Nephrol Dial Transplant (2018) 33: 1397–1403

doi: 10.1093/ndt/gfx274
Advance Access publication 6 October 2017

Urinalysis for the diagnosis of glomerulonephritis: role

of dysmorphic red blood cells

ORIGINAL ARTICLE
Abdurrahman M. Hamadah1,*, Kamel Gharaibeh1,*, Kristin C. Mara2, Katherine A. Thompson3,
John C. Lieske1, Samar Said3, Samih H. Nasr3 and Nelson Leung1
1
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA, 2Division of Biostatistics, Mayo Clinic, Rochester, MN, USA and

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3
Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA

Correspondence and offprint requests to: Abdurrahman M. Hamadah; E-mail: Hamadah.Abdurrahman@gmail.com

*These authors contributed equally to this work.

ABSTRACT
Background. Dysmorphic red blood cells (dRBCs) on urine
microscopy have been associated with glomerulonephritis
(GN). We assessed the prevalence and ability of dRBCs to dif-
ferentiate GN from other kidney diseases.
Methods. Adult patients with kidney biopsy performed
between 2012 and 2015 at a single center who had a concurrent
urinalysis were retrospectively studied. The association of
25% dRBCs with the presence of glomerular pathology was
assessed. Univariate and multivariate logistic regression were
performed on significantly associated variables.
Results. The mean age of the 482 eligible subjects was 55 years
and 47.7% were female. Overall, 173 (35.9%) had <25% and
76 (15.8%) had 25% urine dRBCs. Kidney biopsies revealed
glomerular disease in 372 (77.2%) (GN 46% and non-GN
54%). At the dRBC threshold of 25% used at our center, a
sensitivity of 20.4%, specificity of 96.3% and positive predic-
tive value of 94.6% for glomerular disease were observed. In a
logistic regression model, urine RBCs [>10 versus 10
(P < 0.001)] but not dRBCs 25% (P ¼ 0.3) independently
predicted the presence of GN. A scoring system (0–3) based
on hematuria and proteinuria levels revealed the risk for
biopsy-proven GN was 15% when the score was 0 compared
with 83% when it was 3.
Conclusions. The presence of 25% urine dRBCs is specific
but not sensitive for GN. In this cohort, the combined hematu-
ria (>10 RBCs/high-power field) and proteinuria performed
just as well as dRBCs plus proteinuria to predict underlying
GN. A model based on the degree of hematuria and proteinuria
found on urinalysis was able to predict the presence of GN.
Keywords: dysmorphic RBCs, glomerulonephritis, hematuria,
proteinuria, renal biopsy
INTRODUCTION
Urinalysis with microscopy remains an essential tool for timely
diagnosis and management of kidney diseases [1, 2]. The pres-
ence of dysmorphic red blood cells (dRBCs) has been associated
with glomerular diseases (GDs) and thus is reported by some
laboratories. In 1979, Birch and Fairly initially described the
distorted morphology of RBCs seen under phase contrast
microscopy that they associated with glomerular bleeding, coin-
ing the term dRBC [3, 4]. Phase contrast microscopy offers the
best ability to discriminate urinary sediment elements and is
felt to be superior to bright field microscopy for this purpose
[4–6]. Up to nine different morphologies of dRBCs have been
described in the literature [7–10]. Of these, acanthocytes seem
most specific for GD [8]. A recent report suggested that urinary
acanthocytes associate with proliferative lesions on renal biop-
sies of lupus nephritis patients [11]. However, the exact mor-
phologies used to categorize dRBCs and the number needed to
make disease associations has not been standardized, likely
impacting its sensitivity and specificity [1]. Depending on the
study design and selected population, the clinical cutoff for sig-
nificant dRBCs in the literature varies between 10% and 90%
[12]. Factors that have impacted the interpretation of these
studies include the relatively small size, small number of biopsy
proven kidney disease entities and sometimes the use of clin-
ically established (rather than biopsy-proven) diagnoses [7, 9,
12–14]. Our laboratory has used a standard approach to iden-
tify dRBCs in any urinalysis with microscopic hematuria since
1998 and reports whether the total exceeds 25% of all RBCs
observed. This provided an opportunity to evaluate the clinical
utility of dRBCs assessed in a standardized way in a consecutive
cohort over many years. In the current study, we retrospectively
analyzed the association of dRBCs and renal pathology in a

