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Hematuria

Laura Binari/Patrick Steadman

Background

  • Definition: 3 urinalyses with three or more RBC/hpf; 1 urinalysis with 100 RBC/hpf or gross hematuria (1 cc blood/L urine can induce color change)

  • Causes:

    • Can be transient (exercise-induced, menses, trauma)

    • Concurrent pyuria/dysuria: consider urinary tract infection or bladder malignancy

      • Malignancy risk factors: male sex, age > 50, smoking Hx, exposures to benzene/aromatic amine, cyclophosphamide, indwelling foreign body, pelvis irradiation, chronic UTIs, heavy NSAID use, urologic disorders (nephrolithiasis, BPH)

    • Recent URI: think infection related glomerulonephritis, IgA, vasculitis, anti-GBM

    • Positive Family Hx of Hematuria: consider PKD, Sickle Cell Disease

    • Bleeding from other sites: think inherited/acquired bleeding disorder, anticoagulation

    • Unilateral Flank Pain: Ureteral calculus, renal malignancy, IgA Nephropathy

Glomerular Extraglomerular (Non-Glomerular Source)
Kidney

Ureter/

Bladder

Prostate/

Urethra

 Other

IgA Nephropathy

IgA Vasculitis

 Pyelo Cystitis BPH Exercise-Induced
Lupus Nephritis Renal Cell Carcinoma Urothelial Malignancy Prostate Cancer Bleeding Diathesis
Infection-related glomerulonephritis PKD Nephrolithiasis TURP Meds (AC)
Anti-GBM Disease (Goodpasture’s)

Sickle Cell

Papillary Necrosis

 Ureteral Stricture Urethritis (STI) Menses
ANCA-associated Malignant HTN Hemorrhagic Cystitis (chemo/rads)

TB

Schistoso-miasis
Genetic (Thin Basement Membrane Nephropathy/Alport Syndrome)

Arterial embolism

Vein thrombus

 Traumatic Foley/procedure

Evaluation

  • Step 1: Confirm the presence of hematuria

    • Dipstick positive heme: urinary RBCs (hematuria), free myoglobin or free hemoglobin

    • Centrifuge the urine

      • Red sediment -> true hematuria (urinary RBCs)

      • Red supernatant +

        • Positive dipstick: myoglobulin or hemoglobin

        • Negative dipstick porphyria, Pyridium, beets, rhubarb, or ingestion of food dyes

Glomerular Extraglomerular
Color (if gross hematuria) Red, Cola, Smoky Red/Pink
Clots Absent Present/Absent
Proteinuria May be >500 mg/day \<500 mg/day
RBC morphology Dysmorphic RBCs present Normal (isomorphic)
RBC casts May be present Absent

  • Step 2: Determine if there is a GLOMERULAR or NON-GLOMERULAR source of bleeding

    • Glomerular Bleeding:

      • Isolated Hematuria: Differential includes IgA Nephropathy, thin BM dx, Alport’s

      • Nephritic syndrome (new proteinuria, pyuria, HTN, edema, rise in Cr): post-infectious GN, MPGN, ANCA vasculitis, Goodpasture’s, lupus nephritis

      • Workup: anti-GMB, anti-DNase/ASO, ANA, ANCA, C3, C4, cryo, Hep B & C, HIV

      • Indications for Renal Biopsy: glomerular bleeding + risk factors for progressive disease, including albuminuria > 30 mg/day, new hypertension > 140/90 or significant elevation over baseline BP, rise in serum creatinine

    • Extraglomerular Bleeding (Imaging Section)

      • If historical clues suggest nephrolithiasis, start with non-con CT A/P

      • Gross Hematuria otherwise should be evaluated with CT A/P w/ and w/o contrast (CT urography); consult urology for cystoscopy (often done as outpatient referral)

      • If clots are passed, more likely to be secondary to lower urinary source, and if a high burden of clots poses a risk of obstruction (urologic emergency)

      • If extraglomerular bleeding with clots: hematuria catheter needs to be placed ASAP (2 valve catheter, 20-24 Fr (!); page urology if nursing unable to obtain)

  • CT Urography is more sensitive than IV pyelogram for renal masses and stones.

  • Prefer Renal and Bladder Ultrasound in pregnant patients

  • All pts w/gross hematuria that is non-glomerular in source, in whom infection has been ruled out, warrant cystoscopy. Additionally, all patients with clots need cystoscopy