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Nephrology Hematuria Hematuria is classified as glomerular and extraglomerular. Erythrocyte casts and dysmorphic erythrocytes (acanthoc)'tes, erythrocytes with "Mickey Mouse" ears) in the urine indicate glomerular disease (see The Nephritic Syndrome following). Coexisting proteinuria supports glomerular causes ofhematuria, even in the absence ofcasts. Hematuria with preserved erythrocyte morphologz in the urine and without proteinuria or casts is consistent with extraglo- merular bleeding (GU cancer, kidney stones, trauma, infection, and medications) and requires additional diagnostic studies to Iocate the extraglomerular source. The proper evaluation is directed by findings in the history and physical examination. AMH (>3 erythrocytes/hpf on UA with microscopy) History of gross hematuria (even if selfJimited) History and physical Repeated UA after + assessment for other potential treatment of AMH causes other causes (e.9,, infection, menstruation, or recent urologic procedures) + No further evaluation I I Nephrologic I evaluation if I

I I Nephrologic I evaluation if I I proteinuria, erythrocyte Renal function testing, I morphology, or other cystoscopy, and I signs indicate imaging I I nephrologic causes I I Areas of uncertainty: I I Age threshold for urologic evaluation (35-50 years) I I lmaging modality of choice (CT for all vs. risk-stratified approach to CT vs. ultrasonography for all) I I Nephrology evaluation as concurrent vs. alternative pathway I

I lmaging modality of choice (CT for all vs. risk-stratified approach to CT vs. ultrasonography for all) I I Nephrology evaluation as concurrent vs. alternative pathway I Evaluation of Patients With Hcmaturia: Algorithm summarizing the American College of physicians recommendations for the evaluation of patients with hematuria. AMH = asymptomatic microscopic hematuria; UA= urinalysis. Reprinted with permission from Nielsen M,0aseem A; High Value CareTask Force oftheAmerican College of physicians. Hematuria as a markerofoccult urinary.tract cancer: advicefor high-value care from theAmerican College of physicians.Ann lntern Med.2016;164:4BB-97. IpMlD:26810935] Copyright 201 6, American College of physicians. DON'T BE TRICKED o Evaluate hematuria even in patients taking antiplatelet drugs or anticoagulants. 260