What distinguishes glomerular hematuria from non‑glomerular hematuria?

Distinguishing Glomerular from Non-Glomerular Hematuria

The key differentiators are urine microscopy findings: glomerular hematuria shows >80% dysmorphic red blood cells (especially acanthocytes) and/or red cell casts, while non-glomerular hematuria shows >80% normal-shaped (isomorphic) red blood cells. 1

Urinary Sediment Examination

Glomerular Hematuria Features

• Dysmorphic red blood cells (>80%) are the hallmark of glomerular bleeding, appearing morphologically variable under phase-contrast microscopy due to environmental changes suffered while passing through renal tubules 1, 2
• Red cell casts are pathognomonic for glomerulonephritis and indicate active glomerular disease requiring urgent nephrology evaluation 1, 3
• Acanthocytes (ring-shaped RBCs with protruding blebs) are particularly specific markers of glomerular injury, with specificities and positive predictive values of 90-100% for diagnosing glomerular disease 4
• Tea-colored or cola-colored urine is a visual clue suggesting glomerular bleeding 1, 3

Non-Glomerular Hematuria Features

• Isomorphic (uniform) red blood cells (>80%) characterize urologic or non-glomerular bleeding, appearing morphologically normal under microscopy 1, 5, 2
• Bright red urine suggests lower urinary tract bleeding rather than glomerular disease 1

Associated Clinical Findings

Glomerular Disease Indicators

• Significant proteinuria (protein-to-creatinine ratio >0.5 g/g) strongly suggests renal parenchymal disease when present with hematuria 1, 6
• Elevated serum creatinine or declining renal function indicates potential glomerular disease 1, 3
• Hypertension accompanying hematuria and proteinuria forms the classic triad for glomerular involvement 1
• The combination of hematuria with proteinuria, particularly when accompanied by dysmorphic RBCs or red cell casts, is pathognomonic for glomerular bleeding 6

Non-Glomerular Disease Indicators

• Absence of proteinuria or only trace amounts suggests non-glomerular sources 1
• Irritative voiding symptoms (urgency, frequency, dysuria) without infection suggest urologic pathology 1
• Flank pain or suprapubic pain can indicate nephrolithiasis, renal mass, or bladder pathology 1

Diagnostic Methodology

Phase-Contrast Microscopy

• Phase-contrast microscopy by a skilled observer is the gold standard for differentiating glomerular from non-glomerular hematuria, demonstrating 97% accuracy in predicting the source 5, 7
• This technique reveals the range of dysmorphic changes characteristic of glomerular bleeding that result from environmental changes within renal tubules 2
• In glomerular disease, urine microscopy is second only to renal biopsy in diagnostic value 7

Automated Analysis

• Coulter counter analysis can accurately predict glomerular versus non-glomerular hematuria in 97 of 100 patients, providing a rapid, simple, and reproducible test with permanent graphic records 5

Critical Thresholds

• >80% dysmorphic RBCs indicates glomerular origin and warrants nephrology referral 1
• >80% normal RBCs indicates lower urinary tract bleeding 1
• Mixed morphologic patterns (neither >80%) suggest dual pathology and require both urologic and nephrologic evaluation 2

Common Pitfalls

• Do not rely solely on dipstick results—microscopic examination is mandatory to differentiate the source of bleeding 1
• Never dismiss the combination of hematuria and proteinuria as benign, as this strongly suggests underlying glomerular disease 6
• Recognize that urine microscopy is highly operator-dependent; skilled examination is essential for accurate interpretation 4, 7
• In healthy individuals, 95% have <8,000 RBCs/mL in urine, and these typically show a dysmorphic pattern, suggesting physiologic glomerular passage 2