Hematuria laboratory findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Steven C. Campbell, M.D., Ph.D. Adnan Ezici, M.D[2] Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [3]

Overview

Patients with GH must be assessed for hemodynamic stability with careful attention to vital signs, anemia with a complete blood count, and, for patients on anticoagulation, coagulation parameters to ensure that levels are within the therapeutic range. After initial stabilization, diagnostic evaluation should then proceed, with cause-specific management. Often, the diagnosis is made on the basis of the medical history and urine and blood tests—especially in young people in whom the risk of malignancy is negligible and the symptoms are generally self-limited.

Diagnosis

Urinalysis

Urinalysis is a helpful test to diagnose renal and urological diseases. The urine dipstick test for blood initially identifies patients with microscopic hematuria. The urine sediment should be obtained from the mid stream of first voiding in the morning and should be evaluated within 1-2 hours. Red blood cell amount in the urine sediment should be less than 2 or 3 per high power field to exclude hematuria. If red blood cells in the urine sediment are more than 2 or 3 per high power field, at least one more urinalysis might be required to confirm hematuria. The urine microscopic evaluation not only confirms hematuria but also helps differentiate glomerular from non-glomerular sources of bleeding. In glomerular hematuria, the RBCs are exposed to large changes in pH and osmotic pressure as they go through the renal tubules, making them dysmorphic.  In non-glomerular hematuria, the RBCs tend to be homogeneous and normal in shape. The presence of proteinuria of 2+ or greater by dipstick also suggests glomerular hematuria.  

Microscopy findings

• Positive for urinary casts (suggesting renal disease)
• Urinary crystals (suggesting calculous disease)
• Dysmorphic red cells (suggesting a glomerular cause of hematuria)
• Atypical or malignant epithelial cells suggest a tumour.

Urine Cytology

Urine cytology might be recommended in patients with gross hematuria and/or symptomatic hematuria as an adjunct to cystoscopy. Its sensitivity is higher for high-grade bladder tumors and lower for low-grade tumors; only 15% of patients with “atypical and/or suspicious” cytologic findings may have underlying urinary tract malignancy. Poorly-adhesive grossly abnormal cells are suggestive of poorly differentiated tumors and carcinoma in-situ.

Urine Tumor Markers

Urine tumor marker tests detect antigens and other substances unique to cancer cells, mostly of the bladder, including the bladder tumor antigen (BTA) test, nuclear matrix protein 22 (NMP22), carcinoembryonic antigen (CEA), cytokeratin tissue polypeptide-specific antigen (TPS), fluorescence in situ hybridization (FISH) assay, Lewis X antigen, telomerase activity, and urinary bladder cancer tumor marker (UBCTM) tests. Food and Drug Administration (FDA) approved the use of BTA and NMP22 together with cystoscopy for the diagnosis of bladder cancer. However, the use of BTA and NMP22 without cystoscopy is associated with false-positive results.

Urine Culture

Detects bacterial cause of UTI particularly from those with irritative voiding symptoms or a history of urinary tract infection.

Serum Creatinine and Calculation of Glomerular Filtration Rate

If the clinical evaluation and urinalysis suggest a glomerular (nephrological) cause of hematuria, then the renal function should be measured. Glomerular filtration rate (GFR) is the most reliable estimate of the renal function. GFR cannot be measured directly, so it is estimated using the urinary clearance of a filtration marker. Clearance is the rate at which a substance is cleared from the plasma by excretion in the urine. Serum creatinine is the most commonly used endogenous filtration marker.

Other Blood Tests

When suspecting a nephrological disease, other tests to consider would include complete blood count, blood urea nitrogen, coagulation studies, and serologic studies such as complement levels, antinuclear antibody (ANA), hepatitis B and C titers, antiglomerular basement membrane antibody, antineutrophilic cytoplasmic antibody (ANCA), antistreptolysin O titer (ASO), and cryoglobulin assay.