Hematuria differential diagnosis: Difference between revisions

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{| class="wikitable"
! rowspan="20" |Gross hematuria
! colspan="2" rowspan="2" |Causes of hematuria
! rowspan="2" |Sub-entity
! rowspan="2" |Causes and associations
! colspan="11" |History and Symtoms
! colspan="11" |Laboratory Findings
|-
!History
!Shaking, chills and rigors
!Fever
!Nausea/vomiting
!Dysuria
!Frequency
!Pitting edema
!Hypertension
!Hemoptysis
!Oliguria
!Peri-orbital edema (Facial puffiness)
!Urinalysis
!Cystoscopy
!Hyperlipidemia and hypercholesterolemia
!Nephrotic features
!Nephritic features
!ANCA
!Anti-glomerular basement membrane antibody (Anti-GBM antibody)
!Immune complex formation
!Light microscope
!Electron microscope
!Immunoflourescence pattern
|-
! colspan="2" |Urolithiasis (Renal stones)- may be microscopic
!
* Calcium oxalate stones
* Calcium phosphate stones
* Uric acid stones
* Magnesium ammonium phosphate stones
* Cysteine stones
!
* Low calcium diet
* Hyperparathyroidism
* Hypocalcemic hypercalciuria
* Anatomic abnormalities of the urinary tract
* Obesity
* Dehydration
* Diets rich in oxalate
* Urinary tract infection
* Increased or decreased urinary pH
!
* Episodic lower back pain radiating to the groin
!+/-
!+/-
!+
!+
!-
!-
!-
!-
!+
!-
!
* > 5 RBCs/hpf (exaggerated in gross hematuria)
!-
!-
!-
!-
!-
!-
!-
!-
!-
!-
|-
! colspan="2" |Renal tumors- may be microscopic
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Renal cysts
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Prostatitis
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Benign prostatic hyperplasia (BPH)- may be micrscopic
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" rowspan="6" |Anti-coagulant use- may be microscopic
!Oral anticoagulant use
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
!Heparin
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
!Aspirin
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
!Clopidogrel
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
!Ticlopidine
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
!Factor Xa inhibitors
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Bladder tumors- may be micrscopic
!Transitional cell carcinoma
!
* Male sex
* Past or current smoking
* Exposure to known carcinogenic agents or alkylating chemotherapeutic agents
!
* Age older than 35 years
* Exposure to chemicals or dyes (benzenes or aromatic amines)
* Chronic indwelling foreign body
* Chronic urinary tract infection
* Pelvic irradiation
!-
!-
!
!+/-
!+/-
!-
!-
!-
!-
!-
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Urinary tract infection- may be microscopic
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Tuberculosis
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Schistomsomiasis
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
|-
! colspan="2" |Hemorrhagic cystitis
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
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!
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|-
! colspan="2" |Renal infarction
!
!
!
!
!
!
!
!
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!
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!
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! colspan="2" |Recent urologic procedure
!
!
!
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!
!
|-
! rowspan="16" |Microscopic hematuria
! rowspan="10" |'''Glomerulonephritides'''
! rowspan="3" |Non-proliferative
!Minimal change disease
!
* Idiopathic
* Protein tyrosine phosphatase receptor type O (glomerular epithelial protein 1- GLEPP1)
!
* Young children
* Recent infection and immunization
* Atopy
* Hodgkin lymphoma
* Thrombosis (due to urinary loss of antithrombin-III)
!
!
!
!
!
!+
!-
!-
!+/-
!-
!
!
!+
!+
!-
!-
!-
!-
!
* Normal
!
* Fusion of podocytes
!-
|-
!Focal segmental glomerulosclerosis
|
* Idiopathic
* HIV
* Heroine use
* Sickle cell disease
* Interferon
* Severe obesity
* Mixed cryoglobunemia (Hepatitis C)
|
* Adults
|
|
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|
|
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
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| +
| +
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
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* Focal (some glomeruli) and segmental (only part of glomerulus)
|
* Effacement of podocytes
|<nowiki>-</nowiki>
|-
!Membranous glomerulonephritis
|
* Idiopathic