C The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
V 1397
large cohort of patients that had available renal biopsies. Our
objectives were to assess the prevalence of dRBCs in common
kidney diseases and the factors that determine their presence
and to establish whether the presence of dRBCs differentiates
between glomerular and nonglomerular processes.
Additionally, we investigated whether other elements of a
standard urinalysis associated with a pathologic diagnosis of
GN.
MATERIALS AND METHODS
Study design and subjects
This study was approved by the Mayo Clinic Institutional
Review Board. All patients who underwent a kidney biopsy
between August 2012 and January 2015 at the Mayo Clinic in
Rochester, MN, USA were identified using an existing pathol-
ogy database. All adult patients with a kidney biopsy performed
at our institution and with a urinalysis available within 2 weeks
prior to the biopsy were identified. Kidney transplant allograft
biopsies, pediatric kidney biopsies, those with insufficient tissue
to make a definitive diagnosis and patients that declined
authorization to use their medical records for research purposes
were excluded. Baseline demographics, including age at the
time of biopsy, sex and race/ethnicity were retrieved by elec-
tronic chart review.
Urinalysis and dRBCs
Urine was collected into a clean, sterile container by random
void, midstream or catheterization, depending on the clinical
situation. All samples were analyzed in the Mayo Clinic Renal
Testing Laboratory within 2 h of collection. Urine chemistries
and electrolytes were measured using a Roche Chemistry
Autoanalyzer (Cobas c511), while pH and osmolality were
assessed using a pH meter and PSI osmometer (Tecan). A 24-h
urinary protein excretion was estimated from the protein:
osmolality ratio (e24P [15]). The Mayo Renal Laboratory uses a
spot protein:osmolality ratio to estimate the 24-h urinary pro-
tein (estimated 24-h protein or e24P) as a part of every urinaly-
sis done, based on previously published data demonstrating
that the protein:osmolality ratio is analogous to the
protein:creatinine ratio and correlates at least as well with a 24-
h protein collection [15, 16]. Since the osmolality and urine pro-
tein concentration (not dipstick) are measured on all urinalyses
in our laboratory, a protein:osmolality ratio and e24P are avail-
able on all standard urinalyses. The unit of this measurement is
(mg/L)/(mOsm/kg). Urinary hemoglobin was analyzed by
automated dipstick on the IRIS system. Urinalyses were read by
trained laboratory personnel blinded to the protocol.
In the Mayo Renal Testing Laboratory workflow, the major-
ity of samples are analyzed unspun using the IRIS imaging sys-
tem. All images are reviewed and verified before results are
reported. Abnormal samples (total protein >100 mg/dL), sam-
ples with a cloudy appearance or samples flagged with casts,
abnormal cells (e.g. renal tubular epithelial cells) or dRBCs on
the IRIS are selected for manual microscopy. By these criteria
 30% of samples, those that contain any pathologic findings
listed above, undergo confirmatory manual microscopy. This
1398
approach has been shown to produce an accurate characteriza-
tion of urine since the IRIS platform can reproducibly detect
abnormal sediment in an unspun urine sample regardless of the
dilution and concentration of the sample [17]. Manual micro-
scopy is performed by centrifuging 12 mL of urine for 5 min at
2000 g, removing the supernatant and resuspending the sedi-
ment in the residual urine (500 mL). Resuspended sediment of
25 ml was placed on a slide for microscopic review of a mini-
mum of 10 fields. The following elements were documented:
RBCs, RBC casts, white blood cells (WBCs), WBC casts, renal
tubular epithelial cells, renal epithelial cell casts, granular casts,
hyaline casts, transitional epithelial cells, fat and crystals. The
urinalysis result included in this study was the one that was
closest to and preceded the biopsy. We only intended to assess
one urinalysis and correlate that with biopsy findings since
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commonly these patients will have only one close to the time of
kidney biopsy.
Hematuria was reported in grades as follows: <3 RBCs/
high-power field (hpf) (normal), 3–10, 11–20, 21–30, 31–40,
41–50, 51–100 and >100. If 3 RBCs/hpf were present, techni-
cians assessed the presence of dRBCs under phase contrast
microscopy at 400 and expressed this as the percentage of all
RBCs observed in 10–12 hpf (<25% or 25%). The standard
laboratory protocol is to identify mainly acanthocytes and their
variants as dRBCs; crenated and ghost cells are specifically
excluded (Supplementary Figure S1). When necessary, 25 mL of
25% acetic acid was added to the sediment to lyse RBCs and
exclude budding yeast. A second technician verified any ques-
tionable cases. By these criteria, clinical validation studies in the
laboratory in the 1990s established a cutoff of 25% dRBCs as
optimal for distinguishing GD.
Kidney biopsy and pathologic examination
The kidney biopsy diagnosis was retrieved from the Mayo
Renal Pathology database and verified by manual electronic
chart review. All had light microscopy, immunofluorescence
and electron microscopy evaluation. Two renal pathologists
(S.H.N. and S.S.) reviewed the individual diagnosis to establish
three broad renal disease categories: glomerular, vascular and
tubulointerstitial. When patients had clear evidence of more
than one process, a primary and a secondary diagnosis were
reported and those cases were classified as ‘dual lesions’. When
the pathologic process was glomerular (GD), it was subclassi-
fied into glomerulonephritis (GN) versus non-GN. GN was
based on the presence of glomerular hypercellularity and/or
intracapillary infiltrating inflammatory cells. Examples of typi-
cal entities classified in this group included pauci-immune GN
and immunoglobulin A nephropathy (IgAN). Otherwise, glo-
merular involvement was noted as non-GN, including diabetic
glomerulosclerosis and membranous nephropathy. Although
grouping pauci-immune GN and anti-glomerular basement
membrane nephritis with IgAN and other GNs represents mul-
tiple different pathological entities, all are proliferative lesions
that result in destruction of glomerular structures, and it seems
reasonable to group these together in comparison with the non-
proliferative nephrotic pathologies. If the written reports were
A.M. Hamadah et al.
Table 1. Baseline demographics and urinalysis characteristics

