Management of Urinalysis with Proteinuria and Hematuria

Initial Assessment

The American Academy of Family Physicians recommends excluding benign causes of hematuria, including menstruation, vigorous exercise, sexual activity, viral illness, trauma, and infection, when urinalysis shows both proteinuria and hematuria 1, 2
Obtain a 24-hour urine collection to quantitate proteinuria when dipstick shows ≥1+ protein, as recommended by the American Academy of Family Physicians 1, 3
Examine urinary sediment for dysmorphic red blood cells and red cell casts, which suggest glomerular origin, according to the American Academy of Family Physicians 2, 4
Measure serum creatinine to assess renal function, as suggested by the American Academy of Family Physicians 2, 5

A glomerular source is likely if there is significant proteinuria (>500 mg/24 hours), dysmorphic RBCs (>80% dysmorphic RBCs), red cell casts, or elevated serum creatinine, as indicated by the American Academy of Family Physicians 1, 2, 4
A non-glomerular (urologic) source is likely if there are normal-shaped RBCs (>80% normal RBCs), minimal proteinuria (<500 mg/24 hours), or normal serum creatinine, according to the American Academy of Family Physicians 1, 2, 4

Refer to nephrology if there is proteinuria >1,000 mg/24 hours, proteinuria >500 mg/24 hours that is persistent or increasing, red cell casts, or predominantly dysmorphic RBCs, as recommended by the American Academy of Family Physicians 1, 2, 4
Nephrology evaluation may include evaluation for systemic diseases, consideration of renal biopsy, and assessment of renal function, according to the American Academy of Family Physicians 4

Complete urologic evaluation, including history and physical examination, radiologic imaging of upper urinary tract, and cystoscopic examination of urinary bladder, as suggested by the American Academy of Family Physicians 4, 5
Refer to urology if there is age >40 years, smoking history, history of gross hematuria, occupational exposure to chemicals or dyes, previous urologic disorder, irritative voiding symptoms, or recurrent urinary tract infections, according to the American Academy of Family Physicians 2, 3, 4, 5

For patients with persistent hematuria after negative initial evaluation, repeat urinalysis at 6, 12, 24, and 36 months, monitor blood pressure, and consider nephrology referral if hematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding, as recommended by the American Academy of Family Physicians 5
For patients with isolated hematuria (no proteinuria or other abnormalities), follow for development of hypertension, renal insufficiency, or proteinuria, according to the American Academy of Family Physicians 4

Patients with microscopic hematuria, negative urologic evaluation, and no evidence of glomerular bleeding have low risk for progressive renal disease but should still be monitored, as indicated by the American Academy of Family Physicians 4
In women, obtain a catheterized specimen if clean-catch cannot be reliably obtained due to vaginal contamination, as suggested by the American Academy of Family Physicians 4