1. What is hematuria?
Hematuria is a higher than normal excretion of red blood cells in the urine. It is clinically divided into microscopic hematuria and visual hematuria. Urine that has a normal appearance but meets the diagnostic criteria on microscopic examination is called microscopic hematuria; if there is 1 ml of blood per liter of urine, the color of the appearance of the urine changes and is called sarcoid hematuria. Most of the carnal hematuria is light red or washed flesh water-like, or it can be tea water-like. When the urine is alkaline, the hematuria is bright red. When the urine is acidic, hematuria can be coffee-colored, reddish-brown, strong tea-colored or soy sauce-colored. Normal urine can not be seen under the microscope or occasionally see red blood cells, take 10 ml of fresh urine (preferably mid-morning urine), centrifuge and precipitate the sediment for microscopic examination, such as per high-powered field, more than 3 red blood cells, or Addis count (i.e. 12-hour urine sediment red blood cell count) > 500,000 can be diagnosed Hematuria. Zhai Wensheng, Department of Pediatrics, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
2. How to diagnose hematuria?
(1) Hematuria in the naked eye: if the bleeding volume exceeds lml/L, hematuria in the naked eye can be diagnosed.
(2) Microscopic hematuria: normal urine appearance, 3 times in 1~2 weeks, the number of red blood cells in urine exceeds the normal range, i.e. ≥3/HPF or ≥8000/ml in centrifugal urine, 12-hour urine sediment count (Addis count) >500,000/12h, can be diagnosed as microscopic hematuria.
(3) Occult blood positive hematuria: no red blood cells are found in the urine, but the urine is positive for occult blood, indicating the lysis of red blood cells into hemoglobinuria.
(4) Etiological diagnosis: The causes of hematuria are complex and involve a wide range of diseases; therefore, the key aspect of diagnosis is to determine glomerular and non-glomerular hematuria. Clinical tests such as urine triple cup test, urine red blood cell morphology, urine mean red blood cell volume (MCV), urine sediment red blood cell tubular pattern, urine protein, urine immunoglobulin granule tubular pattern, urine calcium, urine bacterial culture, urine exfoliative cytology and many other tests can be selected to establish the etiological diagnosis. If necessary, ultrasound of both kidneys, ureter, bladder, abdominal plain film, intravenous pyelogram, cystoscopy, CT, MRI and serum biochemical or immunological tests (such as antinuclear antibody, anti-double-stranded DNA antibody, serum complement, anti-basement membrane antibody, immunoglobulin level, etc.) should be done to aid in the diagnosis. One of the most commonly used is identification by urine red blood cell morphology.
3. What diseases are common causes of hematuria?
Hematuria is commonly caused by three main types of diseases: systemic diseases, diseases of the organs adjacent to the urinary tract, and kidney and urinary tract diseases.
The causes of hematuria are commonly found in three main types of diseases: systemic diseases, diseases of the organs adjacent to the urinary tract, and kidney and urinary tract diseases. It can be divided into glomerular and non-glomerular hematuria.
Glomerular hematuria: Whether it is acute nephritis, chronic nephritis, IgA nephropathy, nephrotic syndrome, purpura nephritis, lupus nephritis, thin basement membrane nephropathy, hereditary nephritis, etc., hematuria can be seen, and can be clinically differentiated based on history, symptoms, signs and laboratory tests. Thin basement membrane nephropathy and hereditary nephritis are hereditary kidney diseases and often have a family history. It differs from hereditary nephritis (also known as Alport syndrome) in that there is no damage to the eyes (congenital cataracts, nystagmus, strabismus, etc.) or ears (high frequency neurological deafness) and progressive renal impairment.
Non-glomerular hematuria, such as systemic severe infections (sepsis, epidemic hemorrhagic fever, etc.), urinary tract infections, urinary stones, renal tuberculosis, polycystic kidney, urological tumors, etc. The clinical manifestations of urinary tract infections are symptoms of infection poisoning and local symptoms of bladder irritation. In the advanced stage of renal tuberculosis, the entire urinary system is involved. The possibility of renal tuberculosis should be considered in cases of persistent pyuria and should be confirmed by further bacteriological examination. (3) Stones: The urinary tract is prone to stone disease. When stones are active, they cut through the mucosa, resulting in microscopic or microscopic hematuria, which is characterized by colic pain. For long-lasting bladder symptoms in the elderly, the possibility of bladder cancer should be considered Ultrasound, CT and cystoscopy can confirm the diagnosis early and take appropriate treatment in time.
In addition, nutcracker phenomenon, also known as left renal vein compression syndrome, is one of the common causes of non-renal hematuria in children. It is a clinical condition caused by compression of the left renal vein during its journey into the inferior vena cava due to the angle formed between the abdominal aorta and the superior mesenteric artery. The diagnosis is often made clinically with the help of ultrasound, and the diagnostic criteria are: the proximal internal diameter of the dilated site before left renal vein stenosis in supine position is more than 3 times wider than the internal diameter of the stenosis site, and the internal diameter of the dilated site is more than 4 times wider than the internal diameter of the stenosis site after 15-20 minutes in posterior spinal extension position, and the diagnosis can be made by meeting one of them.
4. What tests should be selected for hematuria?
(1) Physician’s physical examination In addition to general physical examination, the urinary system should be the focus of physical examination, such as pressure pain in the kidney area, percussion pain in the upper ureter, and double diagnosis of the kidney.