Patient characteristics Overall dRBCs < 25% dRBCs  25%

(n ¼ 482) [n ¼ 173 (35.9%)] [n ¼ 76 (15.8%)]
Age at time of biopsy (years), mean 6 SD 55 6 17 53.5 6 18 55.9 6 18
Gender, n (%)
Male 252 (52.3) 79 (45.7) 42 (55.3)
Female 230 (47.7) 94 (54.3) 34 (44.7)
Race/ethnicity, n (%)
White 421 (87.3) 157 (90.8) 69 (90.8)
African American 10 (2.1) 4 (2.3) 0 (0.0)
Asian 13 (2.7) 4 (2.3) 1 (1.3)
Hispanic 2 (0.4) 1 (0.6) 1 (1.3)
Other/unknown 36 (7.5) 7 (4.0) 5 (6.6)
Serum creatinine (mg/dL), median (IQR) 2 (1.3–3.3) 2.3 (1.2–3.9) 1.8 (1.1–2.5)
Serum albumin (mg/dL), mean 6 SD 3.4 6 0.9 3.2 6 0.8 3.1 6 0.8
UA findings

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UA source, n (%)
Void 323 (67) 104 (60.1) 48 (63.2)
Midstream 110 (22.8) 35 (20.2) 24 (31.6)
Catheter 49 (10.2) 34 (19.7) 4 (5.3)
UA osmolality (mOsm/kg), median (IQR) 409 (2.4–963) 386 (314.5–485) 454 (388–542)
UA pH, mean 6 SD 5.7 6 0.7 5.6 6 0.7 5.7 6 0.6
UA glucose (mg/dL), median (IQR) 9 (4–23) 8 (5–22) 9.5 (6–19)
UA predicted 24-h protein (mg), median (IQR) 2518 (740–6963) 3325 (895–8180) 3090.5 (1494–8512.5)
UA, urinalysis.

