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Flashcards in Hematuria DSA Deck (54):
1

 Gross hematuria is defined as what?

Presence of blood that is visible to the naked eye (>3500 RBC per high-power field)

2

 Microscopic hematuria is defined as what?

2-3 RBC per high field on urine microscopy

3

ALL patients with hematuria should have a ___________, regardless if there is liklihood of infection.

urine culture

4

Dx gross (macroscopic) hematuria

- Patient presents with red/brown urine (sometimes w clots)

  • Dx of gross hematuria is confirmed by centrifuging the urine specimen
    • UNLESS, symptoms are highly suggestive

5

Dx microscopic hematuria

  1. - Perform a careful history (often, pt comes in for UTI treatment or routine UA)
  2. - Conduct urine dipstick test
  3. - Several days later, repeat urine dipstick test 
  4. - Microscopic examination of urine 
    1. (+): at least 2 properly collected urine specimens show >3 RBC/high-powered field (hpf)
    2.  (-): No RBCs; consider hemoglobinuria or myoglobinuria 

6

Dx macroscopic/gross hematuria

7

Is microscopic hematuria noticed by the patient?

No.

It is diagnosed on UA after treatment for UTI or a routine UA. 

8

Prevelance of microscopic hematuria

High in older people

High in women

9

Prevelance of a serious disease (cancer) is higher in patients with ______ hematuria, however _____ hematuria can also indicate significant GU pathology. 

Gross

Microscopic 

10

Non-glomerular microscopic hematuria can be indicative of what?

Bladder cancer

 

11

What are risk factors for bladder cancer?

  1. Smoking
  2. Aniline dyes in leather, tire and rubber factories
  3. Heavy phenacetin use 
  4. Past use of high doses of cyclophosphamide 
  5. Herbal weight-loss preps with aristolochic acid found in

12

All patients with a single episode of gross hematuria need what?

  • 1. Thorough H & P
  • 2. Urologic or nephrologic evaluation
    • Unless a self-limited transient cause is found (trauma, infection, menses, exercise-induced).
      • However, even if the patient has transient causes, if significant risk factors for maligancy are found, eval further. 

13

Is one episode of microscopic hematuria less serious than recurrent episodes?

NO.

14

Hematuria in patients receiving anticoagulation therapy should/should not be solely attributed to anticoagulant.

Should not

15

Blood in the urine can be an ____ and cause _____, even without a UTI or kidney stones.

irritant

dysuria

16

Because ____ men with microscopic/gross hematuria are more likely to have a GU malignancy, we should evaluate for it even in the prescense of what ?

Older men

Symptoms of BPH (nocturia, polyuria and decreased force of urinary stream)

17

What can help us define a patients diagnosis more accuretely and why?

Determining glomerular vs. non-glomerular causes of hematuria, because there is alot of overlap in microscopic and gross hematuria. 

18

What are alarm symptoms associated with hematuria?

  1. Increased age (>40-50); Males
    • increased risk of neoplasm (cancer)
  2. Constituional symptoms (WL, loss of appetite, chronic malaise, fatigue)
    1. Cancer or infection
  3. Personal and social history factors that increase risk of cancer
    1. Smoking 
    • Aniline dyes in leather, tire and rubber factories
    • Cyclophosphamide 
    • Pelvic irradiation
    • WL herbal preparations that contain aristolochoic acid
  4. + family history of deafness or renal disease 
    • Alport syndrome, a familial diseaes

19

___________ hematuria is always pathologic.

True macroscopic hematuria

20

Microscopic (nonvisible) hematuria can be ______, ______ or _____.

Transient, spurious, persistant 

21

What are the differences between the transient and spurious causes of microscopic hematuria?

  • Transient causes: UTIs (which can also cause macroscopic) and strenous exercise 
    • Hematuria goes away on repeat testing 48 hours later or after not exercising for 72 hours. 
  • Spurious causes: urinary contamination from mentstruation and sexual intercourse

22

DDx of hematuria is divided into what?

1. Microscopic hematuria

2. Macroscopic hematuria

23

If there is considerable overlap in the causes of microscopic and macroscopic hematuria, it may be most pracitical to consider what?

If the hematuria is glomerular in origin.

24

How can we distinguish if hematuria is glomerular/non-glomerular in origin?

  • 1. Dysmoprhic RBC (acanthocytes)
  • 2. Red cell casts
  • 3. New or acutely worsening HTN or proteinuria
  • 4. Increased creatnine. 

THESE ARE NOT found when hematuria is d/t renal structural abnormality or abnormality distal to kidneys.

25

Visible clots indicate what type of cause? 

Lower urinary tract, NOT glomerular cause. 

26

What are the 2 categories of non-glomerular causes of hematuria?

1. Lower UT source (may see visible clots)

2. Upper UT source

27

What are examples of lower UT sources that cause hematuria?

  • 1. Urethritis
  • 2. BPH
  • 3. Cystitis
  • 4. Bladder/prostate cancer
  • 5. Exercise

28

What are examples of upper UT sources that cause hematuria?

  1. Ureteral calculus 
  2. Renal calculus
  3. Hydronephrosis
  4. Pyelonephritis 
  5. PCKD
  6. Hypercalciuria
  7. Papillary necrosis 

29

What are the 3 categories of glomerular causes of hematuria?

