Figure 61-2 Approach to the patient with hematuria.
1. Hematuria.
-blood may be present in the urine either in the form of intact red blood cells (hematuria) or as the product of red blood cell
destruction, hemoglobin (hemoglobinuria)
-isolated hematuria without proteinuria, other cells, or casts is often indicative of bleeding from the urinary tract
-defined as two to five RBCs per high-power field (HPF) and can be detected by dipstick
false-positive results if there are presence of strong oxidizing agents, bacterial peroxidases, menstrual contamination and
rhabdomyolysis (which causes myoglobinuria)
false-negative results if high specific gravity/crenated cells, use of formalin and captopril, presence of high concentrations
of nitrite and ascorbic acid (> 25 mg/dL)
-common causes of isolated hematuria include stones, neoplasms, tuberculosis, trauma, and prostatitis
-gross hematuria with blood clots usually is not an intrinsic renal process; rather, it suggests a postrenal source in the urinary
collecting system
-a single urinalysis with hematuria is common and can result from menstruation, viral illness, allergy, exercise, or mild trauma
-persistent or significant hematuria (>3 RBCs/ HPF on three urinalyses, a single urinalysis with >100 RBCs, or gross hematuria) is
associated with significant renal or urologic lesions in 9.1% of cases
2. Presence of hematuria WITHOUT proteinuria and dysmorphic RBCs or RBC casts.
a. Check for the presence of pyuria and WBC cast
-if positive, perform urine culture and check for the presence of urine eosinophils
urine culture to check for urinary tract infections
urine eosinophils for the diagnosis of acute interstitial nephritis
b. If negative pyuria and WBC cast
-perform Hemoglobin electrophoresis, Urine cytology, UA of family members and 24h urinary calcium/uric acid
urine cytology to look for abnormal cells in the urine
hypercalciuria and hyperuricosuria are risk factors for unexplained isolated hematuria in both children and adults
c. If negative Hemoglobin electrophoresis, Urine cytology, UA of family members and 24h urinary calcium/uric acid
-perform IVP (intravenous pyelography) +/- Renal ultrasound
d. IVP (intravenous pyelography) +/- Renal ultrasound
-IVP is a form of imaging of the renal pelvis and ureter
-if positive, do retrograde pyelography or arteriogram or cyst aspiration (as indicated)
-if negative, do Cystoscopy
e. Cystoscopy
-an endoscopy of the urinary bladder via the urethra
-if positive, perform Urogenital biopsy and evaluate
-if negative, perform Renal CT Scan
f. Renal CT Scan
-if positive, perform renal biopsy of mass/lesion for definitive diagnosis
-if negative, FOLLOW PERIODIC URINALYSIS
3. Presence of hematuria WITH proteinuria (>500 mg/24 hr) and dysmorphic RBCs or RBC casts.
-dysmorphic RBCs are of glomerular in origin
-hematuria with dysmorphic RBCs, RBC casts, and protein excretion >500 mg/d is virtually diagnostic of glomerulonephritis
a. perform Serologic and Hematologic evaluation:
Blood cultures
Anti-GBM antibodies- to check presence of an autoimmune disorder in which circulating antibodies are directed
against an antigen normally present in the GBM and alveolar basement membrane
ANCA- antineutrophil cytoplasmic antibody; to check presence of Granulomatosis with Polyangiitis (Wegener
Granulomatosis)
Complement levels
Cryoglobulins
Hepatitis B and C serologies
VDRL- to check presence of syphilis
HIV
ASLO- antistreptolysin O; to check presence of recent strep infection
b. perform Renal Biopsy for definitive diagnosis
Figure 61-3 Approach to the patient with proteinuria.
1. Investigation of proteinuria initiated by a positive dipstick on routine urinalysis.
-the dipstick measurement detects only albumin
-false-positive results if pH >7.0; high specific gravity; when the urine is very concentrated or contaminated with blood;
presence of pigmented specimens (phenazopyridine), quaternary ammonium compounds (detergents), antiseptics,
chlorhexidine
-false-negative results if urine is very dilute; presence of proteins other than albumin (such as Bence-Jones proteins in the
urine of patients with multiple myeloma); microalbuminuria
2. Quantification of urinary albumin.
-24-h urine collection (mg/24 h) of protein and albumin
-spot urine sample (ideally from a first morning void) to measure albumin-to-creatinine ratio (ACR)
3. Microalbuminuria.
-30-300 mg/d or 30-300 mg/g
-onset of renal complications can first be predicted by detection of microalbuminuria
-to consider:
Early diabetes: the development of diabetic nephropathy leading to reduced glomerular filtration and eventual renal
failure is a common occurrence in persons with both type 1 and type 2 DM.
Essential hypertension
Early stages of GN (especially with RBCs and RBC casts)
-the progression of renal disease can be prevented through better stabilization of blood glucose levels and control of
hypertension
-presence of microalbuminuria is also associated with an increased risk of cardiovascular disease
4. Macroalbuminuria.
-300-3,500 mg/d or 300-3,500 mg/g
-in addition to disorders listed under microalbuminuria, consider:
Myeloma-associated kidney disease: in multiple myeloma, a proliferative disorder of the immunoglobulin-producing
plasma cells, the serum contains markedly elevated levels of monoclonal immunoglobulin light chains (Bence Jones
protein). This low molecular-weight protein is filtered in quantities exceeding the tubular reabsorption capacity and is
excreted in the urine. Check with UPEP, urine protein electrophoresis.
Intermittent proteinuria, Postural proteinuria, Congestive heart failure, Fever, Exercise
5. Nephrotic range.
- >3,500 mg/d or >3,500 mg/g
-when the total daily urinary excretion of protein is >3.5 g, hypoalbuminemia, hyperlipidemia, and edema are often present
as well
-Nephrotic Syndrome:
Diabetes, Amyloidosis, Minimal Change Disease, FSGS, Membranous Glomerulopathy, IgA nephropathy
