Hematuria resident survival guide

Hematuria Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]

Overview

Presence of >5 red blood cells (RBCs) per high-power microscopic field in the urine is called hematuria. It can have either benign or malignant etiology. Patients with hematuria could be asymptomatic. Therefore, all patients presenting with a single episode of haematuria require urgent investigation. Microscopic hematuria, or microhematuria (MH), is defined as the presence of RBC on microscopic examination of the urine not evident on visual inspection of the urine. The prevalence of MH among healthy participants in screening studies is 6.5% (95% confidence interval [CI] 3.4 to 12.2), with higher rates in studies with a predominance of males, older patients, and smokers.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Intraperitoneal bladder rupture

• Ureteroarterial fistula

• Hemorrhagic cystitis

• Heart failure

• Malignant hypertension

• Shock

Common Causes

Children	Age <50 years	Age >50 years
Urinary tract infection Benign familial hematuria or Thin basement membrane disease IgA nephropathy Idiopathic hypercalciuria Transient unexplained	Urinary tract infection Transient unexplained Stones Exercise Trauma Polycystic kidney disease	Urinary tract infection Transient unexplained Stones Benign prostatic hyperplasia Bladder cancer Renal carcinoma Prostate cancer

Diagnosis

The approach to diagnosis of hematuria is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of hematuria.

Seek proper history: ❑ Onset ❑ Progression ❑ Pain/burning on urination ❑ Fever ❑ Abdominal pain/flank pain ❑ Polyuria, frequency ❑ Straining during urination ❑ Nocturia ❑ Weak stream ❑ Dribbling

Examine the patient: ❑ Tachypnea ❑ Cold and clammy skin ❑ Hypotension ❑ HEENT signs: Conjunctival pallor Jaundice ❑ Cardiovascular exam: Tachycardia Systolic murmur ❑ Abdominal exam: Enlarged spleen RUQ pain may indicate bilirubin gallstones ❑ Skin exam: Pallor of nail beds, palmar creases Bronze skin colour in case of repeated transfusions Leg ulcers ❑ Fever and neurological signs are seen in TTP ❑ Hemoglobinuria in some cases

Initial workup for hemolysis: ❑ Indirect bilirubin ❑ serum haptoglobin ❑ Lactate dehydrogenase level ❑ Reticulocyte count ❑ Urinalysis

Peripheral blood smear

No laboratory evidence of hemolysis

Consider differential diagnosis ❑ Iron deficiency anemia ❑ Anemia of chronic disease ❑ Vitamin B12 deficiency ❑ Folate deficiency

Degmacytes

Normal cell morphology

Spherocytes

Elliptocytes

Shistocytes

Sickle shaped cells

Hypochromic, microcytic cells

G6PD deficiency

❑ Family history ❑ Drug history ❑ Recent infections

Coomb's test

Hereditary elliptocytosis

Sickle cell disease

H/o exercise, exertion, trauma or surgery?

Beta thalassemia

Negative

Positive

Yes

No

CD55/59

❑ Drug induced hemolytic anemia ❑ Autoimmune disease

❑Exercise induced hemolysis ❑Prosthetic heart valve ❑Severe aortic stenosis

Microangiopathic hemolytic anemia

Positive

Negative

Pre-eclampsia and eclampsia

Recent diarrhea

Decreased ADAMTS13 activity

Paroxysmal nocturnal hemoglobinuria

Hereditary spherocytosis

HELLP syndrome

Hemolytic uremic syndrome

Thrombotic thrombocytopenic purpura

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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