HEMATURIA

dr. Ita Murbani Handajaningrum. SpPD KGH

 CONTENT
Definition of hematuria
Etiology
Clinical feature
Differential diagnosis
Laboratory tests
Accompanied symptoms
 DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field microscopy
( > 3 RBC/HP).

Normal urine:
no red blood cell or less than three red blood cell
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
 ETIOLOGY
Diseases of the urinary systemthe most
common cause
Vascular
arteriovenous malformation
arterial emboli or thrombosis
arteriovenous fistular
nutcracker syndrome
renal vein thrombosis
loin-pain hematuria syndrom
cogulation abnormality
excessive anticogulation
Glomerular
IgA nehropathy
thin basement membrane disease (incl.Alport syndrome)
other causes of primary and secondary glomerulonephritis

Interstitial
allergic interstitial nephritis
analgesic nephropathy
renal cystic diseases
acute pyelonephritis
tuberculosis
renal allograft rejection
Uroepithelium
malignancy
vigorous excise
trauma
papillary necrosis
cystitis/urethritis/prostatitis(usually caused by infection)
parasitic diseases (e.g. schistosomiasis)
nephrolithiasis or bladder calculi

Multiple sites or source unknown

hypercalciuria
hyperuricosuria
 System disorders
a. Hematological disorders
aplastic anemia leukemia
allergic purpura hemophilia
ITP (idiopathy thrombocytopenic purpura)

b. Infection
infective endocarditis
septicemia
epidemic hemorrhagic fever (Hantaan virus)
scarlet fever (-hemolytic streptococcus)
leptospirosis (leptospire)
filariasis (Wuchereria bancrofti, Brugia malayi)
c. Connective tissue diseases
systemic lupus erythematosus (SLE)
polyarteritis nodosa

d. Cariovascular diseases
hypertensive nephropathy
chronic heart failure
renal artery sclerosis

e. Endocrine and metabolism diseases

gout
diabetes mellitus
 Diseases of adjacent organs to urinary tract
appendicitis salpingitis
carcinoma of the rectum
carcinoma of the colon
uterocervical cancer

Drug and chemical agents

sulfanilamides anticogulation
cyclophosphamide mannitol

miscellaneous
exercise idopathic hematuria
 CLINICAL FEATURE
Color
depends on the amount of red blood cell
in the urine and the pH (see slide 4)
normal: light yellow, pH 6.5
pH
acidic : more darker (brown or black)
alkaline: red
 DIFFERENTIAL DIAGNOSIS
Polluted urine: menstruation
Drug and food: phenosulfonphtha lein (PSP),uric
acid, vegetable
Porphyrism: 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 RBCthe urethra
the last specimen containing RBCthe bladder
neck and trianglar area, posturethra
all the specimens containing RBCupper 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)
 ACCOMPANIED SYMPTOMS

Hematuria with renal colic

renal stone, ureter stone
if with dysuria, miction 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
 --Approaching to the patient
HEMATURIA (Harrisons Principle of Internal
Medicine,14th Ed)

proteinuria (>500mg/24h)
(-) Dysmorphic RBC or RBC casts
(+)
(+)
Pyuria,WBC casts urine culture
eosinophils
(-) serologic and hematologic
evaluation: blood culture,
Hb electrophoresis, urine cytology, anti-GBM Ab, ANCA,
UA of family member, 24h urinary complement, cryoglobulin
calcium/uric acid HBV,HCV,VDRL,HIV,
(-) As indicated: ASLO
(+)
IVP+/-renal retrograde
ultrasound pyelography or
renal biopsy
(-) arteriogram of cyst
(+) aspiration
cystoscopy
(-) biopsy
CT scan (+) ANCA:antineutrophil cytoplasmic
antibody, VDRL:venereal dis. research
(-) open renal biopsy laboratory, ASLO: antisteptolysin O,
follow IVP: intravenous pyelography
THANK YOU