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HEMATURIA BASIC COURSE OF DIAGNOSIS. Xiaoqi Xu Renji Hospital Shanghai Second Medical University. CONTENT. Definition of hematuria Etiology Clinical feature Differential diagnosis Laboratory tests Accompanied symptoms. DEFINITION. - PowerPoint PPT Presentation
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HEMATURIAHEMATURIABASIC COURSE OF DIAGNOSISBASIC COURSE OF DIAGNOSIS
Xiaoqi Xu
Renji Hospital
Shanghai Second Medical University
CONTENTCONTENT
Definition of hematuria Etiology Clinical feature Differential diagnosis Laboratory tests Accompanied symptoms
DEFINITIONDEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field microscopy
( > 3 RBC/HP).
Normal urine:
no red blood cell or less than three red blood cell
According to the amount of RBC in the According to the amount of RBC in the urine, hematuria can be classified as:urine, hematuria can be classified as:
microscopic hematuria:
normal colour with eyes
gross hematuria:
tea-colored, cola-colored, pink or
even red
ETIOLOGYETIOLOGY
Diseases of the urinary system—the most common cause
Vascular arteriovenous malformation arterial emboli or thrombosis arteriovenous fistular nutcracker syndrome renal vein thrombosis loin-pain hematuria syndrom cogulation abnormality excessive anticogulation
Glomerular
IgA nehropathy
thin basement membrane disease (incl.Alport syndrome)
other causes of primary and secondary glomerulonephritis
Interstitial
allergic interstitial nephritis
analgesic nephropathy
renal cystic diseases
acute pyelonephritis
tuberculosis
renal allograft rejection
Uroepithelium
malignancy
vigorous excise
trauma
papillary necrosis
cystitis/urethritis/prostatitis(usually caused by infection)
parasitic diseases (e.g. schistosomiasis)
nephrolithiasis or bladder calculi
Multiple sites or source unknown
hypercalciuria
hyperuricosuria
System disorders a. Hematological disorders
aplastic anemia leukemia allergic purpura hemophilia ITP (idiopathy thrombocytopenic purpura)
b. Infection
infective endocarditis septicemia epidemic hemorrhagic fever (Hantaan virus) scarlet fever (-hemolytic streptococcus) leptospirosis (leptospire) filariasis (Wuchereria bancrofti, Brugia malayi)
c. Connective tissue diseases systemic lupus erythematosus (SLE) polyarteritis nodosa
d. Cariovascular diseases hypertensive nephropathy chronic heart failure renal artery sclerosis
e. Endocrine and metabolism diseases gout diabetes mellitus
Diseases of adjacent organs to urinary tract appendicitis salpingitis carcinoma of the rectum carcinoma of the colon uterocervical cancer
Drug and chemical agents sulfanilamides anticogulation cyclophosphamide mannitol
miscellaneous exercise “idopathic” hematuria
CLINICAL FEATURECLINICAL FEATURE
Color
depends on the amount of red blood cell in the urine and the pH (see slide 4)
normal: light yellow, pH 6.5pH
acidic: more darker (brown or black)
alkaline: red
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
Polluted urine: menstruation
Drug and food: phenosulfonphtha lein (PSP),uric
acid, vegetable
Porphyrism: porphyrin in urine (+)
Hemoglobinuria
hemolysis
soy-like, very few RBC under the microscopy
occult blood test (+)
HEMOGLOBINURIAHEMOGLOBINURIA
RBC abnormality Defects of RBC membrane structure and function
(hereditary spherocytosis)
Deficiency of enzymes (favism)
Hemoglobinopathy (thalassemia)
PNH
Mechanical factor (artificial heart valve), infection
or mismatched blood transfusion
LABORATORY TESTSLABORATORY TESTS
Three-glass test
Method: collecting the three stages of urine of
a patient during micturition
Result:
the initial specimen containing RBC—the urethra
the last specimen containing RBC—the bladder
neck and trianglar area, posturethra
all the specimens containing RBC—upper urinary
tract, bladder
Phase-contrast microscopy
to distinguish glomerular from post glomerular
bleeding
• post glomerular bleeding: normal size and shape
of RBC
• glomerular bleeding: dysmorphic RBC
(acanthocyte)
EXAMPLE OF PHASE-CONTRAST EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST MICROSCOPY TEST (non-glomerlar)(non-glomerlar)
RBC MCV: 92.8 um3
EXAMPLE OF PHASE-CONTRAST EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST MICROSCOPY TEST (glomerlar)(glomerlar)
ACCOMPANIED SYMPTOMSACCOMPANIED SYMPTOMS
Hematuria with renal colic
renal stone, ureter stone
if with dysuria, miction pause or staining to void: bladder or urethra stone
Hematuria with urinary frequency,urgency and dysuria
bladder or lower urinary tract (tuberculosis or tumor)
if accompanied by high spiking fever, chill and loin pain: pyelonephritis
Hematuria with edema and hypertension
glomerulonephritis
hypertensive nephropathy
Hematuria with mass in the kidney
neoplasm
hereditary polycystic kidney
Hematuria with hemorrhage in skin and mucosa
hematological disorders
infectious diseases
Hematuria with chyluria
filariasis
--Approaching to the patient–
(Harrison’s Principle of Internal Medicine,14th Ed)
HEMATURIA
proteinuria (>500mg/24h)
Dysmorphic RBC or RBC casts
Pyuria,WBC casts urine culture eosinophils
serologic and hematologic evaluation: blood culture, anti-GBM Ab, ANCA, complement, cryoglobulin HBV,HCV,VDRL,HIV, ASLO
renal biopsy
Hb electrophoresis, urine cytology, UA of family member, 24h urinary calcium/uric acid
IVP+/-renal ultrasound
As indicated: retrograde pyelography or arteriogram of cyst aspiration
cystoscopy
CT scan
biopsy
open renal biopsy
follow
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(+)
(+)
(+)
(+) ANCA:antineutrophil cytoplasmic antibody, VDRL:venereal dis. research laboratory, ASLO: antisteptolysin O, IVP: intravenous pyelography