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Blood in Urine: A Hard Nut to Crack

Axial contrast-enhanced CT image shows the left renal vein (arrow) being compressed between the superior mesenteric artery (*) and the abdominal aorta (A).

Axial contrast-enhanced CT image shows the left renal vein (arrow) being compressed between the superior mesenteric artery (*) and the abdominal aorta (A).

A 34-year-old woman presented with a 2-week history of intermittent painless macroscopic hematuria. She had a similar episode of macroscopic hematuria 5 years ago during her last pregnancy, which resolved spontaneously. Apart from this, she had no significant medical history. She was not taking any regular medications or supplements.

On examination, she appeared well. She had a blood pressure of 109/63 mm Hg, heart rate of 64 beats/min, and temperature of 97.8°F (36.6°C). Abdominal examination was unremarkable. No tenderness was elicited over the flanks and costovertebral angles.


Investigations showed hemoglobin of 126 g/L, white cell count of 4.85 × 109/L and platelets of 230 × 109/L. Clotting profile was normal. The urine dipstick examination was positive for blood and protein. Urine microscopic examination showed 792 red blood cells and 14 white blood cells per high-power field. Urine red cell morphology showed 97% dysmorphic cells. The urine protein creatinine ratio was increased at 217 mg/mmol (total urine protein excretion equivalent to 1.9 g/d). Urine culture did not show any bacterial growth. Renal function was normal with serum creatinine of 0.92 mg/dL and blood urea nitrogen of 14.6 mg/dL. An ultrasound examination of the urinary tract was essentially normal. Urine cytology did not show any malignant cells. The patient had a flexible cystoscopy examination that did not reveal any abnormality. Because of negative urologic investigations, the presence of both protein and blood in the urine, and predominantly dysmorphic red cells on urine microscopy, a primary glomerular pathology was suspected, and the patient was referred to the nephrology service for further evaluation. Further investigations revealed that antinuclear antibody, antineutrophil cytoplasmic antibody, anti–double-stranded DNA antibody, and complement C3 and C4 were all normal. A renal biopsy was being considered. In the interim, the patient had a computed tomography (CT) urogram that had been booked by the urology service before nephrology referral. It showed that both kidneys were normal in size with symmetric enhancement and contrast excretion. No suspicious solid renal lesion or radio-opaque urinary calculus was seen. There was no hydronephrosis, hydroureter, or perinephric fat stranding. The urinary bladder was normal in appearance. The uterus was retroverted with no abnormal adnexal masses. The left renal vein was attenuated as it coursed posterior to the proximal superior mesenteric artery (Figure 1). The aorta-superior mesenteric artery angle was reduced at 30 degrees (Figure 2). The left gonadal vein was more prominent compared with the contralateral side.

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- Muhammad Masoom Javaid, MBBS, FRCP, Ching Ching Ong, MBBS, FRCR, Srinivas Subramanian, MBBS, DABIM

This article originally appeared in the March 2017 issue of The American Journal of Medicine.

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