KEYWORDS: ..The initial determination of microscopic hematuria should be based on microscopic examination of urinary sediment from a freshly voided, clean-catch, midstream urine specimen. ..Recommended definition of microscopic hematuria : ≥ 3 RBC/HPF from two of three properly collected urinalysis specimens (정상적으로 하루에 250만개의 적혈구가 소변으로 배설되기 때문에 원심분리된 소변의 침전물을 현미경으로 보았을 때 한 시야에 적혈구가 3개 이상은 보여야 비정상적이다.) ..Asymptomatic microscopic hematuria prevalence : 0.19~21% (위험요인이 있는 older men의 경우 21%까지 그 빈도가 증가한다.) ..Asymptomatic microscopic hematuria가 심각한 요로계 질병과 관련된 경우가 많지 않기 때문에 통상적인 선별검사로는 권고되지 않으나, 일단 혈뇨가 확 인되면 검사를 통해 심각한 질환이 배제될때까지 중대한 증상으로 간주하는 것이 현명하다. (Asymptomatic hematuria는 신장에서, gross hematuria는 요로상피에서 기원하는 경우가 많 지만 혈뇨의 정도는 질병의 심각성과 별 관계가 없다.) < Risk factors for significant disease in Patients with Microscopic Hematuria > i. Smoking history ii. Occupational exposure to chemicals or dyes : benzenes or aromatic amines iii. History of gross hematuria iv. Age > 40 years v. History of urologic disorder or disease vi. History of irritative voiding symptoms vii. History of urinary tract infection viii. Analgesic abuse ix. History of pelvic irradiation ▶ 위험요인이 있는 경우 단 1회의 혈뇨라도 철저한 검사를 요한다. Hematuria (Microscopic) 493 The Root of ambulatory care ..증상이 없는 소아에서 고혈압이나 신장기능의 악화를 보이지 않으며 순수한 현미경적 혈뇨일 때는 긴급한 진단을 요하지 않는다. 이런 경우라면 적어도 1주일 이상 간격으로 검사한 세번의 소변검사에서 한 시야에 5개 이상의 적 혈구가 보일때 지속적인 혈뇨가 있다고 간주하여 원인을 찾기 위한 검사를 시행한다. Primary glomerulonephritis : IgA nephropathy (Berger's disease), Postinfectious glomerulonephritis, Membranoproliferative glomerulonephritis, Focal glomerular sclerosis, Rapidly progressing glomerulonephritis Secondary glomerulonephritis : Lupus nephritis, Henoch- Schonlein syndrome, Vasculitis (polyarteritis nodosa, Wegener's granulomatosis), Essential mixed cryoglobulinemia, Hemolyticuremic syndrome, TTP, Medications Familial conditions : Thin glomerular basement membrane nephropathy, Hereditary nephritis (Alport's syndrome), Fabry's disease Exercise Conditions affecting renal parenchyma : Renal tumors (renal cell carcinoma, angiomyolipoma, oncocytoma), Vascular disorders (nutcracker syndrome, malignant hypertension, sickle cell trait or disease, arteriovenous malformation, renal vein thrombosis or infarct, transplant rejection), Metabolic disorder (hypercalciuria, hyperuricosuria), Familial condition (polycystic kidney disease, medullary sponge kidney), Infection (acute or chronic pyelonephritis, tuberculosis, cytomegalovirus infection, infectious mononucleosis), Papillary necrosis Extrarenal conditions : Tumors (renal pelvis, ureter, bladder, prostate), Benign prostatic hyperplasia, Stone or foreign body, Infections (cystitis, prostatitis, urinary schistosomiasis, tuberculosis, condyloma acuminatum), Systemic bleeding disorder or coagulopathy, Trauma, Radiation therapy, Indwelling catheters, Drugs (heparin, warfarin, cyclophosphamide) Common causes : ▶ Urinary tract infection (e.g., cystitis, pyelonephritis)-34% of all cases of gross hematuria, 28% of all cases of microscopic hematuria. Glomerular causes : dysmorphic RBC Nonglomerular causes : normal RBC Hematuria (Microscopic) ▶ Prostatic disease (e.g., BPH, Prostatitis)-18% of all cases of gross hematuria, 13.2% of all cases of microscopic hematuria. ▶ Neoplasm (renal, bladder, prostatic cancer)-22.5% of all cases of gross hematuria, 3~10% of all cases of microscopic hematuria. ▶ Urinary stones-5.3% of all cases of gross hematuria, 0.4% of all cases of microscopic hematuria. ▶ Trauma - 2% of all cases of gross hematuria ; may either be direct (ie, blunt trauma) or indirect (prolonged physical exertion in a marathon runner) ▶ Intrinsic renal diseases (e.g., glomerulonephritis)-rare in adults, however post-streptococcal glomerulonephritis is responsible for 50% of pediatric hematuria. ▶ Drugs/Pseudohematuria Most common causes of isolated glomerular hematuria : IgA nephropathy, Hereditary nephritis(Alport's syndrome), Thin basement membrane disease. 495 The Root of ambulatory care Fig 1. Evaluation of Asymptomatic Microscopic Hematuria Asymptomatic microscopic hematuria Upper tract imaging： IVP, CT, Ultrasonography Cytology Cystoscopy Treat Cystoscopy Treat No further urologic monitoring Evaluation for primary renal disease： Consider renal blopsy Repeat complete evaluation Upper tract imaging： IVP, CT, Ultrasonography, Cytology, Cystoscopy U/A, BP, Cytology at 6, 12, 24 and 36months Three or more RBC/HPF of two of three properly collected specimens 48시간후 재검사： If negative, no further evaluation Evaluation for primary renal disease： Consider renal biopsy Risk factors Smoking history/Occupational exposure to chemicals or dyes/History of gross hematuria /Age>40 years/Previous urologic disorder, disease/History of irritative voiding symptoms /History of recurrent UTI/Analgesic abuse/History of pelvic irradiation Exclude benign causes：menstruation, vigorous exercise, sexual activity, viral illness, trauma, infection If one or more of the following are present : Microscopic hematuria accompanied by significant proteinuria, Dysmorphic RBC or Red cell casts, Elevated serum creatinine No No No (+) (+) (+) (-) (-) (-) (-) Yes Yes Yes Negative for 3years (+) atypical, suspicious Persistent hematuria. HTN, Proteinuria, Glomerular bleeding Gross hematuria, Abnormal cytology, Irritative voiding symptoms without infection Hematuria (Microscopic) ..Proteinuria of 1+ or greater on dipstick urinalysis should prompt a 24-hour urine collection to quantitate the degree of proteinuria. A total excretion of >1, 000mg per 24hours (1g per day) should prompt a thorough evaluation or nephrology referral. (Such an evaluation should also be considered for lower levels of proteinuria ( >500mg per 24hours), particularly if the protein excretion is increasing or persistent, or if there are other factors suggestive of renal parenchymal disease.) ▶ Proteinuria는 육안적 혈뇨가 있을 때 2+까지도 위양성이 나올 수 있으므로 주의해야 한다. ..증상이 없고, 40세 미만이면서 위험요인이 없는 사람에게서 혈뇨가 있을 때 질환이 발견될 가능성은 1~2%정도이고, 대체로 작은 요석이며 악성 질환은 0.1% 정도이다. i. Artificial food coloring ii. Beets iii. Berries iv. Chloroquine v. Furazolidone vi. Hydroxychloroquine vii. Nitrofurantoin viii.Phenazopyridine ix. Phenolphthalein x. Rifampin 참고 문헌 Gary D. Grossfeld, M.D., J.Stuart Wole, JR., M.D., Mark S. Litwin, M.D., M.P.H., Hedvig Hricak, M.D., Ph.D., Cathryn L. Shuler, M.D., Ph.D., David C.Agerter, M.D., Peter R.Carroll, M.D. : Asymptomatic Microscopic Hematuria in Adults. A journal of the American Family Physicains 2001 ; 63 : 1145-1154 Timothy R. Thaller, M.D., Lester P. Wang, M.D. : Evaluation of Asymptomatic Microscopic Hematuria in Adults. A journal of the American Family Physicains 1999 ; 60 : 1143-1154 Linda E. Tepper : Hematuria, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 688-689 심재응 : 혈뇨, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1275-1281 Martin S. Lipsky, M.D., Mitchell S. King, M.D. : Hematuria, in Blueprints in Family Medicine. Massachusetts, Blackwell Publishing, 2003, P 123-126 성균관대학교의과대학 삼성서울병원내과 : 혈뇨환자의 접근방법. in Handbook of Internal Medicine, 2nd ed. 서울, 군자출판사, 2004, P 458-459 497 The Root of ambulatory care