Gematuria

Hematuria - the presence of blood in the urine. Distinguish macro and micro hematuria.

In the urine of a healthy person, no more than 1-2 erythrocytes are found in the field of view, or 10 ⁴ -10 ^{5 of} these cells in a portion of urine collected within 12 hours. The presence of 3-5 or more erythrocytes in the field of view is called hematuria.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Causes of the health care

Normally, hematuria is observed extremely rarely. A relatively benign condition, accompanied by microhematuria, is considered a disease of the thin basement membrane of the glomerulus. As a rule, in such patients it is possible to identify cases of this disease in relatives; microhematuria is isolated and renal failure does not develop.

Microhematuria occurs after a long walk or run, for example, long-distance runners or soldiers taking long marches. As a rule, red blood cells disappear after the cessation of physical activity. The mechanism of development of marching microhematuria has not been established. The results of long-term, prospective observation of people with march microhematuria suggest that its presence does not increase the likelihood of developing chronic progressive kidney disease.

Gross hematuria is never found in healthy people. As a rule, the presence of gross hematuria indicates the severity of damage to the renal tissue and / or urinary tract.

Non-renal hematuria is most often caused by a violation of the integrity of the mucous membrane of the urinary tract due to an inflammatory, neoplastic lesion, as well as injuries, often accompanied by ulceration. One of the most common causes of non-renal hematuria is stone formation or stone passage through the ureters, urinary bladder, and urethra. Bleeding from the mucous membrane of the urinary tract may be caused by an overdose of anticoagulants.

Renal hematuria is associated with destructive processes in the kidney tissue, impaired venous outflow, and necrotizing vasculitis. The glomerular hematuria is based, as a rule, on the immune inflammatory damage of the glomerular basement membrane (BMC) or its congenital anomalies. In addition, renal hematuria is observed with toxic and inflammatory lesions of tubulointerstitium and tubules, as well as with increased renal intravascular coagulation [disseminated intravascular coagulation syndrome (DIC), antiphospholipid syndrome].

[11], [12], [13], [14], [15]

Causes of non-renal hematuria

Cause	Source of hematuria
Stones	Ureters Bladder
Tumors	Urinary tract Prostate adenocarcinoma Benign prostatic hyperplasia
Infections and parasitic invasions	Acute cystitis, prostatitis, urethritis caused by bacteria or  Chlamydia trachomatis  Tuberculosis, urinary tract schistosomiasis
Medicines	Cyclophosphamide (hemorrhagic cystitis) Sodium heparin Warfarin
Injuries	Urinary tract foreign body Urinary tract contusion Continuous walking / running

[16], [17], [18], [19], [20], [21], [22]

Causes of glomerular hematuria

Group

Examples of diseases

Primary lesions of the renal glomeruli Secondary lesions (with systemic diseases) Hereditary / Family

IgA-nephropathy Acute postinfectious glomerulonephritis Mezangiocapillary glomerulonephritis Fast progressive glomerulonephritis Fibrillary glomerulonephritis Nephropathy with minimal changes Focal-segmental glomerulosclerosis Purpura Shönleina-Genoa Systemic lupus erythematosus Goodpasture syndrome Systemic vasculitis (especially ANCA-associated) Subacute infective endocarditis Essential and HCV-associated mixed cryoglobulinemia Thrombotic thrombocytopenic purpura (TTP) Hemolytic uremic syndrome Alport syndrome Disease of the thin basement membranes of the renal glomeruli (“benign” familial hematuria) Fabry disease Hereditary Onychoarthrosis

[23], [24], [25], [26], [27]

Causes of non-shallow hematuria

Group	Examples of diseases
Tumors	Renal cell carcinoma
	Wilms tumor (nephroblastoma)
	Multiple myeloma
	Angiomyolipoma (tuberous sclerosis)
Vascular	Kidney infarction
	Renal vein thrombosis
	Arteriovenous malformations
	Malignant arterial hypertension
Metabolic	Hypercalciuria
	Giperoxalluria
	Gipeuricosuria
	Cistinuria
Necrosis of the renal papillae	Taking analgesics
	Kidney tuberculosis
	Obstructive uropathy
	Sickle cell anemia
	Alcohol abuse
Medicines	Acute Medicinal Tubulo-Interstitial Nephritis
Hydronephrosis	Any origin
Cystic kidney disease	Autosomal dominant polycystic kidney disease
	Medullary cystic disease / familial juvenile nephronophthiasis
	Medullary spongy kidney
Injury	Contusion or crush of the kidney
	Long walk / run

In all variants of hematuria, it is necessary to search for its causes. In patients with already diagnosed chronic kidney and / or urinary tract diseases, hematuria, especially gross hematuria, always indicates an increase in activity or an exacerbation of the disease.