not clear, the pathology slides were retrieved and rereviewed
(by S.H.N. and S.S.) to ascertain the diagnosis and classification.
Statistical analysis
Continuous variables were expressed as mean (SD) if they
were normally distributed or as median [interquartile range
(IQR)] if they were nonnormally distributed. Categorical varia-
bles were reported as count (percentage). Logistic regression was
used to look at the association between dRBCs 25% and demo-
graphics and urinalysis variables (such as urine pH, osmolality
and number of RBCs). Variables potentially associated with GN
(proteinuria, level of hematuria, dRBCs 25%, creatinine and
serum albumin) were assessed using univariable and multivari-
able logistic regression. Sensitivity, specificity, positive predictive
value (PPV) and negative predictive value (NPV) were computed
from these data. A P-value <0.05 indicated statistical significance.
Statistical analyses were performed using SAS version 9.4 (SAS
Institute Cary, NC, USA).
RESULTS
Patients and urinalysis findings
A total of 482 patients with kidney biopsies and concurrent
urinalyses were eligible for this study (Table 1). The mean age
was 55 years (SD 17), 230 (47.7%) were female and 421 (87.3%)
were white. The median protein:osmolality ratio was 3.5 (mg/
L)/(mOsm/kg) corresponding to an estimated 24-h protein of
2518 mg (IQR 740–6963) [15] and median serum creatinine for
the group was 2.0 mg/dL (IQR 1.3–3.3). For the entire cohort,
233 (48.3%) lacked microscopic hematuria (urine RBC < 3/
hpf). Among the remaining 249 (51.7%) with hematuria, 173
(35.9%) had <25% urine dRBCs and 76 (15.8%) had 25%
urine dRBCs. RBC casts were noted in 2.7% of the patients.
Findings on kidney biopsy
Overall, 372 (77.2%) had GD by biopsy and 110 (22.8%) had
non-GD. Among the GD group, 46% had GN and 54% non-
GN. For the entire study group, 32 (6.6%) had vascular disease,
109 (22.6%) had tubulointerstitial disease and 31 (6.4%) had
two primary diagnoses (Table 2). The most common GD diag-
noses were IgAN [n ¼ 58 (12%)], pauci-immune GN [n ¼ 44
(9.1%)], focal segmental glomerulosclerosis [n ¼ 37 (7.7%)],
diabetic glomerulosclerosis [n ¼ 37 (7.7%)] and membranous
nephropathy [n ¼ 35 (7.3%)]. The most common tubulo-
interstitial disease entities were acute tubular necrosis [n ¼ 40
(8.3%)] and acute interstitial nephritis [n ¼ 17 (3.5%)], while
the most common vascular disease entities were hypertensive
arteriolosclerosis [n ¼ 19 (3.9%)] and atheroembolic disease
[n ¼ 4 (0.8%)]. Figure 1 presents the most common pathologies
and their respective degrees of hematuria and the percentage of
patients with dRBCs (<25% versus 25%). Overall, patients
with GD pathologies were more likely to have hematuria and
25% dRBCs. However, 10% of those with vascular disease
(primarily hypertensive arteriolosclerosis) had microscopic
hematuria and 25% dRBCs. Among those with tubulointersti-
tial disease (primarily acute tubular necrosis), 55% had micro-
scopic hematuria but only 2.5% manifested 25% dRBCs.
Variables affecting the presence of dRBCs
Next, we determined the clinical and laboratory characteris-
tics that associated with odds of having 25% dRBCs.
Midstream (as opposed to random nonmidstream) void associ-
ated with the presence of 25% dRBCs {odds ratio [OR] 1.6
[95% confidence interval (CI) 0.93–2.76], P ¼ 0.024}, while
catheter specimens were not [OR 0.51 (95% CI 0.18–1.48),
P ¼ 0.09]. A greater RBC level (11–50 versus 3–10 RBCs/hpf

