Transcript Hot Topic - Hematuria

SAIMA USMAN
HAEMATURIA
 Common finding
 Incidental
 DEFINING HAEMATURIA
 Visible haematuria
 Non visible haematuria (dipstick and microscopic)
Indication for urine dipstik testing
 Lower urinary tract symptoms
 Upper urinary tract symptoms
 Diagnosis of hypertension
 Diabetes(at least annually)
 Newly detected renal dysfunction(e GFR<60ml/min)
 Suspected multisystem disease with possible renal
involvement.
Innocent haematuria
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Haemoglobinuria
Myoglobinuria
Menstruation
Sexual intercourse
Acute intermittent porphyria
Food :beet root, black berries, rhubarb
Drugs:
nitrofurantoin,senna,rifampicin,phenolphthalein,chlo
roquine,doxorubicin
 Chronic lead or mercury poisoning
HAEMATURIA
 UTI typically causes non visible transient haematuria
and if simple doesn't require further investigations.
 Presence of bacterial peroxidases can cause a false
positive dipstick test
 Dipstick testing for blood is less sensitive in the urine
with high specific gravity and heavy proteinuria
CAUSES OF HAEMATURIA
 PRE RENAL CAUSES
 Bleeding diathesis
 Purpura
 Atrial fibrillation
 Leukaemia
 Infective endocarditis
 Thrombocytopenia
 Scurvy
 haemophilia
CAUSES OF HAEMATURIA
 RENAL CAUSES
 NEPHROLOGICAL
 IgA nephropathy
 Polycystic kidney disease
 Glomerulonephritis
 Haemolytic uremic
 Polyarteritis nodosa
syndrome
 Alport’s syndrome
 Good pasture’s
syndrome
 Acute pyelonephritis
Causes of haematuria
UROLOGICAL
GENERALIZED
 Malignancy
 Benign tumour
 Trauma
 Renal toxins
 Calculus
 SLE
 PKD
 Renal vasculature problems
 Medullary sponge kidney
CAUSES OF HEMATURIA
POST RENAL CAUSES
BLADDER/PROSTATIC
 Tumour
URETERIC
 BPH
 Prostatic cancer
 Calculus
 Carcinoma
 Papilloma
 schistosomiasis
 Calculus
 Cystitis
 Injury/FB
 Purpura
 Schistosomiasis
CAUSES OF HAEMATURIA
URETHRAL
 Acute urethritis
 Calculus
 Injury
 Carcinoma
 Papilloma
 Urethral meatal ulcer
 F.B
Approach to haematuria
 Thorough history including
 Urinary symptoms
 Recent history (trauma/muscle injury/causes of
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factitious haematuria/exercise/foreign travel)
Systemic features (fever, weight loss) other
symptoms(bleeding,bruising)
Co-morbidity
Drug history
Occupation
Family history
EXAMINATION
Anaemia , wt. loss , skin colour,
bruising/bleeding
General
Pulse rate, blood pressure, temp.
Vital signs
Signs of infective endocarditis, murmur
Cardiovascular
Lung signs (rare)
Respiratory
Palpable masses, distended bladder
Abdominal
Prostatic enlargement-BPH/cancer
Rectal examination
INVESTIGATING HAEMATURIA
Urine MCS
To exclude UTI .Red cell cast
indicates glomerulonephritis
Urine albumin:creatinine ratio
Perform if proteinuria on dipstick of 1+
or more. 24 hrs protein collection is
rarely necessary
Full blood count
Anaemia, signs of infection,
thrombocytopenia
ESR/PV
Raised in infection or malignancy
U&Es
For renal function and eGFR
INVESTIGATING HAEMATURIA
Clotting screen
Remember that haematuria in those
on anti coagulants can occur with
normal clotting screen
PSA
Not in context of UTI that may give a
false high reading. Measure 4-6 weeks
later.
Kidney ,Ureter and Bladder X-ray
To look for stones
Ultrasound scan
To look for abnormalities of the renal
tract and the kidneys. USS is as
sensitive to hydronephrosis and renal
masses as IVU and is more cost
effective.
REFERRAL CRITERIA
 URGENT (2 WEEKS WAIT) REFERRAL (urology)
 Visible haematuria (unless GN is suspected)
 Haematuria with recurrent or persistent UTI in adult
over 40 years
 Persistent non visible haematuria in adult over 50
years.
 Abdominal mass identified clinically or on imaging
that is thought to arise from urinary tract.
REFERRAL CRITERIA
 UROLOGY
 All patient with symptomatic non-visible haematuria
who don't meet the criteria for urgent referral.
 Patient with persistent asymptomatic non-visible
haematuria age 40-50 years.
REFERRAL CRITERIA
 NEPHROLOGY
 Evidence of decline of eGFR (by >10ml/min in previous 5
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years or by >5ml/min in the last year).
Stage 4 or 5 kidney disease.
Significant proteinuria (ACR 30 or more or PCR 50 or
more).
Isolated haematuria with hypertension in those under 40
years.
Visible haematuria coinciding with intercurrent ,usually
upper respiratory, infection.
If no cause established
 Annual assessment(while haematuria persists)of BP,
eGFR and ACR/PCR
 Re referral to urology if;
 Significant or increasing proteinuria(ACR>30 or
PCR>50)
 Estimated GFR <30ml/min(Confirmed on at least 2
readings and without an identifiable reversible cause)
 Deteriorating eGFR(>5ml/min in 1 year or>10ml/min
in 5 years.
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