[28], [29], [30], [31], [32], [33], [34], [35], [36]

Pathogenetic factors of hematuria

The sudden appearance of an unusual, blood-like urine stain, sometimes among full health, in the absence of any other painful manifestations, certainly frightens the patient, prompting him to seek emergency help. However, not always visually intense coloring of urine with blood indicates massive bleeding. Arterial bleeding from the kidney and urinary tract without prior injury or surgery is an exception. Most hemorrhages that manifest hematuria are usually venous. Most often they arise from the fornical plexus, surrounding the arches of the calyx of the kidney or varicose submucous veins of the calyx-pelvis system, ureters, bladder or urethra.

Intensive bleeding is indicated by the presence of clots in the urine stained with blood, in especially severe cases their formation in the eyes of the patient and the doctor immediately after urination is a sign of massive bleeding that threatens the patient's life. When hematuria due to urological disease, there is proteinuria, which, as a rule, is of a false character and is associated primarily with the presence of hemoglobin in the urine, as well as plasma proteins. The false proteinuria level of 0.015 g and more against the background of gross hematuria characterizes severe, life-threatening bleeding and requires urgent diagnostic and therapeutic measures.

In cases of massive bleeding from the kidney and upper urinary tract in trauma and neoplasms, as well as a swelling of the bladder and prostate gland, the bladder can overflow with urine with a large amount of blood and clots that obtrude the bladder neck and the internal opening of the urethra, and the muscular wall elements prohibitively overstretched, making the reduction of the detrusor and the opening of the neck impossible. There is an acute urinary retention due to tamponade of the bladder. Such patients need emergency urological intervention.

[37], [38], [39], [40], [41]

Pathogenesis

The sudden appearance of unusual, blood-color-like urine, sometimes among full health, in the absence of any other disease manifestations, of course, scares the patient, prompting him to seek emergency help. However, visually intense color of urine blood doesn’t always indicate massive bleeding. Arterial bleeding from the kidney and urinary tract without prior injury or surgery aren’t an exception. Most bleedings manifested by hematuria are usually venous. Most often they arise from renal plexus surrounding the vaults of kidney cups or varicose veins submucosal pyelocaliceal system, ureters, bladder or urethra.

Presence of blood clots in the colored urine indicates the amount of bleeding; in severe cases formation of clots in front of the patient and the doctor immediately after urination is a sign of massive bleeding, threatening the patient life. If hematuria is caused by an urological disease, proteinuria occurs; it tends to have false character and primarily concerns with finding the hemoglobin and blood plasma proteins in the urine. False level of proteinuria 0,015g or more with macrohematuria characterizes severe, life-threatening bleeding and requires emergency diagnostic and therapeutic measures.

In case of major bleeding from the kidney and upper urinary tract due to neoplasms and trauma, as well as due to tumors of the bladder and prostate bladder may overflow with urine with a large admixture of blood and clots tumors, which occlusive bladder neck area and internal opening of the urethra, and the muscle elements of the wall are stretched a lot, making detrusor contractions and cervical opening impossible. There is an acute urinary retention due to bladder tamponade. These patients require emergency urological surgeries.

Symptoms of the health care

Hematuria, along with edema and severe arterial hypertension, is considered as an essential component of acute-nephritic syndrome. It is characteristic of acute glomerulonephritis, including post-streptococcal, or indicates an increase in the activity of chronic glomerulonephritis. For acute nephritis syndrome, gross hematuria is more characteristic.

Acute nephritis syndrome in acute glomerulonephritis is sometimes combined with signs of acute renal failure - an increase in the concentration of serum creatinine and oligo- or anuria. Hypervolemia causes the severity of arterial hypertension. Dilation of predominantly left heart regions with signs of stagnation in the pulmonary circulation is often rapidly developing. Acute nephritis syndrome in acute glomerulonephritis in most cases is completely reversible, immunosuppressive therapy, as a rule, is not required.

A significant increase in urinary protein excretion is not characteristic of acute post-streptococcal glomerulonephritis and, rather, indicates an exacerbation of chronic glomerulonephritis. The disappearance of gross hematuria in patients with chronic glomerulonephritis indicates the achievement of remission, although microhematuria can persist for a very long time. The presence of hematuria in chronic glomerulonephritis always indicates the activity of kidney damage.

