Skip to main content

Cost-effectiveness of mass screening for dipstick hematuria in Japan

A Correction to this article was published on 02 February 2022

This article has been updated



Dipstick urine tests are a simple and inexpensive method for detecting kidney and urological diseases, such as IgA nephropathy and bladder cancer. The nationwide mass screening program, Specific Health Checkup (SHC), started in Japan in 2008 and targeted all adults between 40 and 74 years of age. Dipstick urine tests for proteinuria and glucosuria are mandatory as part of the SHC, but dipstick urine tests for hematuria are not. However, the dipstick hematuria test is often administered simultaneously with these mandatory tests by some health insurers. Hematuria is common in Japanese general screening participants, particularly elderly women, and the necessity of mass screening using the dipstick hematuria test has been discussed. This study aimed to evaluate the cost-effectiveness of mass screening for dipstick hematuria tests in addition to the SHC.


Using a decision tree and Markov modeling, we conducted a cost-effectiveness analysis from a Japanese societal perspective.


Compared with the current SHC, mass screening for dipstick hematuria tests, in addition to the SHC, costs less and gains more, which means cost-saving. Similar findings were observed in the sex-specific analysis.


Our results suggest that mandating the dipstick hematuria test could be justifiable as an efficient use of finite healthcare resources. The results have implications for mass screening programs not only in Japan but worldwide.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Change history


  1. Yamagata K, Yamagata Y, Kobayashi M, et al. A long-term follow-up study of asymptomatic hematuria and/or proteinuria in adults. Clin Nephrol. 1996;45:281–8.

    CAS  PubMed  Google Scholar 

  2. Iseki K, Iseki C, Ikemiya Y, et al. Risk of developing end-stage renal disease in a cohort of mass screening. Kidney Int. 1996;49:800–5.

    CAS  PubMed  Google Scholar 

  3. Iseki K. Evidence for asymptomatic microhematuria as a risk factor for the development of ESRD. Am J Kidney Dis. 2012;60:12–4.

    PubMed  Google Scholar 

  4. Japanese Urological Association. Practice guidelines of bladder cancer 2019 (in Japanese). Tokyo: Igakutosho Shuppan; 2019.

    Google Scholar 

  5. Yamagata K, Takahashi H, Tomida C, et al. Prognosis of asymptomatic hematuria and/or proteinuria in men. High prevalence of IgA nephropathy among proteinuric patients found in mass screening. Nephron. 2002;91:34–42.

    PubMed  Google Scholar 

  6. Chow KM, Kwan BC, Li PK, et al. Asymptomatic isolated microscopic haematuria: Long-term follow-up. QJM. 2004;97:739–45.

    CAS  PubMed  Google Scholar 

  7. Horie S, Ito S, Okada H, et al. Japanese guidelines of the management of hematuria 2013. Clin Exp Nephrol. 2014;18:679–89.

    PubMed  Google Scholar 

  8. Vivante A, Afek A, Frenkel-Nir Y, et al. Persistent asymptomatic isolated microscopic hematuria in Israeli adolescents and young adults and risk for end-stage renal disease. JAMA. 2011;306:729–36.

    CAS  PubMed  Google Scholar 

  9. Iseki K, Konta T, Asahi K, et al. Association of dipstick hematuria with all-cause mortality in the general population: results from the specific health check and guidance program in Japan. Nephrol Dial Transplant. 2018;33:825–32.

    CAS  PubMed  Google Scholar 

  10. Iseki K, Konta T, Asahi K, et al. Higher cardiovascular mortality in men with persistent dipstick hematuria. Clin Exp Nephrol. 2020;25:1–7.

    Google Scholar 

  11. Linder BJ, Bass EJ, Mostafid H, et al. Guideline of guidelines: asymptomatic microscopic haematuria. BJU Int. 2018;121:176–83.

    PubMed  Google Scholar 

  12. Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Can Urol Assoc J. 2009;3:77–80.

    PubMed  PubMed Central  Google Scholar 

  13. Davis R, Jones JS, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol. 2012;188:2473–81.

    PubMed  Google Scholar 

  14. Kohro T, Furui Y, Mitsutake N, et al. The Japanese national health screening and intervention program aimed at preventing worsening of the metabolic syndrome. Int Heart J. 2008;49:193–203.

    PubMed  Google Scholar 

  15. Ministry of Health, Labour and Welfare. Heisei 27 nendo tokutei kenko shinsatokutei hoken shidono jisshi jyokyo ni tsuite. 2017. Accessed October 23, 2020.

