Hematuria in hemodialysis patients may be a manifestation of the bleeding diatheses seen in renal failure. But it certainly needs further evaluation for structural causes specific to the genito urinary tract and to prevent massive bleeding.The authors of the article “Unusual causes of hematuria in dialysis patients”[1] in this journal have added to the repertoire of causes of hematuria in dialysis. This report also highlights the urgency required in both diagnosis and treatment in view of preexisting anemia, platelet dysfunction, and kidney failure. A systematic approach to this problem would be useful.Presence of red blood cell (RBC) casts, proteinuria, dysmorphic RBCs on urinalysis indicate a glomerular source whereas clots indicate a urologic cause. Loin pain and renal mass would indicate an upper urinary tract involvement. A combination of fever, dysuria, and flank pain suggests infection, stones or malignancy. A colicky pain with radiation suggests ureteral obstruction due to stone, blood clot or sloughed papillae. Initiation hematuria is of urethral source and termination hematuria due to bladder neck or prostatic urethra pathology. When history and physical examination suggest a non-glomerular bleeding source, this warrants a urine culture and imaging.[2] Coagulation profile, ultrasound exam of the abdomen and computed tomography (CT) urography followed by cystoscopy and angiographic localization of the bleeding site may be necessary.[3]The causes of hematuria in dialysis patients include the bleeding diatheses due to platelet dysfunction of uremia, use of anticoagulants during the procedure, dissection of blood from a hemorrhagic cyst into the collecting system in polycystic kidney disease.[3] Other causes include urinary tract infection, nephrolithiasis, retro peritoneal bleed, and malignancy in the kidney or urinary tract,[3] renal papillary necrosis,[4] and rarely spontaneous rupture of the kidney.[5] One of the important causes specific to dialysis patients is acquired cystic kidney disease with an overall incidence of 40-50% especially after 3 years and approaches 90% incidence at 10 years of dialysis.[6] This may pre dispose to adenocarcinoma.[78]Management of hematuria includes assessment of severity and hemodynamic stabilization. Correction of the platelet dysfunction requires desmopressin with or without cryoprecipitate, heparin-free dialysis till bleeding settles and packed RBC, if necessary. Intravenous conjugated estrogens are useful in prolonged bleeding.[9] Angio-embolization of the bleeding source in the affected kidney or endoscopic coagulation of the bleeding sites in the calyces would be necessary in severe bleeding.[3] Nephrectomy is indicated in uncontrolled bleeding,[3] intractable pain, and in suspected or proven malignancy. Presence of recurrent hematuria without apparent cause warrants use of alternatives to systemic heparinization during dialysis such as low dose heparin, regional heparinization with protamine, low molecular weight heparin, regional citrate or switching of modality of dialysis to peritoneal dialysis.To conclude, as emphasized in the article published in this issue, though hematuria in dialysis patients may be due to bleeding abnormalities of uremia, it should not be ignored. Careful history taking, physical examination, and judicious use of imaging are necessary to identify the cause. Treatment includes hemodynamic stabilization, correction of platelet dysfunction, and use of packed red cells, angioembolization, and nephrectomy as a last resort.