Hematuria is observed in various variants of chronic glomerulonephritis (IgA-nephropathy), including in the framework of systemic diseases (Schönlein-Genoch purpura). A combination of hematuria with deafness and a history of kidney disease indicates Alport syndrome (hereditary nephritis with deafness).

The frequency of hematuria in different variants of chronic glomeruloneitis in adults and children is not the same. Microhematuria is observed in 15-20% of children suffering from nephropathy with minimal changes; nephrotic syndrome in them, as a rule, is sensitive to treatment with corticosteroids. In adult patients with nephropathy with minimal changes, microhematuria is observed much less frequently.

Microhematuria is a characteristic sign of tubulointerstitial nephropathy, including the exchangeable nature (hypercalciuria, hyperuricosuria). This feature may exist for a long time in isolation or be combined with a moderate decrease in the relative density of urine.

Hematuria and rapidly increasing renal failure, accompanied by bloody diarrhea, are characteristic of hemolytic-uremic syndrome. In addition, hemolytic anemia and clinical signs of hypohydration are found in these patients.

Hematuria is also caused by urinary tract infections and nephrolithiasis. In elderly patients with isolated microhematuria, especially in combination with fever or subfebrile condition, urinary tract tumors, including kidney cancer, should be excluded.

Asymptomatic total hematuria with intense urine staining, accompanied by the release of clots is a very serious symptom of kidney and bladder tumors. Often, hematuria is absent for a long time or is intermittent. This should not reassure the doctor or the patient. It is necessary to conduct a full range of special studies confirming or excluding diseases that caused hematuria. If the results of ultrasound and other objective methods do not provide information about the cause of hematuria, then a cystoscopic examination should be performed at the height of hematuria to establish the source of bleeding. In addition to examining the cavity of the bladder, you need to find out the nature and color of urine secreted from the mouths of both ureters. This simple technique will allow you to establish not only the degree of hematuria, but also its single or bilateral origin.

Various clinical symptoms should be analyzed. The combination of several signs, the timing of their occurrence allows the doctor with a high probability to make an assumption about the possible etiology of hematuria. The definition of topical diagnosis contributes to the analysis of the interdependence of the occurrence of pain and hematuria. In urolithiasis, pain is always preceded by the latter, and the intensity of bleeding is most often low. At the same time, with intensive hematuria with clots, caused by the destructive process, pain occurs after it due to the violation of the outflow of urine by the resulting blood clot. Painful frequent urination with concomitant hematuria indicates a pathological process (swelling, stone, inflammation) in the bladder.

With stones in the bladder, hematuria occurs after intense walking, shaky driving in transport and is accompanied by frequent urination. Often, pain radiates to the head of the penis.

Hematuria is a very important symptom of urological diseases. Any patient who has hematuria at least once (if it is not associated with acute cystitis) needs urgent urological examination.

With asymptomatic hematuria, if there is no absolute confidence in the localization of the pathological process, it is advisable to perform cystoscopy. It should be remembered that the wrong tactics of the doctor in hematuria can cause late diagnosis of the tumor process.

Diagnostics of the health care

Gross hematuria in freshly isolated urine is determined visually. At the same time, the color of urine ranges from “meat slop” to scarlet, sometimes described by patients as “cherry color”, “fresh blood”. Gross hematuria in all cases accompanied by microhematuria.

Microhematuria (erythrocyturia) is determined by microscopic examination of urine sediment. During the external examination of the blood in the urine may be missing. Of great importance is the state of the cell wall of erythrocytes, for example, their leached forms are more often found in glomerulonephritis. The more distal the source of hematuria in the urinary tract, the smaller the morphological changes erythrocytes undergo urinary sediment. The presence of blood in the urine is a serious sign of various diseases of the urogenital system (for example, the tumor process in the kidneys, upper urinary tract, bladder, urethra).

With tumors of the upper and lower urinary tract hematuria may be the only symptom of the disease or be combined with other signs.

The source of hematuria can often be established when assessing anamnestic data and macroscopic examination of urine. Her inspection carried out using dvuhstakannoy samples. The patient is offered to urinate into two vessels, without interrupting the stream of urine, so that about one-third of the total volume is released into the first and the remaining two-thirds into the second.