Dysmorphic urinary RBCs in glomerulonephritis 1399

and >50 versus <11 RBCs/hpf) was also associated with the
presence of 25% dRBCs (OR 6.5, P ¼ 0.003 and OR 7.8,
P ¼ 0.0005, respectively). Higher urine osmolality (per 50 unit
increment) was associated with increased odds of significant
dRBCs [OR 1.1 (95% CI 1.04–1.20), P ¼ 0.003]. On the other
hand, urine pH (per 0.3 unit increment) [OR 0.96 (95% CI
0.86–1.08), P ¼ 0.53], estimated 24-h urine protein (per 100 mg
increment) [OR 1 (95% CI 0.998–1.003), P ¼ 0.76] and age at
the time of biopsy [OR 1.004 (95% CI 0.99–1.02), P ¼ 0.63]
Table 2. Pathologic diagnosis on kidney biopsy and level of dRBCs—com-
mon entities
Type of lesion/disease n (%) of the
total group
were not associated with the presence of dRBCs
(Supplementary Table S1).
Diagnostic performance of dRBCs
The sensitivity, specificity, PPV and NPV of dRBCs for GD
were next assessed after excluding biopsies with dual lesions
(n ¼ 31) (Table 3). The presence of hematuria (RBCs > 3/hpf)
had 62.2% sensitivity and 65.2% specificity of a diagnosis of
GD. The presence of 25% dRBCs was less sensitive (20.4%)
but highly specific (96.3%) for the presence of any glomerular
lesion, with a PPV of 94.6% and an NPV of 27.3%. Next, the
additive value of estimated 24-h protein (>1000 mg and
n (%) of patients >3500 mg) and 25% dRBCs was assessed. The presence of
in the group >1000 mg of protein combined with dRBCs 25% led to a sen-

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with sitivity of 17.1%, specificity of 98.2%, PPV of 96.9% and NPV of
dRBCs 25%
25.9% for a diagnosis of GD. For protein 3500 mg in combi-
Glomerular disease 372 (77.2) 72 (19.4) nation with dRBCs 25%, sensitivity was 9.9%, specificity was
GN 170 (35.3) 47 (27.6) 99.1%, PPV was 97.1% and NPV was 25.5% for any form of
IgAN 58 (12) 18 (31)
Pauci-immune GN 44 (9.1) 16 (36)
GD. Table 3 also shows the diagnostic performance values for
Lupus nephritis 20 (4.1) 4 (20) GD and GN (subcategory of GD) with the degree of proteinu-
Cryoglobulinemic GN 10 (2.1) 5 (50) ria. The diagnostic performance of different degrees of hematu-
C3 GN 7 (1.5) 2 (29) ria and proteinuria is shown in Supplementary Table S3.
Non-GN 202 (41.9) 25 (12.4) Similar results were obtained when the analysis included the
FSGS 37 (7.7) 3 (8.1)
Diabetic glomerulosclerosis 37 (7.7) 4 (11)
patients with dual lesions (data not shown).
Nonamyloid monoclonal entities 37 (7.7) 2 (5.4) Next, models were constructed to determine predictors of
Membranous nephropathy 35 (7.3) 9 (26) the presence of GN on biopsy. The univariate analysis revealed
Thrombotic microangiopathy 21 (4.4) 2 (9.5) that dRBCs 25% [OR 3.73 (95% CI 2.26–6.3), P < 0.001] and
Amyloidosis 19 (3.9) 0 (0) urine RBC level {>10 versus 10 RBCs/hpf [OR 7.22 (95% CI
Minimal change disease 16 (3.3) 3 (19)
Nonglomerular disease 110 (22.8) 4 (3.6)
4.31–12.08), P < 0.001]} were predictors of the presence of
Tubulointerstitial 109 (22.6) 3 (2.8) GN (Supplementary data, Table S2). In a multivariate model,
Acute tubular necrosis 40 (8.3) 1 (2.5) only urine RBC level {>10 versus 10 RBCs/hpf [OR 6.67
Acute interstitial nephritis 17 (3.5) 1 (5.9) (95% CI 3.89–11.45), P < 0.001]} was predictive of GN (Table
Chronic interstitial nephritis 14 (2.9) 1 (7) 4). This was also noted for RBC levels >50 versus 50 RBCs/
Vascular 32 (6.6) 1 (3.1)
Hypertensive arteriolosclerosis 19 (3.9) 2 (10.5)
hpf (Supplementary Table S4).
Dual lesions 31 (6.4) 2 (6.5) Based on an analysis of combined hematuria and proteinu-
FSGS, focal segmental glomerulosclerosis.
ria, a scoring system was devised using urinary RBCs (< 3, 3–10
and >10 RBCs/hpf; each gives a score of 0, 1 or 2, respectively)

