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Diagnostic approach Diagnostic approach of hematuriaof hematuria
Presented by Ri 陳柏璋
Definition of hematuriaDefinition of hematuria
Microscopic hematuria
> 5 RBCs / μl ( 3 RBCs / HPF )
Gross hematuria
> 2500 RBCs / μl
Causes of hematuria (1)Causes of hematuria (1)
Glomerular IGA nephropathy Postinfectious glomerulonephritis Familial glomerulonephritis RPGN MPGN Glomerulonephritis caused by systemic dz Subacute bacterial endocarditis Exercise
Causes of hematuria (2)Causes of hematuria (2)
Nonglomerular Renal (tubulointerstitial) infection, tumor, drug-induced, familial, vascular, metabolic Extrarenal Infection, stone, inflammation, tumor, stricture, endometriosis, BPH, congenital abnormalities
Causes of hematuria (3)Causes of hematuria (3)
Coagulopathy related Drug induced (warfarin/heparin) Secondary to systemic diseaseTraumaFactitious ex. Menstruation
Most common causes of hematurMost common causes of hematuria by age and sexia by age and sex
Age/sex Common causes0-20 AGN, UTI, congenital urinary tract anomalies with obstruction20-40 male UTI, stones, bladder tumor40-60 female bladder tumor, stone, UTI>60 male BPH, bladder tumor, UTI>60 woman Bladder tumor, UTI
History Taking (1)History Taking (1)
* Past history ( previous episodes, recent food and drug ingestion, exercise, instrumentation, menstruation…)* Dysuria ? Associated bladder irritability or flank pain ?* Time of hematuria initial: urethritis, stricture, meatal stenosis total: bladder, ureter, kidney terminal: bladder neck or prostatic urethra
History Taking (2)History Taking (2)
* Associated symptoms
Fever, chills, other bleeding point, dyspnea,
recent URI,
* Painless gross hematuria
consider tumor
Medical/Family and social Medical/Family and social historyhistory
* Drug history (analgesics, NSAID, chemotherapy agents)
* Coagulopathy
* Family history of PCKD or Alport’s syndrome
* Travel history: schistosomiasis
Physical ExaminationPhysical Examination
Vital signs, esp. BP and BTFlank tendernessEdemaCardiac murmurHemoptysisSuprapubic discomfortGenitourinary exam
Lab DataLab DataUrianalysis ( pH, protein, bacteria, cast ) Glomerular: RBC casts, RBC dysmorphism, hypochromic and hypocytic RBC Nonglomerular: Intact RBC, normocyticU/C, BUN, Cre, CBCAnticoagulation studyImmunologic profiles
Radiologic studyRadiologic study
* Trauma and stone disease
* Intravenous pyelogram (IVP)
Computed tomography (CT)
* Abdominal echo: of limited role
* Others:
retrograde urethrogram, cystogram
++
Evaluation of microscopic heEvaluation of microscopic hematuria in adults (1)maturia in adults (1)
Hematuria on dipstick testing repeat dipstick test urine microscopy for erythrocytes, casts, and bacteria Confirmation of hematuria
Evaluation of microscopic heEvaluation of microscopic hematuria in adults (2)maturia in adults (2)
Assessment History, Physical examination Serum urea, electrolytes, Cre. GFR Immunology (ANCA, ANA, anti-GBM, ASO) Ultrasound for kidney and bladder Urine cytology Coagulation exam
Evaluation of microscopic heEvaluation of microscopic hematuria in adults (3)maturia in adults (3)
Glomerular type hematuria
Dysmorphic RBCs with a low MCV and RBC casts Consideration for a renal biopsy
Evaluation of microscopic heEvaluation of microscopic hematuria in adults (4)maturia in adults (4)
Nonglomerular hematuria ( Isomorphic RBCs with a normal MCV) Adults > 45 y/o < 45 y/o . Urinary Ca excretion . Urinary Ca excretion . UA excretion . UA excretion . Cystoscopy . Renal biopsy . IVP . Echocolor Doppler . CT ? Angio ? . Renal biopsy
Treatment and Management Treatment and Management (1)(1)
Gross hematuria : Note vital signs Severe: three-way, large-bore Foley to prevent acute urinary retention by blood clot Watch out renal function, anemia, coagul
opathy Consult urologist Painless gross hematuria: tumor workup
Treatment and Management Treatment and Management (2)(2)
Microscopic hematuria Repeated followup If persistent full urologic evaluation ( > 3 RBCs / HPF on at least 2/3 proper U/A, or a single episode of > 100 RBC / HPF )
Treatment and Management Treatment and Management (3)(3)
Glomerulonephropathies Supportive care at ER Dialysis for severe hyperkalemia, fluid overload and uremia Antibiotics for susptected infection Steroid for RPGN
Thanks for your direction !!