* Hepatitis B and C
* Solid tumors
* Systemic lupus erythmatosus
* Drugs (NSAIDS, penclliamine, gold, captopril)
|
|
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|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+/-</nowiki>
|<nowiki>-</nowiki>
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| +
| +
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
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* Thick glomerular basement membrance
|
* Sub-epithelial immune complex depositis with 'spike and dome' appearance
|<nowiki>-</nowiki>
|-
| rowspan="7" align="center" style="background:#4479BA; color: #FFFFFF;" + |Proliferative
|IgA nephropathy
|
* Idiopathic
* Viral infections
|
* Young children
* History of mucosal infections (e.g. gastroenteritis) and upper respiratory tract infection
* 2-3 days after infection (synpharyngitic)
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+/-</nowiki>
|
|
| -
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| +
|
* Crescent formation
|
* Mesangial proliferation
|<nowiki>-</nowiki>
|-
| rowspan="5" |Rapidly progressive glomerulonephritis
|
* Goodpasture syndrome
|
* Young adults
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
|
| -
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
* Hypercellular and inflamed glomeruli (Crescent formation)
|
*  Diffuse thickening of the glomerular basement membrane with absence of subepithelial and subendothelial deposits 
|<nowiki>+ (Linear)</nowiki>
|-
|
* Post infectious glomerulonephritis
|
* Streptococcal skin infections
* Streptococcal pharyngitis
* 2-3 weeks after infection
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
|
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|
* Hypercellular and inflamed glomeruli
|
* Sub-epithelial immune complex deposits
| + (Granular)
|-
|
* Granulomatosis with polyangitis (Wegner's granulomatosis)
|
* Necrotizing granulomas (Nasopharynx, lungs, kidneys)
* [[Conjunctivitis]]
* Ulceration of the [[cornea]]
* [[Episcleritis]]
* Peripheral neuropathy
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
|
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+ (C-ANCA)</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* Hypercellular and inflamed glomeruli (Crescent formation)
|<nowiki>-  (pauci-immune)</nowiki>
|<nowiki>+/-</nowiki>
|-
|
* Churg Strauss syndrome
|
* Necrotizing granulomas (Lungs and kidneys)
* Asthma
* Peripheral neuropathy
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
|
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|
+ (C-ANCA)
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* Hypercellular and inflamed glomeruli (Crescent formation)
|<nowiki>- (pauci-immune)</nowiki>
|<nowiki>-</nowiki>
|-
|
* Microscopic polyngitis
|
* Necrotizing vasculitis (no granuloma)
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
|
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| +
|
+ (P-ANCA)
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* Hypercellular and inflamed glomeruli (Crescent formation)
|<nowiki>- (pauci-immune)</nowiki>
|<nowiki>-</nowiki>
|-
|Membranoproliferative glomerulonephritis
|
* Idiopathic
* Hepatitis B and C (Type 1)
* C3 nepritic factor (Type2)
|
* hematuria
* Oliguria
* Periorbital edema
* Hypertension
|
|
|
|
|
|<nowiki>+/-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|<nowiki>+</nowiki>
|
|
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>+</nowiki>
|
* Thick glomerular basement membrane (Tram-track appearance)
|
* Mesangial proliferation and leukocyte infiltration
|<nowiki>+ (Granular)</nowiki>
|-
!Henoch-Schonlein purpura
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
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!
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|-
!Alport's syndrome
!
!
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!
!
!
!
!
!
!
!
!
!
!
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!
!
!
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!Diabetic glomerulosclerosis
!
!
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!
!
!
!
!
!
!
!
!
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!Interestitial nephritis
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!Renal papillary necrosis
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!Renal artery stenosis
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!
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Revision as of 14:19, 10 May 2018

