Hematuria

Blood in the urine is called Hematuria. (Excerpts from Harrisons, Uptodate, NEJM, JASN, Kidney Health Australia)

(See details and standard disclaimer. read this at your own risk. This is simply an educational material.)

Hematuria is very common. It is usually transient and of no consequence. people over age 35 years with hematuria, even if transient, there is a small but significant risk of cancer.

Types of Hematuria

*visible (macroscopic hematuria) and

*detectable only on urine examination (microscopic hematuria) i.e 3 or more red cells per hpf in a centrifuged sediment.

It could also be associated with or without pain

Painful hematuria is usually a urological disorder.
Painless hematuria is usually a medical disorder of the kidneys

Urine Dipsticks for heme detect 1 to 2 RBCs per hpf and are therefore at least as sensitive but result in more false positive tests.

Urine culture to exclude infection prior to further evaluation unless features are suggesting an acute Rapidly progressive glomerulonephritis (GN) or urinary tract lesions

The urinalysis to be repeated in 6 weeks for ensuring hematuria resolved.

Persistent painless hematuria, do urine protein creatinine ratio

Is it a GN ?presence of proteinuria, an active sediment (red cell casts, dysmorphic red blood cells) and abnormal renal function suggest Glomerulonephritis.

Proteinuria is the most reliable indicator of significant glomerular disease in patients with hematuria. However, if the patient has preexisting proteinuria, then a separate pathology may be responsible for the hematuria.

This warrants a nephrologic evaluation as well as potential urologic workup.

Non glomerular bleeding need either a CT with contrast, Ultrasound or CT scan without contrast(if GFR is low, or allergic to iodine) or MR imaging

Cystoscopy should be performed on all patients with gross hematuria with no evidence of glomerular bleeding or infection.

Patients who have blood clots should have cystoscopy

Cystoscopy should be performed on

Those patients with microscopic hematuria who are at increased risk for malignancy, regardless of age.
all patients over 35 years with microscopic hematuria after ruling out benign causes, such as *infection,

*menstruation,

*vigorous exercise,

*medical renal disease,

*viral illness, trauma, or

*recent urological procedures.

Beware of field cancerization effect for urothelial tumors. Those with a bladder tumor, the upper tracts should also be evaluated .

A cause for hematuria is often not identified.

Patients with negative evaluation for hematuria require follow-up with

*Annual urinalysis and blood pressure monitoring;

*in some cases, repeat imaging and cystoscopy may be needed depending on

#‎hematuria‬ was transient or persistent

‪ #‎microscopic‬ or gross

‪#‎the‬ patient's risk for malignancy in three to five years from their initial presentation ( irritative symptoms, tobacco, or chemical exposure, cytology may be useful)

Please note that, if someone present with hematuria, proteinuria and hypertension, you should not wait for investigating for a glomerulonephritis.(inflammation of kidneys) Also rarely it could also be from a blood disorder.

Hematuria in GN is a sign of activity per se. So in chronic burnt out GN such as c/c IgA disease etc, you may not see hematuria

Blood disorders can cause hematuria, simple coagulation tests APTT and INR and platelet count usually rules out such issues.

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