consult urologist Painless gross hematuria: tumor workup

Treatment and Management Treatment and Management (2)(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 )

Treatment and Management Treatment and Management (3)(3)

Glomerulonephropathies Supportive care at ER Dialysis for severe hyperkalemia, fluid overload and uremia Antibiotics for susptected infection Steroid for RPGN

Thanks for your direction !!