  16. Kannno M, Okushi Y. Comparison of judgment rates before and after specific medical examination (in Japanese). Health Eval Promot. 2010;37:143.

    Google Scholar 

  17. Yamashita M. Urine sediment examination (in Japanese). Med Technol. 2011;910–5.

  18. Murakami S, Igarashi T, Hara S, et al. Strategies for asymptomatic microscopic hematuria: a prospective study of 1,034 patients. J Urol. 1990;144:99–101.

    CAS  PubMed  Google Scholar 

  19. Mishina T. Clinical study of 824 cases of microscopic hematuria (in Japanese). Jpn J Clin Urol. 1993;47:131–5.

    Google Scholar 

  20. Terasaki T. Imaging and renal biopsy results in screening for adult diseases (in Japanese). Prev Nephrol Urol. 1994;2:36–9.

    Google Scholar 

  21. Iseki K, Miyasato F, Uehara H, et al. Outcome study of renal biopsy patients in Okinawa. Japan Kidney Int. 2004;66:914–9.

    PubMed  Google Scholar 

  22. Hoshino Y, Kaga T, Abe Y, et al. Renal biopsy findings and clinical indicators of patients with hematuria without overt proteinuria. Clin Exp Nephrol. 2015;19:918–24.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. Yokoyama H, Sugiyama H, Sato H, et al. Renal disease in the elderly and the very elderly Japanese: analysis of the Japan Renal Biopsy Registry (J-RBR). Clin Exp Nephrol. 2012;16:903–20.

    PubMed  Google Scholar 

  24. Okonogi H, Kawamura T, Joh K, et al. A grading system that predicts the risk of dialysis induction in IgA nephropathy patients based on the combination of the clinical and histological severity. Clin Exp Nephrol. 2019;23:16–25.

    CAS  PubMed  Google Scholar 

  25. Matsuo S, Kawamura T, Jyo K. Clinical guides for IgA nephropathy in Japan, third version (in Japanese). Nihon Jinzo Gakkai Shi. 2011;53:123–35.

    Google Scholar 

  26. Cancer Information Service, National Cancer Center Japan. National Cancer Registry data provision for researcher. Accessed 26 Nov 2020

  27. Cancer registration committee of the Japanese Urological Association. The report of clinical statistical studies on registered bladder cancer patients in japan 2002 (in Japanese). Nippon Hinyokika Gakkai Zasshi. 2013;1–19

  28. National Cancer Center Japan. The cancer registry report of the nationwide designated cancer care hospitals. 2016. Accessed 26 Nov 2020

  29. Endo M. Epidemiology, symptoms and prognosis of IgA nephropathy (in Japanese). Nihon Jinzo Gakkai Shi. 2008;50:442–7.

    PubMed  Google Scholar 

  30. Kato T. Primary care for kidney disease (in Japanese). Nippon Naika Gakkai Zasshi. 2001;90:1231–5.

    CAS  PubMed  Google Scholar 

  31. Hattori R, Matsuura O, Takeuchi N, et al. Clinical importance of microhematuria as an initial sign of bladder tumor (in Japanese). Nippon Hinyokika Gakkai Zasshi. 1990;81:414–9.

    CAS  PubMed  Google Scholar 

  32. Tanaka S, Ninomiya T, Katafuchi R, et al. The effect of renin-angiotensin system blockade on the incidence of end-stage renal disease in IgA nephropathy. Clin Exp Nephrol. 2016;20:689–98.

    CAS  PubMed  Google Scholar 

  33. Komatsu H, Kikuchi M, Nakagawa H, et al. Long-term survival of patients with IgA nephropathy after dialysis therapy. Kidney Blood Press Res. 2013;37:649–56.

    CAS  PubMed  Google Scholar 

  34. Ministry of Health, Labour and Welfare. Vital statistics of Japan 2015. Health and Welfare Statistics Association, Tokyo, 2017.

  35. Kikuchi E, Fujimoto H, Mizutani Y, et al. Clinical outcome of tumor recurrence for ta, T1 non-muscle invasive bladder cancer from the data on registered bladder cancer patients in Japan: 1999–2001 report from the Japanese urological association. Int J Urol. 2009;16:279–86.

    PubMed  Google Scholar 

  36. Japanese Association of Clinical Cancer Centers. Zengankyo kameishiesetsuno seizonritsu kyodotyosa. Accessed November 26, 2020.

  37. Drummond MF, Sculpher MJ, Claxton K, et al. Methods for the economic evaluation of health care programmes. 4th ed. Oxford: Oxford University Press; 2015.

