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

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 ¾Çȸ¦ 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¸¸ÀÌ¸é¼ 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