Hematuri IPD 2014(1)

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HEMATURIABASIC COURSE OF DIAGNOSIS

CHOLINA TRISA SIREGAR

DEPARTEMEN KMB 2014

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DEFINITION

- Darah yang ditemukan dlaam urin baik

mikroskopok maupun makroskopik.

- > 3 RBC/HP

Normal urine:

- Tidak ditemukan sel darah merah atau kurang

dari tiga sel darah merah yang.

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According to the amount of RBC in the

urine, hematuria can be classified as:

microscopic hematuria:

normal colour with eyes

gross hematuria (macroscopic):

tea-colored, cola-colored, pink oreven red

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HAEMATURIA

Macroscopic tejadi bila sedikitnya 1cc darah/liter urin.

Microscopic > 5 RBCs per high powered field Red urine

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Causes of heme-negative red urine

Medications Food dyes Metabolities

Doxorubicin Beets (in selected patients) Bile pigments

Chloroquine Blackberries Homogentisic acid

Deferoxamine Food coloring Melanin

Ibuprofen Methemoglobin

Iron sorbitol Porphyrin

Nitrofurantoin Tyrosinosis

Phenazopyridine Urates

PhenolphthaleinRifampin

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Haematuria

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etiologi

A patients history of kidney or bladder

stones, urinary infection, or bladder tumors

may indicate that the problem has returnedand is the source of the bleeding. In some

cases, certain medicines, such as

anticoagulants that thin the blood or aspirin,can cause bleeding either from an

underlying medical condition or from the

upper or lower urinary tract.

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ETIOLOGY

Diseases of the urinary systemthe mostcommon cause

Vascular

arteriovenous malformationarterial emboli or thrombosis

arteriovenous fistular

nutcracker syndrome

renal vein thrombosisloin-pain hematuria syndrom

cogulation abnormality

excessive anticogulation

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kidney disease

abnormal blood coagulation

sickle cell disease

infection kidney stones

obstruction, blockage or injury of the

kidney or ureter

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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 diseasesacute pyelonephritis

tuberculosis

renal allograft rejection

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Uroepithelium

malignancy

vigorous excise

trauma

papillary necrosis

cystitis/urethritis/prostatitis(usually caused by infection)parasitic diseases (e.g. schistosomiasis)

nephrolithiasis or bladder calculi

Mul tiple sites or source unknown

hypercalciuria

hyperuricosuria

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System disorders

a. Hematological disorders

aplastic anemia leukemiaallergic purpura hemophilia

ITP (idiopathy thrombocytopenic purpura)

b. I nfection

infective endocarditis

septicemia

epidemic hemorrhagic fever (Hantaan virus)

scarlet fever (-hemolytic streptococcus)

leptospirosis (leptospire)

filariasis (Wuchereria bancrofti, Brugia malayi)

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c. Connective tissue diseases

systemic lupus erythematosus (SLE)

polyarteritis nodosa

d. Cariovascular diseases

hypertensive nephropathychronic heart failure

renal artery sclerosis

e. Endocrine and metabol ism diseasesgout

diabetes mellitus

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Diseases of adjacent organs to urinary tract

appendicitis salpingitiscarcinoma of the rectum

carcinoma of the colon

uterocervical cancer

Drug and chemical agents

sulfanilamides anticogulation

cyclophosphamide mannitol

miscellaneous

exercise idopathic hematuria

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CLINICAL FEATURE

Color

depends on the amount of red blood cell

in the urine and the pH

normal: l ight yel low, pH 6.5

pH

acidic: more darker (brown or black)

alkaline: red

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DIFFERENTIAL DIAGNOSIS

Polluted urine: menstruation

Drug and food: phenosulfonphtha lein (PSP),uric

acid, vegetable

Porphyrism: porphyrin in urine (+)

Hemoglobinuria

hemolysissoy-like, very few RBC under the microscopy

occult blood test (+)

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Hematuria

Patient comes to your office complaining

that their urine is reddish in color...

What is your first step?

Good H+P

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Hematuria

Is it really blood?

Urine Dipstick

Detects Hgb, myoglobin

Detects protein

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Hematuria

Urinalysis

Definitive for the presence of RBC

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Hematuria

Upper urinary tract glomerulus

collecting tubules

interstitium

Lower urinary tract calyx

pelvis

ureter

bladder

urethra

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Differential Diagnosis

glomerular*prompt eval for kidney dz

with

proteinuria

extraglomerular

without

proteinuria

+ RBCs

Hgbmyoglobin

heme +

drugsdyes

heme -

- RBCs

Macroscopic Hematuria

obtain U/A

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Glomerular Hematuria

brown, tea colored urine

proteinuria

deformed urinary RBCs

RBC casts

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Glomerular Hematuria

RENAL

IgA nephropathy

Alport syndrome Thin glomerular BM disease

Post infectious

MPGN

MULTI-SYSTEM

SLE nephritis

HSP nephritis Wegener syndrome

Goodpasture syndrome

HUS

Sickle cell Disease

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Extraglomerular Hematuria

Hematuria from lower urinary tract

terminal hematuria

blood clots

nl urinary RBCs

minimal proteinuria

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Extraglomerular Hematuria

UPPER URINARY TRACT

pyelonephritis

ATN

papillary necrosis

nephrocalcinosis

thrombosis

malformation

SCD tumor

PCKD

LOWER URINARY TRACT

cystitis

urethritis

urolithiasis

trauma

coagulopathy

heavy excersise

UPJ obstruction ureterocele

Munchausen, MBP

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LABORATORY TESTS

Three-glass test

Method:collecting the three stages of urine of

a patient during micturition

Result:

the initial specimen containing RBCthe urethra

the last specimen containing RBCthe bladder

neck and trianglar area, posturethra

all the specimens containing RBCupper urinary

tract, bladder

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Phase-contrast microscopy

to distinguish glomerular from post glomerular

bleeding

post glomerular bleeding:normal size and shape

of RBC

glomerular bleeding:dysmorphic RBC(acanthocyte)

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EXAMPLE OF PHASE-CONTRAST

MICROSCOPY TEST (non-glomerlar)

RBC MCV: 92.8 um3

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EXAMPLE OF PHASE-CONTRAST

MICROSCOPY TEST (glomerlar)

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ACCOMPANIED 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

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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

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Pasienbaru dgn hematuri mikroskopik asimtomatik

Singkirkan: menstruasi, olah raga over, sex activity, infeksi virus,

infeksi bakteri,trauma

Bila ditemuka 1 /lebih:Hematuri mikroskopik+proteinuria **,

Eritrosit, silinder eritrosit,

peningkatan kreatinin

Evaluasi penyakit ginjal perifer

Ada riwayat : merokok, bekerja dgnbahan kimia,

riwayat gross hematuri

- Usia > 40 tahun- gangguan penyakit urologi

- gangguan pengosongan blader

- ISK berulang

Evaluasi urologi

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Physical Examination Findings and Associated

Causes of Hematuria

Physical examination finding Cause of hematuria

General (systemic) examination

Severe dehydration Renal vein thrombosis

Peripheral edema Nephrotic syndrome, vasculitis

Cardiovascular system

Myocardial infarction Renal artery embolus or thrombusAtrial fibrillation Renal artery embolus or thrombus

Hypertension Glomerulosclerosis with or without

proteinuria

Abdomen

Bruit Arteriovenous fistula

Genitourinary system

Enlarged prostate Urinary tract infection

Phimosis Urinary tract infection

Meatal stenosis Urinary tract infection

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