(2) Laboratory tests Routine urinalysis is the most common and important test. Urinary NAG enzymes, urine immunoassay, 24-hour urine protein quantification and urine protein property analysis are also important in understanding the disease, diagnosis and differential diagnosis. In addition, renal function tests should be performed to selectively check autoantibodies, plasma protein electrophoresis, and coagulation and hemolysis mechanisms according to the possible causes. Bone marrow examination is necessary for the diagnosis of hematuria caused by blood disorders.
Microscopic examination of the urine is a simple and non-invasive test to distinguish renal from non-renal disease. Red blood cells filtered through the glomerulus are often deformed in order to be filtered out, and can appear as breadcrumbs, pike shapes, folded shapes, polygons, triangles, and more than 85% of the red blood cells are deformed; red blood cells that do not pass through the glomerulus are often discharged in their original form, and sometimes they are only crumpled due to intracellular dehydration, unlike deformed red blood cells.
Renal biopsy: It is necessary to determine the cause and nature of renal parenchymal disorders. Depending on the condition, renal puncture for pathological examination is necessary, such as IgA nephropathy, thin basement membrane nephropathy, hereditary nephritis can only be confirmed through pathological examination. Skin biopsy to detect the expression of α3 and α5 chains can help in the diagnosis of hereditary nephritis.
(3) Instrumental examinations
Ultrasound: It is helpful to diagnose the size of kidney, contour, hydronephrosis, dilated upper ureter, stone, tumor, nutcracker phenomenon, polycystic kidney.
CT and MRI examinations: mainly used for the diagnosis of tumor, stone and tuberculosis Cystoscopy: useful for the diagnosis of tuberculosis, tumor, stone and ulcer of the bladder If intravenous nephrography cannot be performed due to impaired renal function, retrograde cystoscopy can be performed at the same time to determine the site and cause of obstruction
5. Treatment of hematuria
(1) Western medical treatment
The etiology of hematuria is complex and involves many diseases, so its treatment should mainly be directed at the etiology. Most glomerular hematuria has no ideal treatment in Western medicine.
General methods:Those with severe hematuria should rest in bed, and if there is renal colic, antispasmodics such as atropine or 654-2 can be given.
Non-renal hematuria can be treated with hemostatic agents: in order to improve capillary permeability and shorten the bleeding time and play a hemostatic role, a large amount of vitamin C, rutin, and anilox blood can be used. Anti-fibrinolytic drugs such as 6-aminohexanoic acid, anti-fibrinolytic aromatic acid and hemagglutinin can be used, but they have the disadvantage of blocking the urinary tract with blood clots and must be used with caution.
For those who have severe blood in urine and whose drug treatment is ineffective, we should find the primary cause and treat the cause.
(2) Chinese medicine evidence-based treatment Chinese medicine evidence-based treatment is the main method of treating hematuria, with definite efficacy and greater advantages. It requires an experienced specialist to determine the type of evidence and select the prescription according to the patient’s symptoms, signs and symptoms, tongue and pulse performance.
(3) Chinese medicine single prescription therapy
White foxglove root soup: 30-60g of white foxglove root, decocted in water and taken as tea. Used for all types of blood in urine.
Stopping hemorrhage: 12g of white foxglove root, 15g of fried gardenia, 6g of small thistle, decoction in water, taken 3 times daily. Used for all types of blood in urine with real evidence.
Diyu Tang: 15g of Diyu, 20g of Radix Rehmanniae, 30g of Radix Bupleurum, decoction in water. Used for actual evidence of blood in urine.
Capsicum Capsicum Soup 30-60g, taken with water. Indicated for yin deficiency of blood in urine.
Shepherd’s Purse Soup: Take 30g of Shepherd’s Purse and 12g of Radix et Rhizoma Polygonati in a decoction. Indicated for Yin deficiency urinating blood with hot hands and feet, flushed cheeks, dry stools, etc.
Bamboo leaf tea drink 15g of plantain, 10g of bamboo leaf, 6g of maitake, decoction as tea. Used for blood in urine due to heat in the bladder.
Cyperus rotundus soup Take 30g of Cyperus rotundus in decoction. Indicated for hematuria with small blood clots and other bruises of blood in urine.
Take 3-6g of amber powder, Lanxiangcao and peppermint in decoction, once a day. Indicated for stone gonorrhea with hematuria.
Bitter Ginseng Decoction 6g of bitter ginseng, 10g of cypress, 30g of white foxglove root. clear heat and remove dampness, cool blood and stop bleeding.
7. Care and regulation
(1) During carnal hematuria, pay attention to psychological care, eliminate the child’s fear of disease, avoid emotional excitement, and maintain a calm mood.
(2) Pay attention to the change of urine color and the presence of blood clots when urinating blood, and record the urine volume.
(3) Pay attention to hygiene, do not sit and lie on wet ground, change underwear regularly, and keep the urethra clean.
(4) Promptly treat colds, sores, purpura and other disorders.
(5) Patients with blood in urine should pay attention to rest, avoid strenuous activities, and those with large amounts of blood in urine should rest in bed.
(6) It is advisable to have a light diet and avoid spicy products. Allergy sufferers should avoid shrimp, crab, fish and so on.