    Google Scholar 

  38. Neumann PJ, Sanders GD, Russell LB, et al. Cost-effectiveness in health and medicine. 2nd ed. New York: Oxford University Press; 2016.

    Google Scholar 

  39. Tajima R, Kondo M, Kai H, et al. Measurement of health-related quality of life in patients with chronic kidney disease in Japan with EuroQol (EQ-5D). Clin Exp Nephrol. 2010;14:340–8.

    PubMed  Google Scholar 

  40. Takura T, Nakanishi T, Kawanishi H, et al. Cost-effectiveness of maintenance hemodialysis in Japan. Ther Apher Dial. 2015;19:441–9.

    PubMed  Google Scholar 

  41. Heijnsdijk EAM, Nieboer D, Garg T, et al. Cost-effectiveness of surveillance schedules in older adults with non-muscle-invasive bladder cancer. BJU Int. 2019;123:307–12.

    PubMed  Google Scholar 

  42. Shiroiwa T, Sung YK, Fukuda T, et al. International survey on willingness-to-pay (WTP) for one additional QALY gained: what is the threshold of cost effectiveness? Health Econ. 2010;19:422–37.

    PubMed  Google Scholar 

  43. Bradley MS, Willis-Gray MG, Amundsen CL, et al. Microhematuria in postmenopausal women: adherence to guidelines in a tertiary care setting. J Urol. 2016;195:937–41.

    PubMed  Google Scholar 

  44. Committee on Gynecologic Practice, American Urogynecologic Society. Asymptomatic microscopic hematuria in women. Female Pelvic Med Reconstr Surg. 2017;23:228–31.

  45. Sugimura K, Ikemoto SI, Kawashima H, et al. Microscopic hematuria as a screening marker for urinary tract malignancies. Int J Urol. 2001;8:1–5.

    CAS  PubMed  Google Scholar 

  46. Messing EM, Madeb R, Young T, et al. Long-term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173–9.

    PubMed  Google Scholar 

  47. Boulware LE, Jaar BG, Tarver-Carr ME, et al. Screening for proteinuria in US adults: a cost-effectiveness analysis. JAMA. 2003;290:3101–14.

    CAS  PubMed  Google Scholar 

  48. Wang H, Yang L, Wang F, et al. Strategies and cost-effectiveness evaluation of persistent albuminuria screening among high-risk population of chronic kidney disease. BMC Nephrol. 2017;18:135.

    PubMed  PubMed Central  Google Scholar 

  49. Sutton AJ, Lamont JV, Evans RM, et al. An early analysis of the cost-effectiveness of a diagnostic classifier for risk stratification of haematuria patients (DCRSHP) compared to flexible cystoscopy in the diagnosis of bladder cancer. PLoS ONE. 2018;13:e0202796.

    PubMed  PubMed Central  Google Scholar 

  50. Lotan Y, Svatek RS, Sagalowsky AI. Should we screen for bladder cancer in a high-risk population? A cost per life-year saved analysis. Cancer. 2006;107:982–90.

    PubMed  Google Scholar 

  51. Fiorentino M, Bolignano D, Tesar V, et al. Renal biopsy in 2015—from epidemiology to evidence-based indications. Am J Nephrol. 2016;43:1–19.

    PubMed  Google Scholar 

Download references


We express our thanks to Ryoya Tsunoda, Yukiko Kai, and Yuko Aoki for their assistance with the medical cost calculations.


This work was supported by Practical Research Project for Renal Diseases, Japan Agency for Medical Research and Development, AMED (Grant number JP20ek0310010). This work was also supported by a Japanese Grant-in-Aid for Scientific Research (B) (Grant number 19H03865).

Author information

Authors and Affiliations



Research idea and study design: RO, MK, KI; data acquisition: RO, SH, TK, MK, KA, CI, SF, IN, KY, KI; data analysis/interpretation: RO, SH, TK, MK; writing – original drafts: RO; writing – review and editing: SH, TK, MK, KA, SF, IN, HN, KY, KI.

Corresponding author

Correspondence to Masahide Kondo.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to declare.

Ethics approval

Ethics approval was not required, because we only used published studies or secondary data.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The original online version of this article was revised: "In the original publication, few errors were found in Figure 2c, Table 1 and Table3.

About this article

Verify currency and authenticity via CrossMark

Cite this article

Okubo, R., Hoshi, SL., Kimura, T. et al. Cost-effectiveness of mass screening for dipstick hematuria in Japan. Clin Exp Nephrol 26, 398–412 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Cost-effectiveness
  • Mass screening
  • Dipstick hematuria test
  • IgA nephropathy
  • Bladder cancer