Anti̇koagülan tedavi̇si̇alan hastalarda asemptomaṫik mi̇kroskobi̇k hematüri̇ni̇n INR sevi̇yeṡi ̇ile i̇li̇şki̇ṡi

Introduction: Hemorhage is the most frequent and important complication of anticoagulant therapy. Sites of bleeding include peritoneal or retroperitoneal cavity, brain, stomach, intestine and urinary tract. Urinary tract is the most common site of hemorhage (hematuria). Hematuria can be macroscopic or microscopic and should not be ignored. There is no consensus on the definition of microscopic hematuria, while it is generally defined as the presence of more than five blood cells per high-power field on microscopic examination. On the other hand some authors believe that the presence of even one red blood cell per high-power field is abnormal and warrants further investigation. Possible causes of hematuria are numerous and range from benign urinary system infection to malignant neoplasm. In anticoagulated patients the ratio of hematuria changes between 12-40%. The relationship between anticoagulation and microscopic hematuria has not been well described. International Normalized Ratio (INR) level is used to follow anticoagulated patients and it can be calculated by dividing the observed PT to the control PT. Its level changes between 0.9-1.1. In serious cardiac disease its level must be 2.8-3.2. The aim of this study is to determine whether there is any relation between INR level and the incidence of microscopic hematuria. Materials and methods: Between January 2002 and November 2004, 933 patients were investigated and 112 of them with microscopic hematuria while on warfarin therapy were nrolled in this study. Exclusion criterias were patients with diagnosed urologic pathology, genitourinary trauma, instrumentation, macroscopic haematuria or the short anticoagulation period (less than 1 month). Evaluation consisted of history, examination, routine blood tests, PTZ and INR. In addition patients underwent urinary system ultrasound, IVP and cystoscopy. The IVP was excluded when a glomerulopathic condition was suspected from the urinalysis. No cystoscopy was performed without endocarditis proflaxy. If daily protein excretion is more than 1 gr, renal biopsy was taken. PSA levels were also determined and if its level was greater than 4 ng/ml TRUS as guided prostate biopsy was undertaken. In our study, microscopic hematuria was defined as present of five or more red blood cells per high-power field. The patients were divided into 4 groups according to their INR values; less than 1.5, 1.5-2.5, 2.5-3.5, and greater than 3.5. The risk of bleeding attributable to anticoagulant therapy was evaluated by comparing the frequency of bleeding in each group. Results: A total of 91 males and 21 females with a mean age of 63 years (range 35-78) were included in the study. In this study the ratio of microscopic hematuria was found 12%. The etiology of hematuria could not be identified on 41 patients, while 20 of them discontinued but 21 of them are still continuing, 8 had urologic tumor and 29 had urinary tract infection. The urologic pathology percent in each group was 83%, 75%, 55%, and 50%, respectively. Although all patients' drug doses were adjusted in hospital, 8 patients had an INR level greater than 3.5. Conclusion: The urologic pathology rate is getting lesser when the INR level is increased. Even in group 4 urologic pathology rate is 50% and one of them was bladder cancer and 3 of them were treatable abnormalities. We therefore advocate a full evaluation, regardless of the levels of INR.