今日の臨床サポート

血尿

著者: 前川道隆 藤田医科大学ばんたね病院 腎臓内科

監修: 山中克郎 福島県立医科大学会津医療センター総合内科

著者校正/監修レビュー済:2020/12/09
参考ガイドライン:
  1. 日本腎臓学会/日本泌尿器科学会/日本小児腎臓病学会/日本臨床検査医学会/日本臨床衛生検査技師会血尿診断ガイドライン2013
  1. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults (2016): AUA guideline.
  1. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults.
患者向け説明資料

概要・推奨   

  1. 尿の定性検査で血尿が陽性となった場合には、尿沈渣で血尿の診断を確定させることが推奨される(推奨度1)。
  1. 初めて血尿を指摘されたときに、すぐに精査を行うべきか、尿検査の再検を行ってから方針を決定すべきかについて、現時点でコンセンサスは得られていない。年齢や喫煙歴などの腎癌・膀胱癌のリスクを考慮して総合的に判断することが推奨される(推奨度2)
  1. 無症候性顕微鏡的血尿では、全例への腎生検は推奨されないが、蛋白尿の出現や腎機能低下に注意して、定期的なフォローアップを行うことが望ましい。経過観察中に顕微鏡的血尿に蛋白尿が合併する場合には、腎臓内科への紹介が推奨される(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
前川道隆 : 未申告[2021年]
監修:山中克郎 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行い、尿潜血反応の偽陽性、偽陰性について追記した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. わが国の血尿診断ガイドライン2013では、尿中に赤血球が5個/HPF(400倍強拡大1視野)以上みられるものを「血尿」と定義している。ヘモグロビン色素によるペルオキシダーゼ様活性を利用した尿試験紙法がスクリーニングに用いられる。尿潜血反応はミオグロビン尿やヘモグロビン尿によって陽性になることがあるため、尿沈渣で尿中に赤血球が存在することを確認する必要がある。
  1. 肉眼で色調変化を認めるものを肉眼的血尿といい、尿1Lに血液1mL以上が混入すると肉眼的血尿になる。IgA腎症などの糸球体腎炎によるものもあるが、大部分が泌尿器疾患に由来する。
  1. 顕微鏡的血尿を認める患者の0.5~2%程度に、また肉眼的血尿を呈する患者の10~20%に尿路系悪性腫瘍が診断される。高齢、喫煙、化学物質への曝露、骨盤部への放射線照射などが危険因子として知られる。染料工業、皮革工業、ゴム工業の従事者で膀胱癌のリスクが高まることが知られている。
  1. 50歳以上の無症候性肉眼的血尿では、その原因として膀胱癌が最多である。膀胱腫瘍の85%が無症候性肉眼的血尿を契機として診断される。また、腎癌でもおよそ4割が肉眼的血尿を伴うとされる。初期の精査で悪性腫瘍が見つからなかった場合でも、肉眼的血尿が再発した場合には尿路悪性腫瘍が診断される可能性が比較的高いため、改めて精査を行うことが推奨される。
  1. 抗凝固療法や抗血小板療法そのものでは血尿の頻度は増加しないことが示唆されており、これらの治療を受けている場合でも通常の患者と同じように血尿の原因検索を行うことが推奨される。
  1. 蛋白尿を伴わない無症候性顕微鏡的血尿では、泌尿器疾患の評価で診断がつかない場合、軽症のIgA腎症や菲薄基底膜病などの糸球体疾患が原因であることが多く、積極的な治療の対象にならないことが多い。一方、下腿浮腫、高血圧、腎機能障害を合併するとき、尿検査で変形赤血球や赤血球円柱、蛋白尿を伴うときには糸球体腎炎を疑う。特に、中等度以上の蛋白尿を伴う場合には、活動性の高い糸球体腎炎を見ている可能性が高く、将来的に腎機能低下を生じることがあるため、腎生検を積極的に考慮すべきである。
  1. 動脈と腎静脈の交通や、腎動静脈奇形などの血管異常により血尿が生じることがあるが、侵襲的な検査を要することも多く、診断が難しいこともある。
 