1. Primary glomerulonephropathies

2. Secondary glomerulonephropathies

3. Familial

30

Primary glomerulonephritis that causes hematuria?

  1. IgA nephropathy
  2. Postinfectious 
  3. Idiopathic (FSGS)

31

Secondary glomerulonephritis that causes hematuria?

  1. SLE
  2. Wegners
  3. Other vasculitis 

32

Familial glomerular causes that causes hematuria?

  1. TBMD (benign familal hematuria)
  2. Hereditary nephritis (Alport)

33

What is essential to diagnose renal cell carcinoma?

  • 1. Gross/microscopic hematuria (60% of pts)
  • 2. Flank pain/mass (30% of pts)
  • 3. Systemic symptoms (fever, WL)
    • fever d/t paraneoplastic syndrome
  • 4. Solid renal mass on imaging

34

Renal cell carcinoma occurs most often in whom and assx with what risk factor?

  • 60s
  • Males
  • Cigarette smoking

35

Renal cell carcinoma occurs in increased frequency in which familial disorders and what disease?

  • Familial
    • von-Hippel Lindau syndrome
    • Hereditary papillary RCC
    • Hereditary leiomyoma RCC
  • Acquired cystic disease in dialysis pts

36

DDx of RCC

  • 1. Angiomyolipomas 
  • 2. Renal pelvis urothelial cancers 
  • 3. Renal oncocytomas 
  • 4. Renal abscesses
  • 5. Adrenal tumors 

37

What 3 findings will be seen on lab in RCC?

1. Hematuria

2. Paraneoplastic syndromes

3. Erythrocytosis d/t increase EPO (~5%)

38

What is the most valuable imaging tests for RCC, which will confirm the mass and stage of lesion.

1. CT

2. MRI

 

39

Other imaging studies for RCC to detect:

- Solid renal mass

- Pulmonary metases 

- Large tumors/bone pain

- thrombus in renal vein

  • 1. Abdominal US or CT if a solid renal mass is present
  • 2. CXR for pulmonary metases
  • 3. Bone scans or high alkaline phosphatase levels 
  • 4. MRI and duplex doppler US to assess thrombus in renal vein

40

RCC prognosis:

- Tumors confined to renal capsule (T1-T2): _______ 5 year survial after radical nephrectomy

- Tumors beyond renal capsule (T3-T3) and node-positive tumors: _______ 5 year survial 

  • 90-100%
  • 50-60% (T3-T4)
  • 0-15% (if nodes are present)

41

Patient has RCC. If they present with the following findings, who do we refer them to

  • - Solid renal masses or complex cysts
  • - RCC
  • - Metastatic disease

  1. urologist 
  2. urologic surgeon for remove
  3. oncologist

42

IgA nephropathy is associated with IgA deposition in the glomerular mesanguim. 

Inciting cause is ________. 

Primary or secondary disease?

  • Unknown
  • Either
  • Primary (renal limited)
  • Secondary d/t:
    • cirrohosis
    • celiac DZ
    • HIV
    • CMV

43

IgA nephropathy is the most common _______

Primary glomerular disease in the world, esp Asia

44

What is the common clinical picture of IgA Nephropathy?

Child/young male that has gross hematuria 1-2 days after onset of viral URI. 

-UA shows worsening hematuria + RBC casts with (-) serologies for other GN

45

Pts with IgA nephopathy present where on nephritic syndrome?

anywhere from asymptomatic microscopic hematuria => RPGN.

46

Gross hematuria is uncommon with ___________, but is common in what?

  • Uncommon: intrinsic kidney disease
  • Common: IgA nephropathy and cyst rupture in ADPKD

47

IgA nephropathy

 

  • Serum compliment levels: _____
  • Renal biopsy: _______
  • LM: ________
  • IF: __________

  • Serum compliment levels: NL
  • Renal biopsy: +IgA staining 
  • LM: focal glomerulonephritis with proliferation of mesangial cells 
  • IF: diffuse mesengial IgA and C3 deposits

48

Is IgA nephropathy a benign condition?

NO. Almost 40% get ESRD after 20 years

49

What confirms the diagnosis of IgA nephropathy?

Renal biopsy with IgA deposits in mesangium, bc serum IgA levels have low sensitivity and specificity

50

How do we score pathology if IgA Nephropathy?

Oxford IgA Nephropathy MEST classification

  • Mesangial hypercellularity
  • Endocapillary hypercellularity
  • Segmental glomerulosclerosis
  • Tubular atrophy/interstitial fibrosis

51

Prognosis of IgA Nephropathy is good when __________.

When do we conduct a kidney biopsy?

  • NL function and low proteinuria
  • Pts with sustained proteinuria >1g/day or worsening kidney function

52

Lab tests in IgA Nephropathy

  • UA: 
  • Serum creatinine:
  • Urine protein-to-creatinie ratio:
  • Serum IgA:

  • UA: RBC, RBC casts, proteins 
  • Serum creatinine: may be high
  • Urine protein-to-creatinie ratio: mild increase in proteinuria
  • Serum IgA: high in only 50% of pts

53

Medullary sponge kidney (MSK) presents ______ and is diagnosed ________.

at birth

40/50s, incidentally

54

Patients with MSK present how?

1. Gross/microscopic hematuria,

2. Recurrent UTIs

3. Nephrolithiasis (kidney stones); calcium ox/phos

4. Problem concentrating urine (hyposthuria) and nephrocalcinosis