If the blood is found only in the first portion, then we are talking about the initial (initial) form of hematuria. As a rule, it is observed when the pathological process is localized in the urethra (neoplasms, hemangiomas, and inflammatory diseases of the urethra). Initial hematuria should be distinguished from urethrorrhagia. In this case, blood is released from the urethra involuntarily, outside the act of urination. Most often, urethrorrhagia is observed with injuries of the urethra.

In some diseases (for example, in acute cystitis, posterior urethritis, adenoma and prostate cancer, a bladder tumor located in the neck) blood is released at the end of urination (often in the form of drops). In these cases, they speak of terminal (final) hematuria. Uniform blood content in all portions of urine - total hematuria. It is observed in diseases of the renal parenchyma, upper urinary tract (calyx, pelvis, ureter) and lower urinary tract (bladder). Sometimes total hematuria occurs as a result of traumatization of a large number of venous plexuses in the area of the enlarged prostate (for example, in adenoma).

Total hematuria can be of different intensity: from the color of "meat slop" to the color of cranberry juice and ripe cherry. Total hematuria is the most frequent, prognostically significant symptom, the main and not always the first sign of such serious diseases as tumors of the renal parenchyma, pelvis, ureter, bladder. Moreover, at the present time, hematuria with the listed nosological forms is considered a late clinical sign indicating an unfavorable prognosis. In addition, total hematuria can be a symptom of other destructive processes: kidney tuberculosis, papillary necrosis, bladder ulcers, urolithiasis, acute cystitis. It should be borne in mind that in a number of patients, total hematuria may be a sign of the hematuric form of glomerulonephritis, the visceral form of adenomyosis (endometriosis), a number of parasitic diseases of the bladder (schistosomiasis, bilharciasis). The intensity of total hematuria can be judged by the presence of clots in the selected portion of urine. They may indicate an arrosion of more or less large vessels as a result of a destructive process in the kidneys and urinary tract.

The source of bleeding can also be judged by the form of clots. Length of worm-shaped clots are formed if the source of bleeding is localized in the kidney and / or upper urinary tract. Following the ureter, the blood clots, taking the form of earthworms or leeches. However, a clot can also form in the bladder, and at the same time it takes on a shapeless appearance. Such clots are described as "chunks of narvan liver." Thus, shapeless clots can result from bleeding from the upper urinary tract and bladder. It should be emphasized that the physician during the collection of anamnesis should clarify not only the nature and possible source of hematuria, but also the form of allocated clots.

The clots in the form of films described by patients, fragments with thickness from a paper sheet, are fibrin films imbibed with erythrocytes. It should also be noted that worm-shaped clots are not only found when the source of hematuria is located above the internal urethral sphincter. In case of nonintensive urethrorrhagia (especially when external compression of the urethra for the purpose of hemostasis), the release of the bladder may be preceded by the release of a worm-shaped clot.

So, with macroscopic hematuria, it is necessary to take into account its type (initial, terminal or total), intensity, presence and form of clots.

[42], [43], [44], [45], [46]

Examination and physical examination

The connection of hematuria with chronic glomerulonephritis is confirmed by arterial hypertension, edema. The presence of a skin rash (primarily purpura), arthritis indicates kidney damage within the framework of systemic diseases.

Affordable palpation and an enlarged kidney are observed in its tumor lesion.

[47], [48], [49], [50], [51], [52], [53]

Laboratory diagnosis of hematuria

Hematuria, hemoglobinuria, and myoglobinuria are distinguished by special tests. The most commonly used sample is ammonium sulphate: 2.8 g of ammonium sulphate is added to 5 ml of urine. Hemoglobin precipitates and after filtration or centrifugation settles on the filter; Myoglobin is preserved in dissolved form, and urine remains colored.

Test strips that detect hemoglobin peroxidase activity are used as screening: red blood cells are hemolyzed on indicator paper, and hemoglobin, causing oxidation of the organic peroxide applied on the test strip, changes its color. If there is a large amount of peroxides or massive bacteriuria in the urine, a false positive reaction is possible.

The presence of hematuria should be confirmed by microscopy of the urinary sediment.

Detect unchanged and modified red blood cells contained in the urine. Unchanged red blood cells are round, nuclear-free cells of yellow-orange color. Modified erythrocytes have the form of single or double-circuit bodies (shadows of erythrocytes), usually almost colorless, or discs with jagged edges.

Detection of acanthocytes in the urine — erythrocytes with an uneven surface resembling a maple leaf — is considered one of the reliable signs of glomerular hematuria.