120
100
80
60
40
20 No Hematuria
0 dRBCs < 25%
Glomerulosclerosis
Pauci-immune GN

Membrenous GN
IgA Nephropathy

Microangiopathy
Minimal Change Disease

Amyloidosis
Glomerulosclerosis

Acute Tubular Necrosis

Arteriolosclerosi
Lupus Nephris

Acute Intersal
Focal Segmental

dRBCs ≥ 25%
Hypertensive

Thromboc

Nephris
Diabec

FIGURE 1: Percent dysmorphic RBCs (no hematuria, <25%, 25%) in common kidney disease entities, in decreasing frequency of dRBCs
from left to right.

1400 A.M. Hamadah et al.

Table 3. Performance of dRBCs in diagnosing glomerular versus nonglomerular disease

Parameter dRBCs 25% Hematuria (>10 RBCs/hpf) Hematuria (>10 RBCs/hpf) Dysmorphic (25%) Dysmorphic (25%) and
þ proteinuria >1000mg þ proteinuria >3500mg and proteinuria > 1000mg proteinuria  3500mg

GD GD-GN GD GD-GN GD GD-GN GD GD-GN GD GD-GN

Sensitivity 20.4 28.5 26.8 47.0 14.6 23.8 17.1 24.4 9.9 10.3
Specificity 96.3 90.6 92.7 91.0 97.3 94.5 98.2 92.3 99.1 93.7
PPV 94.6 63.5 92.5 73.8 94.7 70.2 96.9 63.1 97.1 48.6
NPV 27.3 68.7 27.2 76.0 25.2 69.6 25.9 69.3 25.5 64.4
GD-GN, glomerular disease consistent with GN.

Table 4. Multivariate analysis of factors associated with the presence of GN

Variable Level OR Lower CL Upper CL P-value

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a
UA RBC level >10 versus 10 6.67 3.89 11.45 <0.001
UA predicted 24-h protein >1000 versus 1000 0.99 0.55 1.79 0.98
UA dRBCs >25%a Yes versus no 1.41 0.70 2.83 0.34
Serum albumin 4.3 versus >4.3 1.01 0.44 2.31 0.99
Serum creatinine >0.9 versus 0.9 1.04 0.47 2.28 0.93
a
Variables significantly associated with the presence of GN on univariate analysis. CL, confidence limit.

and proteinuria <2 g/day (score of 0) versus >2 g/day (a score Glomerular Disease
of 1). The cutoffs were selected using a receiveroperating char- Glomerulonephris
acteristic curve. When the total score was 0 (no hematuria or 100
<2 g/day of proteinuria), the probability of the presence of GN 90
was 15%. With a score of 1, the probability of GN was 28%,
which increased to 41% with a score of 2, and when the score 80
was 3 (indicating >10 RBCs/hpf and 2 g/day of protein), the 70
likelihood of having GN rose to 83% (P < 0.001). When GD is 60
considered (includes GN and non-GN), having a score of 0 was % 50
49% predictive of GD and having a score of 3 increased the like-
lihood of having GD to 93% (P < 0.001) (Figure 2). 40
30
20
DISCUSSION
10
Since the early recognition of the clinical relevance of dRBCs in
0
1979, multiple studies have evaluated the usefulness of this find-
0 1 2 3
ing on urine microscopy. There have been conflicting results,
with some studies showing benefit in recognizing GD [7, 13, 14, Model Score
18] and correlation with certain histologic findings on kidney FIGURE 2: The probability (%) of finding glomerular disease or GN
biopsy [11], whereas others have found it to be of little added based on the presence of hematuria and proteinuria on urinalysis.
benefit or questioned its usefulness [19–21]. Depending on the The score is based on the presence of urinary RBCs (<3, 3–10 and
definition of dRBC (varied morphologies), the population >10 RBCs/hpf; each gives a score of 0, 1 or 2, respectively), proteinu-
studied (kidney versus urinary collecting system disease and ria <2 g (score of 0) versus >2 g (score of 1).
community versus referral center) and the reference gold stand-
ard (biopsy versus clinical diagnosis), the cutoffs of what are
considered significant dRBCs vary between 10% and 90% [12, found the presence of significant dRBCs (i.e. 25%) to be a rel-
22–24]. Additionally, prior studies have not looked specifically atively uncommon finding (15.8%), but significantly more com-
into the utility of dRBCs for distinguishing glomerular origin mon than RBC casts (2.7%). The entities that were found to
versus other nephron compartments (i.e. the distinction have significant dRBCs present were pauci-immune GN, IgAN,
between glomerular versus tubulointerstitial kidney disease) membranous nephropathy and lupus nephritis. Our study indi-
based solely on kidney biopsy as the gold standard, as opposed cates that dRBCs are quite specific for GD compared with other
to urological evaluation for the source of bleeding. nonglomerular kidney diseases, such as those affecting the
In this study, we took advantage of a large cohort of patients interstitial and vascular compartments. The finding of >25%
with available renal biopsies and a standardized urinalysis with dRBCs of the total RBCs noted in a urine sample offers high
microscopy that included reports of dRBCs (<25%, 25%). In specificity and high PPV for a diagnosis of GD or GN, which
this cohort of biopsy-proven diverse kidney disease entities, we improved when proteinuria was considered.

