title: Diagnostic impact of dysmorphic red blood cells on evaluating microscopic hematuria: the urologist's perspective.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Urology, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
authors.forename: Kyo Chul
authors.initials: KC
authors.lastname: Koo
authors.affiliation: Department of Urology, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
authors.forename: Kwang Suk
authors.initials: KS
authors.lastname: Lee
authors.affiliation: Division of Nephrology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
authors.forename: Ah Ran
authors.initials: AR
authors.lastname: Choi
authors.affiliation: Department of Urology, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
authors.forename: Koon Ho
authors.initials: KH
authors.lastname: Rha
authors.affiliation: Department of Urology, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea.
authors.forename: Sung Joon
authors.initials: SJ
authors.lastname: Hong
authors.affiliation: Department of Urology, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Republic of Korea. chung646@yuhs.ac.
authors.forename: Byung Ha
authors.identifier: http://orcid.org/0000-0003-0048-5717
authors.initials: BH
authors.lastname: Chung
mesh_terms: D000368:Aged; D015331:Cohort Studies; D004906:Erythrocyte Count; D004913:Erythrocytes, Abnormal / Q000473:pathology*; D005260:Female; D006417:Hematuria / Q000097:blood / Q000175:diagnosis*; D006801:Humans; D007674:Kidney Diseases / Q000175:diagnosis* / Q000453:epidemiology; D007678:Kidney Glomerulus / Q000473:pathology* / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D000072178:Urologists
keywords: Dysmorphism; Erythrocytes; Guideline; Hematuria; Neoplasms