  1. 無症候性顕微鏡的血尿では、全例への腎生検は推奨されないが、蛋白尿の出現や腎機能低下に注意して、定期的なフォローアップを行うことが望ましい。経過観察中に顕微鏡的血尿に蛋白尿や腎障害が合併する場合には、腎臓内科への紹介が推奨される(推奨度1)
  1. 蛋白尿を伴わない顕微鏡的血尿の原因には、軽症のIgA腎症、菲薄基底膜病(良性家族性血尿)が多い。長期のフォローを行うと蛋白尿、高血圧が出現することがあり、腎機能低下を生じる例もあることが複数の観察研究で示されている[1][2][3][4][5]
  1. ある観察研究では、蛋白尿を伴わない顕微鏡的血尿の患者89人に腎生検を行い、うちIgA腎症18人(20%)、菲薄基底膜病38人(43%)を含んでいたが、平均46カ月のフォロー期間中に9人(10%)の患者で蛋白尿が出現した[2]
  1. 他の観察研究では、蛋白尿を伴わない無症候性顕微鏡的血尿で泌尿器疾患を除外したもの350例に腎生検を行い、その自然経過を追った。うち164人(47%)はIgA腎症と診断されたが、蛋白尿が陽性となったのは10例(IgA腎症の6%、腎生検例の3%)のみであった[5]
  1. 蛋白尿0.5g未満の症例を含む顕微鏡的血尿の観察研究では、軽度の蛋白尿でも腎予後に影響を与えることが示唆された。蛋白尿が0.1g以下の症例では、腎関連の有害事象は1人/33人(3%)のみであった。
  1. 一方、蛋白尿が0.1g/日を超える症例では、平均5.2年の観察期間で腎関連の有害事象が6人/33人(18%)に出現しており、蛋白尿が少ない症例と比べ有意に多かった[4]。このことより、無症候性顕微鏡的血尿で明らかな泌尿器疾患が診断されない場合、半年から1年ごとに定期的な血圧測定、尿検査、腎機能検査を行い、高血圧の合併や、蛋白尿または腎機能低下の出現があれば腎臓内科へ紹介することが推奨される。
  1. 青年期~成年期に指摘された尿異常は数年以内にしばしば消失することが複数の観察研究で示されている[6][7]
  1. 無症候性顕微鏡的血尿のある患者を対象とした前向きコホート研究(平均20.5歳)では、120例に腎生検を行い、その自然経過を追った。うち約半数(62/120例)が蛋⽩尿<0.3g/⽇(蛋⽩尿陰性群)であった。平均4.5年間フォローアップされ、蛋白尿陰性群では32%で、蛋白尿陽性群では14%で尿異常が消失した。腎生検でIgA腎症と確定した例では、尿異常が消失することは少なかった(蛋白尿陰性でも10%のみ)[6]
  1. わが国で行われた、健診で無症候性顕微鏡的血尿を指摘された患者を対象とした前向きコホート研究(平均36.4歳)でも多くの患者で尿異常が消失することが報告された。平均5.8年のフォローアップ期間中に、蛋白尿を伴わない無症候性顕微鏡的血尿では44.2%で血尿が消失し、蛋白尿と顕微鏡的血尿の合併例でも16.4%で尿異常が消失した。一方で、蛋白尿を伴わない顕微鏡的血尿の10.6%には、蛋白尿が新たに認められた[7]
 
  1. 中高年患者の顕微鏡的血尿では悪性腫瘍が増加するため、はっきりした原因がわからない高齢者の顕微鏡的血尿は膀胱鏡が適応になる可能性が高く、泌尿器科へのコンサルトが推奨される(推奨度2)
  1. 顕微鏡的血尿を認める患者の年齢と悪性腫瘍との関連をみた観察研究が存在する。
  1. その1つの報告では、1,930人の血尿患者で230人の膀胱癌が診断されたが、その97%が40歳以上、88%が50歳以上であった[8]
  1. 血尿を認める患者では高齢であるほど悪性腫瘍が診断される頻度が増えるため、より慎重な対応が必要になる[8][9][10]
  1. 従って、はっきりした原因がわからない中高年患者の血尿は膀胱鏡の適応になる可能性が高く、泌尿器科へのコンサルトが推奨される。
 
膀胱癌の年齢階級別罹患率

若年者や女性に比べ、高齢男性では膀胱癌の発症頻度が高くなることを示している。35~40歳未満での膀胱癌の発症は非常に少ない。

 
  1. 無症候性肉眼的血尿では悪性腫瘍の存在を考えて精査を行う。膀胱鏡の適応になる可能性が高く、泌尿器科へのコンサルトが推奨される(推奨度1)
  1. 肉眼的血尿と悪性腫瘍との関連をみた観察研究が存在する。
  1. その1つの報告では、1,930人の血尿患者(平均58歳)を精査したところ、顕微鏡的血尿を認めた患者の9.4%、肉眼的血尿を認めた患者の24.2%に悪性腫瘍が診断された[8]
  1. このことより、肉眼的血尿では尿路悪性腫瘍の頻度が高く、高齢・リスクを有する場合にはより注意を要する。また膀胱鏡の適応になる可能性が高いため、泌尿器科へのコンサルトが推奨される。
 
顕微鏡的血尿、肉眼的血尿を認める患者において、悪性腫瘍と診断された割合

血尿精査を受けた1,930人の患者のうち、肉眼的血尿を精査された患者では24.2%に、顕微鏡的血尿では9.4%に悪性腫瘍を認めた。顕微鏡的血尿より肉眼的血尿が、女性より男性が、高齢であればあるほど尿路悪性腫瘍の確率が高くなることを示している。

出典

img1:  A prospective analysis of 1,930 patients with hematuria to evaluate current diagnostic practice.
 
 J Urol. 2000 Feb;163(2):524-7.
 
