haematuria prof. mohamed sobh
TRANSCRIPT
Urology & Nephrology Center, Mansoura University, Egypt
HAEMATURIA
ByMohamad A. Sobh, MD, FACP
Prof. of NephrologyUrology & Nephrology Center
Mansoura UniversityEgypt
Urology & Nephrology Center, Mansoura University, Egypt
Definitions:Normally the number of RBCs in urine
should not be more than 5 RBCs/ high power field on microscopic examination of fresh centrifuged urine sample.
So, haematuria is defined as a secretion of more than 5 RBCs/ HPF in urine.
Haematuria
Urology & Nephrology Center, Mansoura University, Egypt
Transient microscopic haematuria is relatively common. Up to 40% of adults between ages of 18 and 33 may have microscopic haematuria at least once, and up to 16% may have it in two or more occasions.
Therefore, an extensive workup is not indicated except in high-risk patients, > 50 years of age and those patients with other clinical or urinary abnormalities.
Urology & Nephrology Center, Mansoura University, Egypt
Initial is usually urethral.Terminal hematuria is usually prostatic or bladder origen.Total hematuria is either bladder, ureteral or renal origen.Gross or Microscopic.Painfull or painless.Symptomatic or Asymptomatic.
Patterns Of Haematuria
Urology & Nephrology Center, Mansoura University, Egypt
Transient haematuria •Exercise ( ‘ joggers ’ nephritis ’ ).
•Menstruation.. •Viral illnesses.
•Trauma
Urology & Nephrology Center, Mansoura University, Egypt
In gross hematuria, urine looks red if alkaline, but brown or coca-cola like if urine is acidic due to denaturation of the hemoglobin.
Urology & Nephrology Center, Mansoura University, Egypt
False positive test for haematuria:
Haemoglobinuria.
Myoglobinuria.
Ascorbic acid.
False negative test for hematuria:
Highly diluted urine.
Urology & Nephrology Center, Mansoura University, Egypt
Differential Diagnosis of Haematuria:A- First, haematuria should be differentiated from other causes of red or brownish urine:
Haemoglobinuria (haemolysis) Myoglobinuria (muscle damage) Porphyrins (in porphyria) Bile (in jaundice) Melanin (in melanoma) Alkaptonuria, Food dyes. Drugs as PAS or phenylphthalein.
Urology & Nephrology Center, Mansoura University, Egypt
Dipsticks (Hemastix) will be positive with haematuria, haemoglobinuria and with myoglobinuria but negative with other causes e.g. porphyrins bile melanin, alkaptonuria, food dyes and drugs as PAS or phenylphthalein.
Microscopy will show RBC’s only with haematuria.
Urology & Nephrology Center, Mansoura University, Egypt
B-Haematuria could be glomerular (because of glomerular disease, sometimes called medical); or non glomerular (sometimes called surgical).
Glomerular haematuria could be differentiated from non glomerular haematuria by:
1. The shape of RBCs in urine are small and dysmorphic in cases with glomerular haematuria while it will be normal in case of non glomerular haematuria.
Urology & Nephrology Center, Mansoura University, Egypt
2. Proteinuria is present in most cases of glomerular hematuria but not in cases of non glomerular hematuria.
3. Casts, especially red cell casts are seen in glomerular haematuria.
4. Blood clots indicate non-glomerular bleeding and can be associated with pain & colic.
Urology & Nephrology Center, Mansoura University, Egypt
(in dipsticks test reaction occurs between orthotolidine and haemoglobin or myoglobin).
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Causes of Haematuria I. Haematuria of renal origin:
Glomerular haematuria Renal infection and tubulointerstitial diseases. Renal neoplastic diseases: Hereditary renal diseases Coagulation defect Stone disease. Renal vascular disease Exertional haematuria.
II. Haematuria of ureteral origin: III. Haematuria of bladder origin: IV. Haematuria of urethral origin.
Urology & Nephrology Center, Mansoura University, Egypt
Haematuria of renal origin: a.Glomerular haematuria: Either primary glomerular disease (e.g. IgA nephropathy, mesangial proliferative glomerulonephritis or crescentic glomerulonephritis); or secondary glomerulonephritis i.e. renal involvement is a part of systemic disease (e.g.post-strephococcal glomerulonephritis, Henoch-Schönlein purpura, SLE, polyarteritis nodosa).
