Arch Hellen Med, 17(3), May-June 2000, 237-255
Evaluation of hematuria
G. TSOUFAKIS,1 K. TZANETOU2
1Department of Nephrology,
2Department of Microbiology, “G. Gennimatas” General Hospital, Athens, Greece
Hematuria is a common manifestation of urinary tract disease and its incidence increases with age. The possibility of discriminating the origin of hematuria between glomerular and non-glomerular sites has recently permitted a more rational investigation of its etiology. During their passage through the nephron, the erythrocytes are subjected to various influences resulting in changes of membrane morphology and hemoglobin content. Of the various dysmorphic erythrocytes which have been described, the acantshocytes are the most specific marker of glomerular hematuria. Glomerular hematuria may present clinically as (a) persistent microscopic hematuria, (b) persistent microscopic hematuria with proteinuria, (c) acute microscopic hematuria with proteinuria, (d) recurrent macroscopic hematuria with or without proteinuria and (e) loin-pain-hematuria syndrome. The most common disease associated with hematuria of the first category is IgA nephropathy, followed by certain forms of hereditary glomerular disease (Alport's syndrome and thin basement membrane nephropathy). In the second category the diagnostic approach is based on the degree of proteinuria and the level of renal function, but in most of these cases renal biopsy is necessary. Hematuria of the third category constitutes the main clinical manifestation of the acute nephritic syndrome, which must be investigated etiologically. The fourth category of glomerular hematuria essentially coincides with IgA nephropathy, which, together with thin basement membrane nephropathy and certain idiopathic cases, constitutes the main cause of the fifth category. The investigation of non-glomerular hematuria is based on the patient's age. Thus, in individuals younger than 45 years, in whom neoplasms are uncommon, the laboratory diagnostic tests include X-ray of kidney-bladder-prostate, culture of urine or prostatic secretion, measurement of calcium and uric acid in a 24-hour urine collection, cytologic examination of urine and intravenous pyelography, in that order. Conversely, in persons over 45 years old the investigation must be more thorough including, in order, X-ray, ultrasonography of kidney, intravenous pyelography, cytologic evaluation of the urine, cystoscopy, computerised tomography, testing for calciuria and uricosuria and in selected cases, magnetic resonance imaging or angiography.
Key words: Dysmorphic erythrocytes, Glomerular hematuria, Hematuria, Non-glomerular hematuria.