Week 3: Clinical evaluation of hematuria Flashcards Preview

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Flashcards in Week 3: Clinical evaluation of hematuria Deck (12):

Definition of hematuria.

Normally 3 RBC/HPF is considered abnormal
-occasionally 3-10 RBCs can be found in normal individuals


Describe the patterns of hematuria.

1. Macroscopic: brownish-red urine, coffee or tea colored. May be bright read when bleeding is active or in alkaline urine
2. Microscopic: abnormal amounts of RBCs detected only microscopic examination of urinary sediment.
3. persistent or transient: transient is common in young adults with no obvious cause. In older patients, transit hematuria has risk of malignancy. Persistent hematuria in patients>40 requires full evaluation
4. symptomatic or asymptomatic
5. Time-based on 3 cup urine test
-initial -urethra
-total: kidney/ureter


What may be the causes of red urine? How to differentiate using dipstick test or presence of RBCs?

If dipstick is negative, consider
-beets, bilirubin, rifampin, carrots, rhubarb, laxatives, porphyria
If dipstick is positive, and RBCs are present after centrifugation
-consider renal causes
If dipstick is positive, and RBCs are absent
-myoglobin from crush injury


What are non-renal causes of hematuria?

-after physical activity: diagnosis of exclusion and must be temporarily related to exercise. Must be differentiated from myoglobinuria due to rhabdomyolysis
-contamination by mentrual blood
-over-anticoagulation. High INR. Likelihood of GU malignancy


What are urinary tract causes of hematuria?

-stones -will have pain
-benign prostatic hypertrophy
-hemorrhagic cystitis (cyclophosphamide)
-radiation cystitis
-over anti coagulation


What are non-glomerular renal causes of hematuria?

-tumors (renal cell carcinoma)
-vascular disorders
-metabolic disorder (hypercalcicuria)
-renal malformation


What are glomerular causes of hematuria?

1. Isolated hematuria
-Familial causes:
a. Benign familial hematuria-thin basement membrane, mutations of Type IV collagen a4 gene
b. Alport's syndrome: X linked disease of type IV collagen a-3,4,5 gene. Associated with renal failure, deafness, and lens abnormalities of the eye
2. Nephritic syndrome
-hematuria, proteinuria, reduced renal function, HTN
-can be caused by:
a. low serum complement: lupus nephritis, post infectious GN, IgA, membranoproliferative GN, cryoglomulinemia
b. normal serum complement: anti-glomerular basement membrane, IgA


How do you distinguish between glomerular vs. extraglomerular hematuria on urinalysis?

1. Glomerular:
-red, smoky brown or coca cola color
-clots absent
-proteinuria may be >500 mg/day
-Dysmorphic RBC
-RBC casts present
2. Extraglomerular
-red or pink color
-clots may be present
-proteinuria <500 mg/day
-RBC morphology is normal
-RBC cast absent


What symptoms are connected to which renal diseases? (Things to look for in evaluating hematuria)

-Dysuria, frequency, pyuria: UTI
-flank pain, fever: pyelonephritis
-uteric colic: stones
-edema, oliguria: Acute GN
-URI 1-3 days: IgA nephropathy
-URI, 1-2 weeks: Post infectious GN
-weight loss: neoplasm
-Hesitancy, dribbling in men: benign prostatic hypertrophy
-bleeding from multiple sites: uncontrolled anticoagulation


What are risk factors for significant disease with findings of hematuria?

Smoking history
Occupational exposure to chemicals or dyes
History of gross hematuria
Age > 40 years
Analgesic abuse
History of pelvic radiation
History of cyclophosphamide use (hemorrhagic cystitis)


Describe workup for hematuria.

-hx and PE
-urinalysis for protein
-urine sediment for dysmorphic RBC, RBC casts
-imaging: ultrasound, IVP, CT, MRI


What are the major causes of acute nephritis, gripped by complement level?

1. Low serum complement
-post streptococcal GN
-mixed cryoglobulinemia
-membranoproliferative GN
2. Normal Serum Complement
-goodpasture syndrome
-IgA nephropathy
-Anti-GBM disease/ Goodpastures