Quantitative methods are also used to determine microhematuria. One of the most frequently used is the Nechiporenko method, based on counting the number of corpuscles (erythrocytes, leukocytes, cylinders) in 1 ml of urine; in normal, the content of erythrocytes in 1 ml of urine does not exceed 2000.

Laboratory diagnosis allows to confirm predominantly renal origin of hematuria.

Laboratory research methods used in the differential diagnosis of hematuria

General urine analysis	Blood chemistry	Immunological blood test
Proteinuria Cylinders Leukocyturia Bacteriuria Crystals (urates, oxalates)	Gypercreatininemia Gyperkaliemia Hypercalcemia Gyperuricemia Increased alkaline phosphatase activity	Gypsomplemented thyme Increased IgA Cryoglobulins Antinuclear antibodies ANCA Antibodies to the glomerular basement membrane Antibodies to cardiolipin Markers of HBV-, HCV infections

[54], [55], [56]

Instrumental diagnosis of hematuria

Diagnostics of  hematuria uses instrumental, including visualizing research methods:

• ultrasound examination of the abdomen and kidneys;
• ultrasound of the bladder and prostate gland;
• computed tomography of the abdominal cavity and small pelvis;
• MRT;
• excretory urography;
• cystoscopy.

The combination of hematuria with significant proteinuria and / or progressive impairment of renal function is considered as an indication for a kidney biopsy.

Renal hematuria is divided into glomerular and non-glomerular. To distinguish between these variants, phase contrast microscopy is used.

With microhematuria, light microscopy of the urine sediment allows detection of both fresh and leached red blood cells, which are an indirect sign of minor bleeding from the kidney and upper urinary tract. The phase-contrast microscopy method proposed in the Therapy and Occupational Diseases Clinic of the Moscow Medical Academy named after M.A. THEM. Sechenov.

Functional exercise test with a combination of microhematuria and proteinuria also helps in the diagnostic search. The increase in the amount of protein and unchanged erythrocytes on the background of physical exertion is more characteristic of urological causes of microhematuria (small calculus, “fornical” bleeding). The increase in the amount of protein with a sharp increase in the number of altered erythrocytes is an indirect sign of impaired outflow of venous blood from the kidney, while a sharp increase in proteinuria with a slight increase in the titer of formed elements in the sediment is more characteristic of nephrological patients.

Detailed consideration of the causes of hematuria is due to diagnostic and tactical errors that can be observed in the outpatient and clinical practice of the nephrologist. The most tragic are situations related to the late diagnosis of oncological diseases - tumors of the renal parenchyma, the calyx-pelvis system and the ureter, bladder, etc. Of particular relevance is a rational diagnostic and treatment tactic for a sudden total painless gross hematuria. It should be considered as an emergency, requiring urgent diagnostic and therapeutic measures that should be carried out by a urologist.

In the presence of clinical data for acute inflammatory process (acute cystitis in women, acute urethritis and prostatitis in men) the cause of hematuria can be understood already on the basis of clinical data. In other cases, an emergency procedure is necessary to conduct a 2-glass test, which will help to confirm the presence of gross hematuria at the time of inspection, roughly (by eye) to assess its intensity, the presence and shape of blood clots. Worm-shaped clots indicate bleeding from the kidney and upper urinary tract; shapeless, most likely formed in the bladder. Visual assessment of the received 2 servings of urine allows to clarify the nature of hematuria (initial, total or terminal). A subsequent emergency laboratory study will allow differentiation of hematuria from hemoglobinuria and estimate the bleeding intensity approximately from the level of false protein and the number of formed elements. Advanced gross hematuria requires emergency urethroscopy and urethrography, and other types require ultrasound and urethrocystoscopy in order to clarify the source of bleeding. In urethrocystoscopy, it may be the affected urethra and the bladder, the mouth of the right or left ureter, or both ureteral orifices.

Bilateral excretion of urine stained with blood is more characteristic of disorders of the blood coagulation system and diffuse inflammatory diseases of the kidneys. Urological diseases, as a rule, manifest unilateral bleeding. To reliably establish the source of bleeding, it is necessary to identify a consistently repetitive rhythmic flow of urine portions, markedly stained with blood from the corresponding ureteral orifice, or having a characteristic visual pattern of the pathological process on the mucous membrane of the bladder (tumor, inflammation, ulcer, calculus, varicose veins, etc.). It is necessary to emphasize that for greater reliability and prevention of subjectivity in the evaluation of the cystoscopic picture, at least two doctors should be involved in such an emergency study, and with the appropriate technical means, it is desirable to perform video recording.

