Hematuria

Madelaine Behrens, 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:
    • Transient hematuria: exercise-induced, menses, trauma, cystitis/prostatitis
    • 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, pelvic 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

Kidney

Ureter/Bladder

Prostate/Urethra

Other
IgA Nephropathy, IgAVasculitis, Lupus Nephritis, Infection related glomerulonephritis, ANCA-associated, Anti-GBM disease, Genetic (thin Basement Membrane Nephropathy/Alport Syndrome), MPGN Pyelo, RCC, PKD, sickle cell disease, papillary necrosis, Malignant HTN, arterial embolism, vein thrombus Cystitis, Urothelial Malignancy, nephrolithiasis, ureteral stricture, hemorrhagic cystitis (chemo/rads), traumatic Foley/procedure BPH, prostate cancer, TURP, urethritis (STI) Exercise-induced, bleeding diathesis, meds (AC), menses, TB, schistosomiasis

Evaluation

  • Step 1: Confirm the presence of hematuria
    • Dipstick positive heme: urinary RBCs (hematuria), free myoglobin or free hgb
    • 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
  • Step 2: Determine if there is a GLOMERULAR or NON-GLOMERULAR source of bleeding

Characteristics of Glomerular vs Extraglomerular Bleeding:

Color (if gross hematuria)

Clots

Proteinuria

RBC morphology

RBC casts
Glomerular Red, Cola, Smoky Absent May be >500 mg/day Dysmorphic RBCs present May be present
Extra-glomerular Red/Pink Present/Absent <500 mg/day Normal (isomorphic) Absent
  • 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
    • 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); will need to see Urology for cystoscopy (often done as outpatient referral)
      • CT Urography is more sensitive than IV pyelogram for renal masses and stones
      • Pregnant patients: renal and bladder ultrasound preferred over CT
    • If clots are passed, more likely to be secondary to lower urinary source; 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)
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