Skip to main content


Log in

Diagnostic impact of dysmorphic red blood cells on evaluating microscopic hematuria: the urologist’s perspective

  • Urology - Original Paper
  • Published:
International Urology and Nephrology Aims and scope Submit manuscript



Dysmorphic red blood cells (dRBCs) are indicative of glomerular disease and considered a first step in evaluating microscopic hematuria (MH). The predominance of dRBCs does not preclude urological disease; however, some contemporary guidelines advise nephrological evaluation without further urological evaluation, in contrast to the American Urological Association guideline. We investigated the feasibility and safety of omitting urological evaluation in patients presenting with MH.


A retrospective analysis was performed on 411 consecutive patients who presented with MH between January 2012 and December 2014. MH was defined as ≥3 RBCs per high-power field. All patients received full urological and nephrological evaluations including history and physical assessment, renal function, urine cytology, %dRBC, cystoscopy, computed tomography (CT) imaging, and renal biopsy when indicated.


The median %dRBC was higher in patients with glomerular disease than in those with urological disease (40.4 vs. 21.1 %; p < 0.001). Among patients exhibiting %dRBC ≥ 40, 33/97 (34.0 %) had urological and 28/97 (28.9 %) had glomerular diseases. Urological diseases included 9/33 (27.3 %) clinically meaningful malignancies and 17/33 (51.5 %) conditions requiring immediate treatment. The rate of malignancy was comparable between %dRBC groups (p = 0.087). Among patients with final diagnoses who exhibited %dRBC ≥ 40, 32/61 (52.5 %) treatment-requiring conditions would have been unrecognized had cystoscopy and/or CT not been performed. For predicting glomerular disease, the presence of proteinuria demonstrated higher AUC than %dRBC ≥ 40 (0.77 vs. 0.65; p < 0.001).


Identification of %dRBC ≥ 40 had modest diagnostic value in identifying glomerular disease, and concomitant presence of proteinuria was more indicative of glomerular origin in patients presenting with MH. Urological evaluation should not be omitted in these patients considering the prevalence of treatment-requiring urological disease.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others


  1. Crop MJ, de Rijke YB, Verhagen PC, Cransberg K, Zietse R (2010) Diagnostic value of urinary dysmorphic erythrocytes in clinical practice. Nephron Clin Pract 115:c203–c212

    Article  PubMed  Google Scholar 

  2. Buteau A, Seideman CA, Svatek RS, Youssef RF, Chakrabarti G, Reed G et al (2014) What is evaluation of hematuria by primary care physicians? Use of electronic medical records to assess practice patterns with intermediate follow-up. Urol Oncol 32:128–134

    Article  PubMed  Google Scholar 

  3. Grossfeld GD, Wolf JS Jr, Litwan MS, Hricak H, Shuler CL, Agerter DC et al (2001) Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations. Am Fam Physician 63:1145–1154

    CAS  PubMed  Google Scholar 

  4. Fogazzi GB, Edefonti A, Garigali G, Giani M, Zolin A, Raimondi S et al (2008) Urine erythrocyte morphology in patients with microscopic haematuria caused by a glomerulopathy. Pediatr Nephrol 23:1093–1100

    Article  PubMed  Google Scholar 

  5. Pollock C, Liu PL, Gyory AZ, Grigg R, Gallery ED, Caterson R et al (1989) Dysmorphism of urinary red blood cells–value in diagnosis. Kidney Int 36:1045–1049

    Article  CAS  PubMed  Google Scholar 

  6. Jones R, Latinovic R, Charlton J, Gulliford MC (2007) Alarm symptoms in early diagnosis of cancer in primary care: cohort study using general practice research database. BMJ 334:1040

    Article  PubMed  PubMed Central  Google Scholar 

  7. Niemi MA, Cohen RA (2015) Evaluation of microscopic hematuria: a critical review and proposed algorithm. Adv Chronic Kidney Dis 22:289–296

    Article  PubMed  Google Scholar 

  8. Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ et al (2012) Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 188:2473–2481