  1. 抗凝固療法中の患者でも、そうでない患者と同様に血尿の評価を行うことが推奨される(推奨度2)
  1. 抗凝固療法を受けていても、コントロール群と比べて顕微鏡的血尿の頻度が増加しないという報告がある[11]。また、抗凝固療法中に肉眼的血尿を認めた患者の25%に尿路系悪性腫瘍が診断されたという報告もある。
  1. 抗血小板薬内服中の血尿頻度についての知見は乏しいが、抗凝固療法を受けている患者と同様に悪性腫瘍が診断されたと報告されており、同様に評価することはおそらく推奨される[12]
 
  1. 肉眼的血尿に対する初期の精査で診断がつかなかった例では、肉眼的血尿が再発した場合に尿路悪性腫瘍の評価をもう一度行うことが推奨される。
  1. 肉眼的血尿ではおよそ2割に尿路悪性腫瘍が診断されるが、半数以上の症例では初期の精査で肉眼的血尿の原因を特定できない。ある研究では造影CT、膀胱鏡などで精査を行っても肉眼的血尿の原因を特定できなかった965例のうち69例で追跡期間中に肉眼的血尿が再発した。その69例中12例(17.4%)で悪性腫瘍が診断された[13]。肉眼的血尿が再発した場合には悪性腫瘍が診断される可能性が比較的高いため、改めて尿路悪性腫瘍に対する精査を行うことが推奨される。
問診・診察のポイント  
 
  1. 血尿は腎、尿路のすべての部位から生じ得る。排尿初期の血尿は尿道からの、排尿終末時血尿は膀胱頚部・前立腺からの、排尿を通して肉眼的血尿が出る場合は膀胱・尿管・腎に由来する血尿を示す。

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文献 

著者: D O McGregor, K L Lynn, R R Bailey, R A Robson, J Gardner
雑誌名: Clin Nephrol. 1998 Jun;49(6):345-8.
Abstract/Text Whether renal biopsies are indicated for the investigation of microscopic hematuria is a subject of debate. In this retrospective study we evaluated our use of renal biopsy in patients who presented between 1985 and 1995 with microscopic hematuria but without proteinuria, hypertension or renal insufficiency. Of 111 patients, 75 had a renal biopsy. Histological diagnoses included thin membrane nephropathy (TMN) (36%), IgA nephropathy (IgAN) (23%), non-IgA mesangioproliferative glomerulonephritis (MPGN) (9%), mild glomerular abnormalities (11%), focal global glomerulosclerosis (FGS) (4%) and normal (17%). After 85 patients had been followed for a mean of 43 months there were no deaths, 3 patients had proteinuria (IgAN 2, no biopsy 1), 1 had proteinuria and renal insufficiency (immune negative MPGN) and 11 were hypertensive (TMN 3, IgAN 2, normal 2, FGS 1, no biopsy 3). Hematuria resolved in 23 patients. Only 11 patients were still attending the nephrology clinic and 27% of the patients who were advised to continue annual follow-up with family doctors had not done so. In summary, the information obtained from renal biopsy rarely altered clinical management. Hypertension developed in 13% of the patients followed but it was not predicted by the biopsy result. Although a renal biopsy will usually be diagnostic it is difficult to justify in patients who have isolated microscopic hematuria.

PMID 9696429  Clin Nephrol. 1998 Jun;49(6):345-8.
著者: C L Hall, R Bradley, A Kerr, R Attoti, D Peat
雑誌名: Clin Nephrol. 2004 Oct;62(4):267-72.
Abstract/Text BACKGROUND: The decision whether to perform renal biopsy on patients with persistent asymptomatic microscopic hematuria (AMH) with and without low-grade proteinuria (LGP) remains controversial as, although often diagnostic, the information gained seldom alters clinical management. Our study investigates the clinical value of renal biopsy in patients with isolated AMH versus those with AMH and LGP.
METHODS: Between 1996 and 2002, we identified 89 patients with AMH and 46 with AMH and LGP. The patients were asymptomatic, free from systemic illness, had a sterile urine, normal serum creatinine, normal renal and bladder ultrasound, less than 2.5 g proteinuria/day, underwent successful renal biopsy and were followed-up for a mean period of 46 +/- 12 months.
RESULTS: In patients with isolated AMH, thin basement membrane nephropathy (TBMN) was diagnosed in 43%, IgA nephropathy in 20%, minor abnormalities in 19% and normal biopsies in 18%. In patients with AMH and LGP, IgA nephropathy was diagnosed in 46%, other major nephropathies in 26%, minor abnormalities in 17%, TBMN in 7% and normal biopsies in 4%. At follow-up, 32% of AMH patients and 38% of AMH with LGP patients had a GFR of less than 90 ml/min and 36% and 56%, respectively were hypertensive.
CONCLUSIONS: The results support the current consensus that routine renal biopsy is not indicated for isolated AMH but suggest that biopsy is indicated for AMH and LGP identifying major and potentially progressive nephropathies in 70% of patients, who should be managed by specialist nephrologists.

PMID 15524056  Clin Nephrol. 2004 Oct;62(4):267-72.
著者: Byung Soo Kim, Yong Kyun Kim, Young Shin Shin, Young Ok Kim, Ho Cheol Song, Yong Soo Kim, Euy Jin Choi
雑誌名: Korean J Intern Med. 2009 Dec;24(4):356-61. doi: 10.3904/kjim.2009.24.4.356. Epub 2009 Nov 27.
Abstract/Text BACKGROUND/AIMS: No definite conclusions have been reached about the natural history of patients with isolated microscopic hematuria (IMH). In this study, we observed the natural history of patients with IMH and examined factors related to a pathologic diagnosis and subsequent prognosis.
METHODS: We retrospectively evaluated 156 subjects with IMH who had a renal biopsy performed. Of the 156 subjects, 33.3% were diagnosed with IgA nephropathy, 23.7% with mesangial proliferative glomerulonephritis, 15.4% with glomerular minor lesion, and 12.8% with thin basement membrane nephropathy; 6.4% had normal biopsies.
RESULTS: We followed up with 100 subjects for about 31 months. During this follow-up period, two subjects who had received a pathologic diagnosis of IgA nephropathy developed chronic kidney disease. During the course of the study, one of these subjects presented with proteinuria and hypertension and the other with proteinuria. The overall incidences of proteinuria and hypertension were 6% and 5% respectively.
CONCLUSIONS: The prognosis for patients with IMH was relatively favorable, but patients developing proteinuria and/or hypertension require careful observation and management during the follow-up period.

PMID 19949735  Korean J Intern Med. 2009 Dec;24(4):356-61. doi: 10.390・・・
著者: K M Chow, B C Kwan, P K Li, C C Szeto
雑誌名: QJM. 2004 Nov;97(11):739-45. doi: 10.1093/qjmed/hch125.
Abstract/Text BACKGROUND: Evidence to support current diagnostic and management approaches to asymptomatic haematuria is lacking and based on short-term clinical observation.
AIM: To ascertain the natural history and long-term outcome of asymptomatic and isolated haematuria, and to determine the clinical correlates of adverse renal events.
DESIGN: Prospective observational referral-based study.
METHODS: We evaluated 90 consecutive patients with isolated microscopic haematuria, first seen between 1985 and 1996 at an out-patient nephrology clinic. We defined adverse renal events as the development of proteinuria (> 0.5 g/24 h) on two consecutive occasions, development of hypertension, or impaired renal function characterized by glomerular filtration rate (GFR) of <60 ml/min/1.73 m(2) for 3 months or more.
RESULTS: There were 24 males and 66 females, median follow-up 5.2 years (total 442 patient-years). Mean age at presentation was 39 +/- 13 years. Fifteen (17%) had complete resolution of microscopic haematuria. One (1%) had transitional cell carcinoma of urinary bladder 20 months after initial presentation. Twelve (13%) developed hypertension, and 10 (11%) proteinuria. Only one developed chronic renal failure, 2.3 years after initial presentation. Altogether, 16 (19%) developed at least one adverse event, after a mean 42 months. Neither history of renal biopsy nor histological diagnosis of glomerular disease was predictive of renal events. Three independent variables were predictive of adverse renal events: baseline proteinuria (RR per 0.1 g/day 2.04; 95%CI 1.13-3.68; p = 0.018); MDRD-estimated GFR at presentation (RR per 10 ml/min/1.73 m(2) decrement 2.01; 95%CI 1.09-3.71; p = 0.025); and baseline serum urate (RR per 100 micromol/l 1.02; 95%CI 1.01-1.03; p = 0.009).
DISCUSSION: Asymptomatic microscopic haematuria can lead to adverse renal events, and warrants nephrologist evaluation and regular follow-up. Its isolated microscopic haematuria is closely related to early hints of chronic kidney disease, such as low-grade proteinuria and renal insufficiency, as well as hyperuricaemia.

PMID 15496530  QJM. 2004 Nov;97(11):739-45. doi: 10.1093/qjmed/hch125.・・・
著者: Hae Min Lee, Ji In Hyun, Ji-Won Min, Kyungsoo Lee, Yong Kyun Kim, Euy Jin Choi, Ho Cheol Song
雑誌名: J Korean Med Sci. 2016 Jun;31(6):909-14. doi: 10.3346/jkms.2016.31.6.909. Epub 2016 Apr 18.
Abstract/Text The increasing interest in healthcare and health screening events is revealing additional cases of asymptomatic isolated microscopic hematuria (IMH). However, a consensus of the evaluation and explanation of the IMH prognosis is controversial among physicians. Here, we present the natural course of IMH together with the pathological diagnosis and features to provide supportive data when approaching patients with IMH. We retrospectively evaluated 350 patients with IMH who underwent a renal biopsy between 2002 and 2011, and the pathological diagnosis and chronic histopathological features (glomerulosclerosis, interstitial fibrosis, and tubular atrophy) were reviewed. Deterioration of renal function was examined during follow up. The patients with IMH were evaluated for a mean of 86 months. IgA nephropathy was the most common diagnosis in 164 patients (46.9%). Chronic histopathological changes were observed in 166 (47.4%) but was not correlated with proteinuria or a decline in renal function. Ten patients developed proteinuria, and all of them had IgA nephropathy. Three patients progressed to chronic kidney disease with an estimated glomerular filtration rate < 60 mL/min/1.73 m(2) but none progressed to end stage renal disease. In conclusion, IMH had a generally benign course during 7-years of observation, although IgA nephropathy should be monitored if it progresses to proteinuria. Future prospective randomized studies may help conclude the long-term prognosis and lead to a consensus for managing IMH.

PMID 27247500  J Korean Med Sci. 2016 Jun;31(6):909-14. doi: 10.3346/j・・・
著者: Z Kovacević, D Jovanović, V Rabrenović, J Dimitrijević, J Djukanović
雑誌名: Int J Clin Pract. 2008 Mar;62(3):406-12. doi: 10.1111/j.1742-1241.2007.01659.x.
Abstract/Text AIM: The study involved 120 young males (aged 20.5 +/- 2.5 years) having undergone successful kidney biopsy because of asymptomatic haematuria with the aims to assess the prevalence of histological diagnosis and the natural history of the disease.
METHODS: The patients were selected from the population of conscripts who were referred to our clinic as a result of asymptomatic microhaematuria. All patients had a negative history of kidney disease, normal creatinine clearance (Ccr), while extrarenal causes of microhaematuria were excluded. The patients were divided into a group of 62 patients with isolated microhaematuria (IMH; proteinuria < 0.3 g/day) and a group of 58 patients with asymptomatic microhaematuria and proteinuria (AMHP; proteinuria > 0.3 g/day). After kidney biopsy patients were monitored for 3-9 years.
RESULTS: Normal biopsies and minor abnormalities were more frequent in IMH than in AMHP patients, who had IgA nephritis more frequently and significantly higher total pathohistological score. Based on the clinical and histological features, recommendations on patients' ability for military service were made. During the follow-up period, normal Ccr maintained in all patients. Macrohaematuria appeared in 42 patients and proteinuria worsened in eight patients (seven with AMHP). Urinary abnormalities disappeared in 20 patients with IMH and in eight with AMHP (p = 0.04).
CONCLUSION: Minimal histological changes and disappearance of urinary abnormalities were more frequent in IMH than in AMHP patients. Kidney biopsy is useful only in patients with AMHP but it is not necessary in IMH patients.

PMID 18261076  Int J Clin Pract. 2008 Mar;62(3):406-12. doi: 10.1111/j・・・
著者: K Yamagata, Y Yamagata, M Kobayashi, A Koyama
雑誌名: Clin Nephrol. 1996 May;45(5):281-8.
Abstract/Text Between January 1, 1983 and December 31, 1992, 805 patients with asymptomatic proteinuria and/or hematuria were selected in the mass screening of 56,269 adults. We conducted prospective long-term follow-up studies of these patients and evaluated their clinical findings and renal histology. They were divided into three groups according to the first dipstick urinalysis findings: 478 patients with pure hematuria (H), 150 patients with concomitant hematuria and proteinuria (H & P), and 177 patients with proteinuria (P). The mean follow-up period was 5.80 +/- 4.42 years. Of the 478 patients with H, a specific cause of hematuria was found in 46 (9.6%), the remaining 432 (90.4%) patients were diagnosed as having asymptomatic hematuria (ASH). During the follow-up period, in the ASH patients, hematuria disappeared in 44.2%, 43.7% had persistent microhematuria without proteinuria, and 10.6% manifested proteinuria, none of the patients showed renal insufficiency. Of the 150 patients with H & P, 134 were diagnosed as having asymptomatic H & P. During the follow-up period, the hematuria and proteinuria disappeared in 16.4% of these patients, the proteinuria disappeared in 8.2%, and 14.9% of the patients showed renal insufficiency. Of the 177 patients with P, 151 were diagnosed has having asymptomatic P. During the follow-up period, proteinuria disappeared in 23.2%, and 10.6% showed renal insufficiency. Renal biopsy was performed in 151 patients in the study population who had a moderate degree of proteinuria; 68.2% of these patients had IgA nephropathy, 12.6% had non-IgA mesangial proliferative GN, 6.0% had membranous nephropathy, 5.3% had minimal change, and 2.6% had focal and segmental glomerular sclerosis. This study of the mass screening of urinalysis in asymptomatic adults showed that although the patients with pure hematuria did not exhibit renal insufficiency, 10.6% of these patients were proteinuric during the follow-up period. Therefore, careful observation and management are needed in these patients.

PMID 8738658  Clin Nephrol. 1996 May;45(5):281-8.
著者: M H Khadra, R S Pickard, M Charlton, P H Powell, D E Neal
雑誌名: J Urol. 2000 Feb;163(2):524-7.
Abstract/Text PURPOSE: The commonly accepted diagnostic algorithm for hematuria includes excretory urography (IVP) and cystoscopy. Some have suggested that ultrasound of the upper urinary tract is adequate and that cystoscopy is not necessary in younger patients with microscopic hematuria. We ascertain whether a less intensive algorithm could be adopted while retaining diagnostic efficacy.
MATERIALS AND METHODS: A total of 1,930 patients were enrolled prospectively in the study at a hematuria clinic between October 1994 and March 1997. Evaluation consisted of basic demographics, history and examination, routine blood tests, urinalysis and cytology. All patients underwent plain abdominal radiography, renal ultrasound, IVP and flexible cystoscopy.
RESULTS: A total of 1,194 males and 736 females with a mean age of 58 years (range 17 to 96) were included in the study. Overall, 61% of patients had no basis found for hematuria, 12% had bladder cancer, 13% had urinary tract infection and 2% had stones. Kidney and upper tract tumors were noted in 14 patients (0.7%), including 4 who presented with microscopic hematuria. If only ultrasound or IVP had been performed 4 of these cases would have been missed. Of 982 patients presenting with microscopic hematuria 51 had cancer. Bladder cancer was found in 7 patients younger than 40 years.
CONCLUSIONS: Our findings suggest that cystoscopy cannot be safely avoided even in younger patients with microscopic hematuria. Only a combination of ultrasound and IVP detected all upper tract tumors.

PMID 10647670  J Urol. 2000 Feb;163(2):524-7.
著者: S Murakami, T Igarashi, S Hara, J Shimazaki
雑誌名: J Urol. 1990 Jul;144(1):99-101.
Abstract/Text To establish strategies for treatment of asymptomatic microscopic hematuria we conducted a prospective study of 1,034 patients with this disease. The patients were examined by cystoscopy, urine cytology, abdominal ultrasound and excretory urography. On initial examination 30 highly significant lesions, including 24 cases of urological malignancies, 195 moderately significant lesions and 246 insignificant lesions were detected. In the remaining 563 patients no underlying lesion could be found. Of the 246 patients with insignificant lesions and 563 with unexplained asymptomatic microscopic hematuria followup was done in 421 at 6-month intervals for more than 1 year. A diagnosis became clear within 3 years in 22 patients, including 3 cases of bladder carcinoma and 1 of prostatic carcinoma.

PMID 2193173  J Urol. 1990 Jul;144(1):99-101.
著者: A J Mariani, M C Mariani, C Macchioni, U K Stams, A Hariharan, A Moriera
雑誌名: J Urol. 1989 Feb;141(2):350-5.
Abstract/Text Between March 1976 and June 1985, 1,000 consecutive adults with asymptomatic gross or microscopic hematuria in the absence of proteinuria were evaluated urologically. Lesions that could account for the hematuria were detected in 88.3 per cent of the patients. Life-threatening lesions were diagnosed in 9.1 per cent of the patients, while lesions requiring at least observation were present in 22.8 per cent. The incidence of life-threatening lesions increased with age, with a sharp increase after age 50 years. Life-threatening lesions were more common in men (13.6 per cent) than in women (4.9 per cent). In general, as the degree of hematuria increased so did the yield of life-threatening lesions; however, there was no "safe" lower limit of hematuria. Of the patients with life-threatening lesions 18.6 per cent had at least 1 urinalysis with less than 3 red blood cells per high power field within 6 months of the diagnosis. The direct medical cost of a hematuria evaluation was $777. The difference in direct medical costs to diagnose and treat localized versus metastatic genitourinary cancer was $48,070 in 3 matched pairs of patients. In this study group 77 of 84 patients (92 per cent) diagnosed with genitourinary cancer had localized disease. A hematuria evaluation was cost-effective for all groups studied. A literature-based estimate of the life-threatening risks of diagnostic studies applied to the study data resulted in a 1.1 per cent life-threatening risk per hematuria evaluation. For all categories studied, except for women less than 40 years old with microscopic hematuria, the risk of a hematuria evaluation was less than the incidence of life-threatening lesions discovered as a result of the evaluation. Asymptomatic hematuria, whether gross or microscopic, is a significant finding and warrants evaluation from a risk-benefit and cost-effectiveness standpoint.

PMID 2492350  J Urol. 1989 Feb;141(2):350-5.
著者: T F Culclasure, V J Bray, J A Hasbargen
雑誌名: Arch Intern Med. 1994 Mar 28;154(6):649-52.
Abstract/Text BACKGROUND: There have been many case reports of substantial renal disease in association with anticoagulation, yet the intensity of anticoagulation has changed over the years. In 1986, the American College of Chest Physicians and the Heart, Lung, and Blood Institute recommended a decrease in anticoagulation intensity. In addition, a variety of new methods to investigate hematuria have evolved, including computed tomography and red blood cell morphologic analysis. Because of these developments, we initiated a prospective study to evaluate the relationship between anticoagulation, microscopic hematuria, and major genitourinary tract disease.
METHODS: To determine the incidence, prevalence, and cause of microscopic hematuria, patients receiving long-term anticoagulation therapy and controls not receiving such therapy were monitored with monthly urinalyses in a 2-year prospective study. Patients who developed hematuria were further studied for genitourinary tract disease. The incidence of hematuria was analyzed with regard to relative levels of anticoagulation.
RESULTS: The incidence of hematuria in the anticoagulated and control groups was 0.05 and 0.08 per 100 patient-months, respectively. The prevalence of hematuria was 3.2% in the anticoagulated group and 4.8% in the control group. Genitourinary tract disease was identified in 81% of patients with more than one episode of microscopic hematuria, and the cause of hematuria did not vary between groups. There was no correlation between the level of anticoagulation and the incidence of hematuria.
CONCLUSIONS: Anticoagulation at currently recommended levels does not predispose patients to hematuria. Identifiable genitourinary tract disease is present in the majority of anticoagulated patients with microscopic hematuria.

PMID 8129498  Arch Intern Med. 1994 Mar 28;154(6):649-52.
著者: Y Avidor, A Nadu, H Matzkin
雑誌名: Urology. 2000 Jan;55(1):22-4.
Abstract/Text OBJECTIVES: To investigate the results of evaluations in patients presenting with gross hematuria while receiving anticoagulant or aspirin treatment and to compare the source of bleeding in these respective groups.
METHODS: We retrospectively studied all patients admitted because of gross hematuria while receiving warfarin or aspirin treatment between 1990 and 1998. The degree of anticoagulation was evaluated in patients taking anticoagulation medication. Almost all patients were evaluated by cystoscopy and either excretory urography or ultrasound.
RESULTS: Patients taking warfarin had a normal evaluation almost twice as often as those taking aspirin: 38% versus 22%, respectively. The leading pathologic findings in both groups were a bleeding benign prostate and a tumor in the urinary tract, in similar proportions. Overall, a tumor was diagnosed in one quarter of patients, and other treatable pathologic findings were diagnosed about half the time. In the 11 patients receiving excessive anticoagulation medication, two tumors were found (18%). Hemorrhagic cystitis was diagnosed in 12 patients. All 12 were taking aspirin.
CONCLUSIONS: A normal evaluation was more prevalent in the warfarin group. A tumor was diagnosed in about one quarter of the patients. The prevalence of hemorrhagic cystitis in patients taking aspirin may point to a specific bleeding diathesis in the urothelium of these patients. In light of these findings, a full evaluation is warranted in patients receiving aspirin or warfarin therapy, and the presence of excessive anticoagulation should not impede a full evaluation.

