Which histologic findings are characteristic of hematuria?

Updated: Jan 03, 2019
  • Author: Sanjeev Gulati, MD, MBBS, DNB(Peds), DM, DNB(Neph), FIPN(Australia), FICN, FRCPC(Canada); Chief Editor: Craig B Langman, MD  more...
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Answer

In most patients, a renal biopsy is either normal or reveals minor changes, such as thin glomerular basement membranes, focal glomerulonephritis, or mild mesangial hypercellularity. In a minority of patients, histologic findings, together with historical or serologic data, may point to specific conditions.

Table. Histologic Findings (Open Table in a new window)

Condition

Histology

History

Laboratory Data

Systemic lupus erythematosus

Mild glomerulitis, proliferative changes, immune complex deposition, crescents, immunoglobulin deposition

Hematuria, proteinuria, hypertension, joint pains, rashes

Abnormal C3, C4, ANA, and dsDNA levels; anemia; thrombocytopenia

IgA nephropathy

IgA deposition in the mesangium, glomerular sclerosis, proliferative changes, crescents in severe cases

Gross, intermittent, painless hematuria

No specific changes, although increased serum

IgA levels observed in some patients

Henoch-Schönlein purpura

Same as IgA nephropathy

Purpura, joint pains, abdominal pain, hematuria

No specific laboratory data

Alport syndrome

Some thinning of basement membranes, "basket weave" changes in the glomerular basement

membrane on electron microscopy

Sensorineural hearing loss, corneal abnormalities, hematuria, renal failure

No specific changes

Thin basement membrane disease

Average glomerular basement membranes reported to be 100-200 nm in children in this condition

Persistent microscopic or gross hematuria, significant family history

No specific changes

Mesangiocapillary glomerulonephritis

Glomerular lobulations, thickening of the mesangial matrix and glomerular basement membranes, crescents

Hematuria, proteinuria, hypertension

C3 levels possibly abnormal

A comprehensive physical examination and a detailed history are indispensable to the evaluation of hematuria.

  • A urinalysis should be obtained (as described above), and a careful microscopic review of the sample should be performed. Examples of microscopic findings are shown in the images below.

    Microscopy of urinary sediment. Typical appearance Microscopy of urinary sediment. Typical appearance in non-glomerular hematuria: RBCs are uniform in size and shape but show two populations of cells because a small number have lost their hemoglobin pigment.
    Microscopy of urinary sediment. Typical appearance Microscopy of urinary sediment. Typical appearance of RBCs in glomerular hematuria: RBCs are small and vary in size, shape, and hemoglobin content.
    Microscopy of urinary sediment. A cast containing Microscopy of urinary sediment. A cast containing numerous erythrocytes, indicating glomerulonephritis.
  • A positive dipstick reaction should be followed by a urine analysis to confirm the presence of RBCs and/or casts. The absence of erythrocytes suggests myoglobinuria or hemoglobinuria, whereas the absence of hemoglobin, red cells, or myoglobin should prompt a search for other causes of red urine.

  • The next step in the differential diagnosis is localization of the bleeding. The presence of red cell casts and preponderance of dysmorphic cells on phase contrast microscopy are consistent with glomerular bleeding. Other urine characteristics that help in distinguishing between glomerular and nonglomerular hematuria are discussed above.

  • A urine culture should be obtained. Significant bacterial growth, indicative of urinary tract infection or pyelonephritis, requires antibiotic treatment and, possibly, further radiologic evaluation of the genitourinary tract for obstruction, vesicoureteral reflux, cystic disease, and other abnormalities. A urine culture showing "no growth" may need to be followed by imaging studies. A urine sample should be sent for determination of the urine calcium-creatinine ratio. An abnormal result should prompt a 24-hour urine collection to confirm the diagnosis of hypercalciuria.

  • If hematuria is of glomerular origin, measurements of protein excretion and serology tests may be in order. Low C3 levels should suggest membranoproliferative glomerulonephritis or systemic lupus erythematosus as diagnostic possibilities. The latter should be confirmed by measurements of ANA or dsDNA. A low C3 level in association with an elevated ASO titer or anti-DNAse B, are indicative of poststreptococcal glomerulonephritis. The concomitant presence of hematuria and proteinuria often indicates serious renal disease. A kidney biopsy should be considered if proteinuria is persistent.

  • The approach to the evaluation of hematuria varies among physicians and no single method applies in all circumstances. One approach is outlined in the images below.

    Approach to hematuria. Approach to hematuria.
    Nonglomerular hematuria. Nonglomerular hematuria.

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