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Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [1]

Overview

Gross hematuria(GH) must be distinguished from pigmenturia, which may be due to endogenous sources (e.g., bilirubin, myoglobin,and porphyrins), foods ingested (e.g., beets and rhubarb), drugs (e.g., phenazopyridine), and simple dehydration. This distinction can be made easily by urinalysis with microscopy. Notably, myoglobinuria and other factors can cause false-positive chemical tests for hemoglobin, so urine microscopy is required to confirm the diagnosis of hematuria. GH also must be distinguished from vaginal bleeding in women, which usually can be achieved by obtaining a careful menstrual history, collecting the specimen when the patient is not having menstrual or gynecologic bleeding, or, if necessary, obtaining a catheterized specimen. GH may also be detected by the presence of blood spotting on the undergarments of incontinent patients. After ruling out vaginal bleeding and mimics of hematuria, a urologic source must be suspected.

Differential Diagnosis

Hematuria should be differentiated from other disease which mimic hematuria especially hemoglobinuria and myoglobinuria which are dipstick positive but negative for microscopy.

Hematuria differential diagnosis

Differentiating the diseases that can cause hematuria:

Diseases Type of hematuria Clinical manifestations Para-clinical findings Gold standard Additional findings
Symptoms Physical examination
Lab Findings Imaging Histopathology
Low back pain Fever Nausea/Vomiting Urinary symptoms Hypertension Pitting edema Other CBC Biomarkers Urinalysis Ultrasonography CT scan Other
Dysuria Frequency Oliguria Light microscopy Electron microscopy Immunoflourescence pattern
Hematuria Glomerular diseases IgA nephropathy (Berger nephropathy) Microscopic
Hereditary nephritis (Alport syndrome) Microscopic
Poststreptococcal glomerulonephritis Microscopic
Mesangioproliferative glomerulonephritis Microscopic
Focal segmental glomerular sclerosis Microscopic
Rapidly progressive glomerulonephritis Microscopic
Lupus nephritis Microscopic
Thin basement membrane disease Microscopic
Fabry disease Microscopic
Tubulointerstitial diseases Renal papillary necrosis Gross
Acute interstitial nephritis
Analgesic
Nephrolithiasis
Reflux nephropathy (hydronephrosis)
Malignancy Renal cell carcinoma (RCC)
Nephroblastoma
Transitional cell carcinoma (TCC)
Prostate cancer
Familial diseases Polycystic kidney disease
Medullary sponge kidney
Vascular diseases Arteriovenous renal malformations
Renal vein thrombosis
Malignant hypertension
Polyarteritis nodosa
Wegner's granulomatosis polyangiitis
Henoch-Schönlein purpura
Lower urinary tract diseases Benign prostatic hyperplasia
Urolithiasis
Interstitial cystitis
Radiogenic cystitis
Systemic diseases Coagulopathy (hemophilia)
Sickle cell anemia
Abdominal aortic aneurysm
Lymphomas
Multiple myeloma
Infectious diseases Pyelonephritis
Cystitis
Prostatitis
Urethritis
Epididymitis
Cytomegalovirus
Infectious mononucleosis
Condylomata acuminata
Urogenital trauma Inserted bladder or ureteral catheters
Drugs Anticoagulants
Dark urine Hemoglobinuria Autoimmune hemolytic anemia
Microangiopathic hemolytic anemia
Thrombotic thrombocytopenic purpura
Paroxysmal nocturnal hemoglobinuria
Paroxysmal cold hemoglobinuria
Falciparum malaria
Prosthetic heart valve
Myoglobinuria Crush injury
Vigorous muscle exercise
Hyperthermia (Heat stroke)
Electric shock
Prolonged seizure
Polymyositis
Trichinosis
Haff disease
Animal venom bite
Chemicals Phenazopyridine
Beet (Beeturia)

References

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