PMID 10654888  Urology. 2000 Jan;55(1):22-4.
著者: Said Fadel Mishriki, Ross Vint, Bhaskar K Somani
雑誌名: J Urol. 2012 May;187(5):1561-5. doi: 10.1016/j.juro.2011.12.100. Epub 2012 Mar 14.
Abstract/Text PURPOSE: Visible hematuria has a cancer yield of up to 24.2%. A large proportion of cases will have no etiology. In this study we determined the incidence of pathology (benign and malignant) in patients with visible hematuria and those with persistent and recurrent visible hematuria, and evaluated the policy for investigations.
MATERIALS AND METHODS: Data were prospectively collected for 1,804 patients with visible hematuria at a United Kingdom teaching hospital from January 1999 to September 2007. In October 2010 the comprehensive hospital electronic database was checked for every individual patient to ensure no urological pathology was missed. All patients underwent standard hematuria investigations, including renal tract ultrasound and excretory urography or contrast enhanced computer tomography urogram, flexible cystoscopy and urine cytology.
RESULTS: The male-to-female ratio was 4.8:1. Median age ± SD was 67 ± 17.0 years (range 21 to 109). Median followup was 6.6 ± 2.5 years (range 1.5 to 11.6). No urological pathology was found in 965 (53.5%) patients. Malignant urological disease was found in 386 (21.4%) patients, of whom 329 had bladder tumors. There were 32 patients with persistent visible hematuria and no malignancy. Repeat investigation was performed in 69 patients reporting recurrence. Of these patients 35 received a significant urological diagnosis, including 12 (17.4%) urological malignancies, while 34 (49.3%) still had no diagnosis. Limitations include the possibility of missing pathology.
CONCLUSIONS: Almost 50% of patients presenting with visible hematuria will have a diagnosis. Therefore, all cases of visible hematuria require full standard investigations. Patients with no diagnosis can be discharged from followup. Recurrent visible hematuria after full initial negative findings requires repeat full standard investigations because 11.6% will have malignant pathology.

Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 22425074  J Urol. 2012 May;187(5):1561-5. doi: 10.1016/j.juro.201・・・
著者: George C Willis, Semhar Z Tewelde
雑誌名: Emerg Med Clin North Am. 2019 Nov;37(4):755-769. doi: 10.1016/j.emc.2019.07.011.
Abstract/Text Hematuria is common; whether gross or microscopic, it is incumbent on emergency providers to consider life-threatening and benign processes when evaluating these patients. Most workup is driven by a focused history and physical, including laboratory studies and diagnostic imaging. The cause originates in the genitourinary tract and, as long as the patient remains stable, they can be discharged with close outpatient follow-up. The importance of this cannot be stressed enough because hematuria, especially in the elderly, frequently signals the presence of urologic malignancy. In addition, the workup occasionally yields a nongenitourinary tract cause, and these patients often require emergent management.

Copyright © 2019 Elsevier Inc. All rights reserved.
PMID 31563206  Emerg Med Clin North Am. 2019 Nov;37(4):755-769. doi: 1・・・
著者:
雑誌名: Kidney Int. 1991 Jul;40(1):115-20.
Abstract/Text
PMID 1921146  Kidney Int. 1991 Jul;40(1):115-20.
著者: E M Messing, T B Young, V B Hunt, J M Wehbie, P Rust
雑誌名: Cancer. 1989 Dec 1;64(11):2361-7.
Abstract/Text In a homescreening study 235 asymptomatic men, 50 years of age and older without known causes of hematuria, tested their urine each week with a chemical reagent strip for the presence of blood for 1 year. Forty-four men had hematuria at least once, and 31 had a full urologic evaluation. Of these, eight were found to have urinary cancers and seven had nonmalignant diseases warranting immediate treatment. In six of these 15 men (only two with cancer) hematuria occurred in over 1/3 of the testings, and in four hematuria was found on microscopic urinalysis at the time of urologic evaluation. The degree of hematuria was unrelated to the seriousness of its cause. We conclude that in this population hematuria occurs intermittently and when found, regardless of quantity or symptoms, serious underlying pathology must be ruled out. Furthermore, regular hematuria home testing offers a promising means of detecting urinary cancers and other diseases that warrant therapy in asymptomatic men 50 years of age and older.