    Article  PubMed  Google Scholar 

  9. Kiragu D, Cifu AS (2015) Evaluation of patients with asymptomatic microhematuria. JAMA 314:1865–1866

    Article  CAS  PubMed  Google Scholar 

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

    PubMed  PubMed Central  Google Scholar 

  11. Loo R, Whittaker J, Rabrenivich V (2009) National practice recommendations for hematuria: how to evaluate in the absence of strong evidence? Perm J 13:37–46

    Article  PubMed  PubMed Central  Google Scholar 

  12. Roth S, Renner E, Rathert P (1991) Microscopic hematuria: advances in identification of glomerular dysmorphic erythrocytes. J Urol 146:680–684

    CAS  PubMed  Google Scholar 

  13. De Santo NG, Nuzzi F, Capodicasa G, Lama G, Caputo G, Rosati P et al (1987) Phase contrast microscopy of the urine sediment for the diagnosis of glomerular and nonglomerular bleeding-data in children and adults with normal creatinine clearance. Nephron 45:35–39

    Article  PubMed  Google Scholar 

  14. Nieder AM, Lotan Y, Nuss GR, Langston JP, Vyas S, Manoharan M et al (2010) Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey. Urol Oncol 28:500–503

    Article  PubMed  Google Scholar 

  15. Friedlander DF, Resnick MJ, You C, Bassett J, Yarlagadda V, Penson DF et al (2014) Variation in the intensity of hematuria evaluation: a target for primary care quality improvement. Am J Med 127:633–640

    Article  PubMed  PubMed Central  Google Scholar 

  16. Degrell P, Wagner Z, Szijarto IA, Wagner L, Marko L, Mohas M et al (2008) Morphology of glomerular hematuria is reproduced in vitro by carbonyl stress. Nephron Exp Nephrol 110:e25–e30

    Article  CAS  PubMed  Google Scholar 

  17. Georgopoulos M, Schuster FX, Porpaczy P, Schramek P (1996) Evaluation of asymptomatic microscopic haematuria–influence and clinical relevance of osmolality and pH on urinary erythrocyte morphology. Br J Urol 78:192–196

    Article  CAS  PubMed  Google Scholar 

  18. House AA, Cattran DC (2002) Nephrology: 2. Evaluation of asymptomatic hematuria and proteinuria in adult primary care. CMAJ 166:348–353

    PubMed  PubMed Central  Google Scholar 

  19. Jung H, Gleason JM, Loo RK, Patel HS, Slezak JM, Jacobsen SJ (2011) Association of hematuria on microscopic urinalysis and risk of urinary tract cancer. J Urol 185:1698–1703

    Article  PubMed  Google Scholar 

  20. El-Galley R, Abo-Kamil R, Burns JR, Phillips J, Kolettis PN (2008) Practical use of investigations in patients with hematuria. J Endourol 22:51–56

    Article  PubMed  Google Scholar 

  21. Jaffe JS, Ginsberg PC, Gill R, Harkaway RC (2001) A new diagnostic algorithm for the evaluation of microscopic hematuria. Urology 57:889–894

    Article  CAS  PubMed  Google Scholar 

  22. Fairley KF, Birch DF (1982) Hematuria: a simple method for identifying glomerular bleeding. Kidney Int 21:105–108

    Article  CAS  PubMed  Google Scholar 

  23. Mohammad KS, Bdesha AS, Snell ME, Witherow RO, Coleman DV (1993) Phase contrast microscopic examination of urinary erythrocytes to localise source of bleeding: an overlooked technique? J Clin Pathol 46:642–645

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Fassett RG, Horgan BA, Mathew TH (1982) Detection of glomerular bleeding by phase-contrast microscopy. Lancet 1:1432–1434

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Byung Ha Chung.

Ethics declarations

Conflict of interest

All of the authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was not required for the purposes of this study as it was based upon retrospective anonymous patient data and did not involve patient intervention or the use of human tissue samples.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Koo, K.C., Lee, K.S., Choi, A.R. et al. Diagnostic impact of dysmorphic red blood cells on evaluating microscopic hematuria: the urologist’s perspective. Int Urol Nephrol 48, 1021–1027 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: