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Hematuria (Microscopic) (Ç÷´¢)(¹Ì¼¼Ç÷´¢)

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The Root of Ambulatory Care

The Root of Ambulatory Care

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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 : ¡Ã 3 RBC/HPF from two of three properly collected urinalysis specimens (Á¤»óÀûÀ¸·Î ÇÏ·ç¿¡ 250¸¸°³ÀÇ ÀûÇ÷±¸°¡ ¼Òº¯À¸·Î ¹è¼³µÇ±â ¶§¹®¿¡ ¿ø½ÉºÐ¸®µÈ ¼Òº¯ÀÇ Ä§Àü¹°À» Çö¹Ì°æÀ¸·Î º¸¾ÒÀ» ¶§ ÇÑ ½Ã¾ß¿¡ ÀûÇ÷±¸°¡ 3°³ ÀÌ»óÀº º¸¿©¾ß ºñÁ¤»óÀûÀÌ´Ù.) ..Asymptomatic microscopic hematuria prevalence : 0.19~21% (À§Çè¿äÀÎÀÌ ÀÖ´Â older menÀÇ °æ¿ì 21%±îÁö ±× ºóµµ°¡ Áõ°¡ÇÑ´Ù.) ..Asymptomatic microscopic hematuria°¡ ½É°¢ÇÑ ¿ä·Î°è Áúº´°ú °ü·ÃµÈ °æ¿ì°¡ ¸¹Áö ¾Ê±â ¶§¹®¿¡ Åë»óÀûÀÎ ¼±º°°Ë»ç·Î´Â ±Ç°íµÇÁö ¾ÊÀ¸³ª, ÀÏ´Ü Ç÷´¢°¡ È® ÀÎµÇ¸é °Ë»ç¸¦ ÅëÇØ ½É°¢ÇÑ ÁúȯÀÌ ¹èÁ¦µÉ¶§±îÁö Áß´ëÇÑ Áõ»óÀ¸·Î °£ÁÖÇÏ´Â °ÍÀÌ Çö¸íÇÏ´Ù. (Asymptomatic hematuria´Â ½ÅÀå¿¡¼­, gross hematuria´Â ¿ä·Î»óÇÇ¿¡¼­ ±â¿øÇÏ´Â °æ¿ì°¡ ¸¹ Áö¸¸ Ç÷´¢ÀÇ Á¤µµ´Â Áúº´ÀÇ ½É°¢¼º°ú º° °ü°è°¡ ¾ø´Ù.) < 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 ¢º À§Çè¿äÀÎÀÌ ÀÖ´Â °æ¿ì ´Ü 1ȸÀÇ Ç÷´¢¶óµµ öÀúÇÑ °Ë»ç¸¦ ¿äÇÑ´Ù. Hematuria (Microscopic) 493 The Root of ambulatory care ..Áõ»óÀÌ ¾ø´Â ¼Ò¾Æ¿¡¼­ °íÇ÷¾ÐÀ̳ª ½ÅÀå±â´ÉÀÇ ¾ÇÈ­¸¦ º¸ÀÌÁö ¾ÊÀ¸¸ç ¼ø¼öÇÑ Çö¹Ì°æÀû Ç÷´¢ÀÏ ¶§´Â ±ä±ÞÇÑ Áø´ÜÀ» ¿äÇÏÁö ¾Ê´Â´Ù. ÀÌ·± °æ¿ì¶ó¸é Àû¾îµµ 1ÁÖÀÏ ÀÌ»ó °£°ÝÀ¸·Î °Ë»çÇÑ ¼¼¹øÀÇ ¼Òº¯°Ë»ç¿¡¼­ ÇÑ ½Ã¾ß¿¡ 5°³ ÀÌ»óÀÇ Àû Ç÷±¸°¡ º¸À϶§ Áö¼ÓÀûÀÎ Ç÷´¢°¡ ÀÖ´Ù°í °£ÁÖÇÏ¿© ¿øÀÎÀ» ã±â À§ÇÑ °Ë»ç¸¦ ½ÃÇàÇÑ´Ù. 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 : ¢º 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) ¢º Prostatic disease (e.g., BPH, Prostatitis)-18% of all cases of gross hematuria, 13.2% of all cases of microscopic hematuria. ¢º Neoplasm (renal, bladder, prostatic cancer)-22.5% of all cases of gross hematuria, 3~10% of all cases of microscopic hematuria. ¢º Urinary stones-5.3% of all cases of gross hematuria, 0.4% of all cases of microscopic hematuria. ¢º Trauma - 2% of all cases of gross hematuria ; may either be direct (ie, blunt trauma) or indirect (prolonged physical exertion in a marathon runner) ¢º Intrinsic renal diseases (e.g., glomerulonephritis)-rare in adults, however post-streptococcal glomerulonephritis is responsible for 50% of pediatric hematuria. ¢º 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£º IVP, CT, Ultrasonography Cytology Cystoscopy Treat Cystoscopy Treat No further urologic monitoring Evaluation for primary renal disease£º Consider renal blopsy Repeat complete evaluation Upper tract imaging£º 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 48½Ã°£ÈÄ Àç°Ë»ç£º If negative, no further evaluation Evaluation for primary renal disease£º 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£ºmenstruation, 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.) ¢º Proteinuria´Â À°¾ÈÀû Ç÷´¢°¡ ÀÖÀ» ¶§ 2+±îÁöµµ À§¾ç¼ºÀÌ ³ª¿Ã ¼ö ÀÖÀ¸¹Ç·Î ÁÖÀÇÇØ¾ß ÇÑ´Ù. ..Áõ»óÀÌ ¾ø°í, 40¼¼ ¹Ì¸¸À̸鼭 À§Çè¿äÀÎÀÌ ¾ø´Â »ç¶÷¿¡°Ô¼­ Ç÷´¢°¡ ÀÖÀ» ¶§ ÁúȯÀÌ ¹ß°ßµÉ °¡´É¼ºÀº 1~2%Á¤µµÀ̰í, ´ëü·Î ÀÛÀº ¿ä¼®ÀÌ¸ç ¾Ç¼º ÁúȯÀº 0.1% Á¤µµÀÌ´Ù. i. Artificial food coloring ii. Beets iii. Berries iv. Chloroquine v. Furazolidone vi. Hydroxychloroquine vii. Nitrofurantoin viii.Phenazopyridine ix. Phenolphthalein x. Rifampin Âü°í ¹®Çå 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 ½ÉÀçÀÀ : Ç÷´¢, in °¡Á¤ÀÇÇÐ ÀÓ»óÆí. ¼­¿ï, °èÃø¹®È­»ç, 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 ¼º±Õ°ü´ëÇб³Àǰú´ëÇÐ »ï¼º¼­¿ïº´¿ø³»°ú : Ç÷´¢È¯ÀÚÀÇ Á¢±Ù¹æ¹ý. in Handbook of Internal Medicine, 2nd ed. ¼­¿ï, ±ºÀÚÃâÆÇ»ç, 2004, P 458-459 497 The Root of ambulatory care