Modern research opportunities (if necessary against the background of medical polyuria) using not only abdominal, but also rectal and vaginal sensors make ultrasound examination especially shown, necessary and informative, nevertheless, the pathological process in the kidney and bladder or should not be the cause of the refusal of an emergency cystoscopic examination for acute total gross hematuria, as the patient may suffer not one, but two or more diseases. Thus, in a kidney tumor, a bladder tumor is possible, and in prostatic hyperplasia, in addition to a bladder tumor, pathological processes can occur in the kidney and upper urinary tract, etc.

Appearing suddenly, hematuria may be short-lived and stop on its own. The absence of any noticeable clinical manifestations (pain, dysuria) can calm the patient and the doctor, convince them that there is no need for a detailed examination. The next episode of hematuria, the appearance of other symptoms of the disease as it progresses may indicate a late diagnosis; in this case, the prognosis is much worse.

Tactics of in-depth examination to clarify the cause of hematuria depends on a comprehensive assessment of clinical symptoms, data of physical, laboratory, ultrasound, endoscopic and other studies. The principles of such a survey should be the selection of optimal methods for obtaining the maximum information necessary to establish a correct diagnosis and determine rational therapy, prevent unjustified treatment for inadequate or erroneous diagnostics, and use the entire necessary arsenal of diagnostic tools, especially for detecting or excluding surgical diseases.

Differential diagnosis of renal hematuria using phase-contrast microscopy

Gematuria	Microscopy results
Glomerular	More than 80% of erythrocytes differ sharply in size and shape (dysmorphism), their membranes are partially broken, their contours uneven
Non-glomerular	More than 80% of red blood cells of the same shape and size (isomorphism), little changed
Mixed	No apparent predominance of dysmorphic or isomorphic erythrocytes

[57], [58], [59], [60], [61], [62], [63], [64], [65]

Differential diagnosis

Before using special instrumental methods of research, it is advisable to conduct a three-cup test. When bleeding from the bladder, ureter and renal pelvis often form blood clots.

Interpretation of the three-shot test

Type of hematuria	Changes in urine analysis	The reasons
Initial hematuria Terminal hematuria Total hematuria	Blood in the first portion Blood in the third portion Blood in all portions	Inflammation, ulceration, trauma, swelling of the initial part of the urethra Inflammation, swelling of the prostate gland, cervical bladder Damage to the bladder (hemorrhagic cystitis), ureters, renal pelvis, kidney parenchyma

Differential diagnosis of hematuria pursues the goal - the establishment of its renal or non-renal origin. A distinction is also required between glomerular and non-glomerular hematuria.

Analysis of the course of the disease and complaints allows you to set the duration of hematuria, paroxysmal or its permanent nature. In addition, hematuria is sometimes combined with various pain syndromes (for example, lower back pain, abdominal pain) and urinary disorders (pollakiuria, polyuria). When interviewing, it is necessary to pay attention to medication, the connection of hematuria with physical activity, a general tendency to bleeding, the presence of kidney disease in the family history. The combination of hematuria with dysuria indicates its extrarenal origin.

General factors should be considered, in particular gender and age. Hematuria, first appeared in the elderly, often has a non-glomerular origin; it is necessary to exclude diseases of the urinary tract (bladder, prostate gland), including tumors, as well as kidney cancer. In addition, it is now necessary to exclude kidney tuberculosis. If the results of most of the available research methods are not very informative in a patient with persistent (6-12 months) hematuria, a kidney biopsy should be discussed.

From hematuria, hemoglobinuria should be distinguished, in which free red blood cells are present in the urine, but free hemoglobin and fragments of its molecules, as well as urethrorrhagia - the discharge of blood from the external opening of the urethra outside the urination act. It must be remembered that the color similar to blood, urine can acquire against the background of the consumption of certain foods (beets), as well as taking the drug (madder extract). The use of phenolphthalein (purgen) in alkaline urine may cause its pink and even crimson color. That is why hematuria as a symptom characterizing hemorrhage from the kidney (kidney) and urinary tract, is indicated solely by the detection of red blood cells in urine sediment by microscopy.

The admixture of blood can appear in the urine when it is ingested from the female genital organs, from the preputial sac — in men, and also introduced deliberately (artifactual hematuria).

[66], [67], [68], [69], [70], [71], [72]

Forecast

Persistent hematuria when combined with “large” proteinuria and severe arterial hypertension is a marker of an unfavorable renal prognosis.

[73], [74], [75], [76]