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
b.Renal infection and tubulointerstitial diseases: Pyelonephritis, renal papillary necrosis, tuberculosis, and toxic nephropathies.
c.Stone disease.d.Renal neoplastic diseases: Renal cell
carcinoma, transitional cell carcinoma of the renal pelvis and others.
e.Hereditary renal diseases: Medularly, sponge kidney, polycystic kidney disease, Alport’s syndrome, and thin basement membrane disease.
Urology & Nephrology Center, Mansoura University, Egypt
f. Coagulation defect: use of anticoagulant, liver disease and thrombocytopaenia.
g. Renal vascular disease: Renal infarction, renal vein thrombosis or malignant hypertension.
h. Exertional haematuria.
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Urology & Nephrology Center, Mansoura University, Egypt
II. Haematuria of ureteral origin: a. Malignancy.b. Nephrolithiasis.c. Ureteral inflammatory condition
secondary to nearby inflammation e.g. diverticulitis, appendicitis or salpingitis.
d. Ureteral trauma e.g. during ureteroscopy.
e. Ureteral varices, aneurysms, or arteriovenous malformation.
Urology & Nephrology Center, Mansoura University, Egypt
III. Haematuria of bladder origin: a. Infection: schistosoma, viral or bacterial
cystitis.b. Neoplasma.c. Foreign body in the bladder e.g.
stones.d. Trauma: During instrumentation or
accidental.e. Drug: e.g. cyclophosphamide induced
haemorrhagic cystitis.
Urology & Nephrology Center, Mansoura University, Egypt
Cyclical haematuria in ♀ suggests endometriosis of the urinary tract
Urology & Nephrology Center, Mansoura University, Egypt
IV. Hematuria of urethral (or associated structures) origen:
a. Urethritis, foreign body or local trauma to the urethra.
b. Prostate: Acute prostatitis, benign prostatic hypertrophy.
Urology & Nephrology Center, Mansoura University, Egypt
1. First exclude haemoglobinuria and myoglobinuria since both of them can also cause positive dipstick test for haematuria. This is done by microscopic examination of fresh urine sample. In case of haematuria, RBCs could be seen while in the other two conditions no RBC’s could be seen.
Investigations of a case of haematuria
Urology & Nephrology Center, Mansoura University, Egypt
In case of myoglobinuria, clinical examination may show manifestations of muscle disease and the examination of urine by immunoelectrophoresis may show myoglobin.
In case of haemoglobinuria, manifestations of haemolysis may be evident
Urology & Nephrology Center, Mansoura University, Egypt
2. Examination of urine for: Proteinuria.
Casts.
Pus.
Bacteria (specific and non specific)
Culture (Ordinary and special)
PCR (TB-DNA)
Urology & Nephrology Center, Mansoura University, Egypt
3. Ultasound, plain X-ray, I.V.P. (if
serum creatinine is normal), and
possibly angiography, for the
diagnosis of surgical diseases e.g.
stone, malignancy, infection, or
malformations.
Urology & Nephrology Center, Mansoura University, Egypt
4. RBCs in urine could be examined for its shape to differentiate glomerular (small, distorted) from non glomerular causes (by phase contrast microscopy).
5. Kidney function tests.6. Specific investigations for diagnosis of
systemic disease causing haematuria e.g. SLE.
7. Kidney biopsy for glomerular haematuria.
Urology & Nephrology Center, Mansoura University, Egypt
Microscopic haematuria and the risk of ESRD• A recent longitudinal study of 1.2 million young individuals (aged
16 – 25) presenting for military service found an initial 0.3% prevalence of persistent microscopic haematuria (with normal SCr and proteinuria <200mg/day).
• Males were affected twice as commonly as females.• During 21 years ’ follow-up, ESRD developed in 0.7% of those with (and
0.045% of those without) initial microscopic haematuria.• This gave an adjusted hazard ratio of 18.5.• The mean age of ESRD treatment was earlier (34 vs 38) in the haematuria
cohort and attributed mainly to glomerular disease.• While the relevant advisory bodies do not presently advocate population
screening, these recent data have led to a call for selected screening of younger patients so that they can be followed up more closely for the development of overt renal disease.
* Vivante A, Afek A, Frenkel-Nir Y, et al . (2011). Persistent asymptomatic isolated microscopic hematuria in adolescents and young adults and risk for end-stage renal disease. JAMA .
Urology & Nephrology Center, Mansoura University, Egypt
1. Treatment of the cause.2. Haemostatic e.g.:
Cyclokapron. Vitamin K DDAVP Frish frozen plasma.
3. Haematenics and blood transfusion.
Treatment Of Haematuria
Urology & Nephrology Center, Mansoura University, Egypt