PMID 2804928  Cancer. 1989 Dec 1;64(11):2361-7.
著者: E M Messing, T B Young, V B Hunt, E B Roecker, A M Vaillancourt, W J Hisgen, E B Greenberg, M E Kuglitsch, J D Wegenke
雑誌名: J Urol. 1992 Aug;148(2 Pt 1):289-92.
Abstract/Text The majority of urinary tract tumors cause bleeding in the urine. A program designed to detect hematuria before it is grossly apparent may contribute to earlier detection and more successful treatment of these malignancies. To test this hypothesis a hematuria home screening study was conducted. A total of 1,340 healthy men 50 years old or older used chemical reagent strips for 14 consecutive days to test the urine. Of the men 283 (21.1%) had at least 1 episode of hematuria. Of the 192 hematuria positive men who received a complete urological evaluation 16 (8.3%) had urological cancers and 47 (24.5%) had other hematuria-causing diseases that required immediate treatment. The quantity and frequency of hematuria were not related to disease severity. A hematuria home screening regimen is feasible and economical, and may promote the early detection of urinary tract cancers and other diseases in men more than 50 years old.

PMID 1635120  J Urol. 1992 Aug;148(2 Pt 1):289-92.
著者: Rodney Davis, J Stephen Jones, Daniel A Barocas, Erik P Castle, Erich K Lang, Raymond J Leveillee, Edward M Messing, Scott D Miller, Andrew C Peterson, Thomas M T Turk, William Weitzel, American Urological Association
雑誌名: J Urol. 2012 Dec;188(6 Suppl):2473-81. doi: 10.1016/j.juro.2012.09.078. Epub 2012 Oct 24.
Abstract/Text PURPOSE: The purpose of this guideline is to provide a clinical framework for the diagnosis, evaluation and follow-up of asymptomatic microhematuria.
MATERIALS AND METHODS: A systematic literature review using the MEDLINE® database was conducted to identify peer reviewed publications relevant to the definition, diagnosis, evaluation and follow-up for AMH. The review yielded 191 evidence-based articles, and these publications were used to create the majority of the guideline statements. There was insufficient evidence-based data for certain concepts; therefore, clinical principles and consensus expert opinions were used for portions of the guideline statements.
RESULTS: Guideline statements are provided for diagnosis, evaluation and follow-up. The panel identified multiphasic computed tomography as the preferred imaging technique and developed guideline statements for persistent or recurrent AMH as well as follow-up.
CONCLUSIONS: AMH is only diagnosed by microscopy; a dipstick reading suggestive of hematuria should not lead to imaging or further investigation without confirmation of three or greater red blood cells per high power field. The evaluation and follow-up algorithm and guidelines provide a systematic approach to the patient with AMH. All patients 35 years or older should undergo cystoscopy, and upper urinary tract imaging is indicated in all adults with AMH in the absence of known benign causation. The imaging modalities and physical evaluation techniques are evolving, and these guidelines will need to be updated as the effectiveness of these become available. Please visit the AUA website at http://www.auanet.org/content/media/asymptomatic_microhematuria_guideline.pdf to view this guideline in its entirety.

Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 23098784  J Urol. 2012 Dec;188(6 Suppl):2473-81. doi: 10.1016/j.j・・・
著者: Tim Wollin, Bruno Laroche, Karen Psooy
雑誌名: Can Urol Assoc J. 2009 Feb;3(1):77-80.
Abstract/Text
PMID 19293985  Can Urol Assoc J. 2009 Feb;3(1):77-80.
著者: Robert A Cohen, Robert S Brown
雑誌名: N Engl J Med. 2003 Jun 5;348(23):2330-8. doi: 10.1056/NEJMcp012694.
Abstract/Text
PMID 12788998  N Engl J Med. 2003 Jun 5;348(23):2330-8. doi: 10.1056/N・・・
著者: Kunitoshi Iseki, Yoshiharu Ikemiya, Chiho Iseki, Shuichi Takishita
雑誌名: Kidney Int. 2003 Apr;63(4):1468-74. doi: 10.1046/j.1523-1755.2003.00868.x.
Abstract/Text BACKGROUND: Dipstick urinalysis for proteinuria and hematuria has been used to screen renal disease, but evidence of the clinical impact of this test on development of end-stage renal disease (ESRD) is lacking.
METHODS: We assessed development of ESRD through 2000 in 106,177 screened patients (50,584 men and 55,593 women), 20 to 98 years old, in Okinawa, Japan, who participated in community-based mass screening between April 1983 and March 1984. We used data from the Okinawa Dialysis Study Registry to identify ESRD patients. Multivariate logistic analyses were performed to calculate adjusted odds ratio and 95% confidence interval (95% CI) for the significance of proteinuria and hematuria on the risk of developing ESRD with confounding variables such as age, gender, blood pressure, and body mass index. A similar analysis was repeated in a subgroup of screened patients in whom serum creatinine data existed.
RESULTS: During 17 years of follow-up, 420 screened persons (246 men and 174 women) entered the ESRD program. We identified a strong, graded relationship between ESRD and dipstick urinalysis positive for proteinuria; adjusted odds ratio (95% CI) was 2.71 (2.51 to 2.92, P < 0.001). Similar trends were observed after adding serum creatinine data. Compared with dipstick-negative proteinuria, adjusted odds ratio (95% CI) of proteinuria (1+) was 1.93 (1.53 to 2.41, P < 0.001) in men and 2.42 (1.91 to 3.06, P < 0.001) in women.
CONCLUSION: Proteinuria was a strong, independent predictor of ESRD in a mass screening setting. Even a slight increase in proteinuria was an independent risk factor for ESRD. Therefore, asymptomatic proteinuria warrants further work-up and intervention.

PMID 12631363  Kidney Int. 2003 Apr;63(4):1468-74. doi: 10.1046/j.1523・・・

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