Dysmorphic urinary RBCs in glomerulonephritis 1401

 In univariate models, hematuria and dRBCs 25% were
both significant predictors of GN. However, in the multivariate
regression analysis that included proteinuria, only hematuria
(RBCs >10/hpf) remained statistically significant as a predictor
of GN. This is perhaps not surprising among this group of
patients with a high pretest probability of parenchymal renal
disease (i.e. warranted a renal biopsy), since hematuria was
more sensitive (but less specific) than dRBCs for GD. In a popu-
lation that included other nonrenal causes of hematuria (e.g.
bladder lesions), dRBCs might perform better than RBCs, even
when combined with proteinuria.
We devised a scoring system for predicting the presence of
GN on biopsy, based on the optimal cutoff points for both protei-
nuria (2 g/day) and hematuria (<3, 3–10 and >10 RBCs/hpf)
that had the best predictive power for GN. In this cohort, patients
with a score of 0 (hematuria <3 RBCs/hpf and proteinuria <2 g/
day) had a 15% chance of having GN. The risk of GN continued
to increase with each point until a score of 3 (>10 RBCs/hpf and
>2 g/day), where the risk of GN rose to 83%. Importantly, this
model would apply to a cohort of patients that met clinical crite-
ria for a parenchymal renal biopsy.
In this study, urine osmolality and pH were investigated
regarding their association with dRBCs. Others have found
in vitro assessment of urine RBCs in hypotonic urine resulted in
hypochromic cells devoid of hemoglobin, or so-called ghost
cells [25]. In another study that exposed RBCs in vitro to
osmotic and enzymatic environment in an attempt to replicate
the nephron milieu, no changes typical of dRBCs were found.
However, when osmotically challenged RBCs were exposed to a
hemolytic environment, characteristics of dRBCs were evident
by light and electron microscopy [26]. Based on our cohort, we
found that age at the time of biopsy, urine pH and predicted 24-
h urine protein did not affect the presence of dRBCs. A urinary
catheter source of urine did not affect the presence of dRBCs,
contrary to common perception. Additionally, urine osmolality
was marginally associated with an increased presence of dRBCs,
with questionable clinical significance. The finding of a higher
RBC level (11–50 versus <11 and >50 versus <11 RBCs/hpf)
on urinalysis was the variable most likely to predict having sig-
nificant dRBCs [OR 6.5 (95% CI 3.58–11.8), P ¼ 0.003 and OR
7.8 (95% CI 3.93–15.7), P < 0.001, respectively], a finding that
was previously noted [13]. Our laboratory defines dRBCs as
mainly those that are ring form (donut shaped) with protru-
sions (blebs), and their variations. These are the most specific
for GD [8, 27], as there exists other forms reported in the litera-
ture that are neither sufficiently sensitive nor specific [7, 8, 28].
The main strength of this study is that all 482 subjects had
biopsy-proven kidney disease, and the pathology was verified
by two expert pathologists. It is the largest report in the litera-
ture on the association of dRBCs with GD. The scoring system
that we devised will allow practitioners to predict the presence
of GN, and its potential benefit comes from the readily available
details of the urinalysis (proteinuria and hematuria).
Our study also has some limitations. The results reflect the
experience of a tertiary referral center with a dedicated renal
laboratory having >20 years of experience identifying dRBCs.
Results might differ in other settings where the assessment of
1402
dRBCs is not standardized. Although automated identification
of dRBCs (and other sediment elements such as casts) may
become feasible and even standard in the future, the process in
our laboratory currently involves automated screening followed
by manual microscopy. Using this workflow, our study indi-
cates that dRBCs are quite specific for GD and also carry a high
PPV. It is also important to interpret all laboratory findings,
including dRBCs, together with associated clinical features.
However, the data in the study provide a stronger rationale for
investing the effort to detect dRBCs in a standardized fashion
for all urinalyses from patients in whom a diagnosis of GN is
being entertained. Importantly, the cohort in the current study
was entirely a group of patients with a clinically indicated kid-
ney biopsy. The utility of dRBCs versus RBCs and proteinuria
might differ in a population that also included patients with
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urologic causes of hematuria. However, it is important to note
that true ascertainment of the origin of hematuria cannot be
made with a high degree of confidence without a kidney biopsy.
This was one issue with prior studies that have considered the
clinical diagnosis of certain glomerular entities without kidney
biopsy. Another issue is that we did not have patients with
dRBCs who underwent a urologic investigation (e.g. stones,
tumor and others along the urogenital tract). We have aimed in
this study to investigate glomerular versus nonglomerular
parenchymal kidney disease and not urologic versus
nonurologic entities. However, given the ability of dRBCs,
based on our study, to establish with certainty the presence of
GD versus tubular or vascular entities, we hypothesize that it
would be unlikely that inclusion of urologic disease entities
would have changed our findings, although this would need to
be verified in future studies using our methodology. Finally, we
did not independently verify the performance of our predictive
model in a second cohort.
The presence of 25% dRBCs by urine microscopy is very
specific but not sensitive for GN. In this cohort with clinical sus-
picion of kidney disease that warranted kidney biopsy, com-
bined hematuria (>10 RBCs/hpf) and proteinuria performed
just as well as dRBCs plus proteinuria to predict underlying
GN. A model based on the degree of hematuria and proteinuria
found on urinalysis was able to predict the presence of GN.
SUPPLEMENTARY DATA
Supplementary data are available online at http://ndt.oxford
journals.org.
FUNDING
This study was supported by a grant from the Division of
Nephrology, Mayo Clinic, Rochester, MN.
CONFLICT OF INTEREST STATEMENT
J.C.L. received consulting fees from Allena, Alnylam, Dicenra
and OxThera. N.L. received consulting fees from Thrasos
Therapeutics. The remaining authors have no conflicts of inter-
est to declare. J.C.L. reports grant support from OxThera and
A.M. Hamadah et al.
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Received: 23.4.2017; Editorial decision: 16.8.2017

Dysmorphic urinary RBCs in glomerulonephritis 1403