Hematuria

GLMS23Feb2019

Case1•  23yearsoldmanotherwisehealthy

•  Nofamilyhistoryofkidneydisease•  Foundtohavemicroscopichematuriaonmedicalcheckupforjoiningarmy(2occasions)

•  HasbeenundergoingrunningforhisfitnessforarmyselecIon

•  Fitlookingandmuscular•  BP130/75mmHg,Pulse64permin,Height1.8m,Weight80kilo

•  NormalphysicalexaminaIon

Case1

•  Urinemicroscopyshowsrbc>100,wbc<10,nilepithelialcell

•  SpoturineAlbumin/CreaInineraIo4(<2.3)•  eGFR>90ml/min/1.73m2

WhatinvesIgaIonsnext?

Case2

•  28yearsoldman,fitandhealthy,regulargymgoer•  Presentedtoemergencydepartmenta\ersustaininggroininjurywhileplayingindoorsoccer

•  Fatherhashypertensionnilelse•  NilregularmedicaIons•  Non-smoker,socialalcohol•  Ayearago,eGFR>90ml/min,UrineAlbumin/CreaInineraIo4.6(2.3),nourinemicroscopyavailable

Case2

•  Xray–nobonyinjury,dischargedonpainreliefwithGPfollowup

•  BP145/90mmHg,P102permin,anxious•  WasgivenBrufenandParacetamol•  Urinemicroscopyrbc>100,wbc15,Albumin/CreaInineraIo110

•  eGFR84ml/min/1.73m2atImeofpresentaIontoED•  Review1weeklaterwithrepeatlabsatregularGP

Case2

•  AnxiouswithhissituaIon•  BP146/87mmHg,Pulse88permin•  NormalphysicalexaminaIonapartfromminorpainfulhip

•  eGFR76ml/min/1.73m2,Urinemicroscopyrbc>100,2++protein,ACR146

! Whatnext?

DefiniIons•  Grosshematuria—Grosshematuriaissuspectedbecauseof

thepresenceofredorbrownurine•  Microscopichematuria—Microscopichematuriarefersto

blooddetectableonlyonexaminaIonoftheurinesedimentbymicroscopy

•  HematuriaiscommonandfrequentlybenigninyoungpaIents,andacauseiso\ennotidenIfied

•  Bycontrast,eventransienthematuriamaybeasymptomofanunderlyingseriouscondiIon,parIcularlyinpaIentsoverage35years

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History•  Concurrentpyuriaanddysuria,whichareusuallyindicaIveofa

urinarytractinfecIonbutmayalsooccurwithbladdermalignancy.•  ArecentupperrespiratoryinfecIonorsymptomsofupper

respiratorydiseaseraisethepossibilityofposInfecIousorinfecIon-relatedglomerulonephriIs,immunoglobulinA(IgA)nephropathy,

•  VasculiIs,anI-glomerularbasementmembrane(GBM)disease,orsomeImeshereditarynephriIs.

•  AposiIvefamilyhistoryofrenaldisease,asinhereditarynephriIs,polycysIckidneydisease,orsicklecelldisease.

•  Unilateralflankpain,whichmayradiatetothegroin,usuallysuggestsureteralobstrucIonduetoacalculusorbloodclotbutcanoccasionallybeseenwithmalignancyorIgAnephropathy.

History•  SymptomsofprostaIcobstrucIoninoldermensuchashesitancy

anddribbling.•  Recentvigorousexerciseortraumaintheabsenceofanother

possiblecause.•  HistoryofableedingdisorderorbleedingfrommulIplesitesdueto

excessiveanIcoagulanttherapy.TheseobservaIonsindicatethathematuriainananIcoagulatedpaIentshouldbeevaluatedinthesamefashionasinotherpaIents.

•  Cyclichematuriainwomenthatismostprominentduringandshortlya\ermenstruaIon,suggesIngendometriosisoftheurinarytract.

•  ContaminaIonwithmenstrualbloodisalwaysapossibilityandshouldberuledoutbyrepeaIngtheurinalysiswhenmenstruaIonhasceased

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Glomerularversusnonglomerularbleeding

•  Redcellcasts-virtuallydiagnosIcofglomerulonephriIsorvasculiIs

•  Redcellmorphology-dysmorphicappearancewithrenallesions

•  Acanthocytes-appeartobemostpredicIveofglomerulardisease

•  Redtobrownurine-typicallyredtopinkwithnonglomerularbleeding,smokybrownorcolacolor

•  Bloodclots-almostalwaysduetononglomerularbleeding

•  Proteinuria-proteinuriathatistemporallyrelatedtothehematuriaissuggesIveofglomerulardisease

Roleofrenalbiopsy•  Presenceofriskfactorsforprogressivediseasesuchasproteinuriaand/oranelevaIonintheserumcreaInineconcentraIon

•  Kidneybiopsyisnotusuallyperformedforisolatedglomerularhematuria

•  Mostcommonfindingsareanormalbiopsy,IgAnephropathy,thinbasementmembranedisease,mildnonspecificglomerularabnormaliIes,andhereditarynephriIs(Alportsyndrome)

TransientorPersistentHematuria•  CommonprobleminadultsProspecIvecohortstudyincluding2,421,585members(ofallages)! 967,297(40percent)hadasymptomaIcmicroscopichematuria

! SecondurinalysiswasposiIveformicroscopichematuriain643,304(66percent)

! Approximatelyone-thirdofindividualswithaniniIallyposiIveurinalysishadtransienthematuria

TransientorPersistentHematuriaStudyevaluated1000youngmenwhohadyearlyurinalysesbetweentheagesof18and33years! Hematuriawasseenin39percentonatleastoneoccasion

! 16percentontwoormoreoccasions! NoobviouseIologycanbeidenIfiedinmostpaIentswithtransienthematuria

! Fever,infecIon,trauma,andexercisearepotenIalcauses

! CanoccurwithUTI(pyuria)

RiskFactorsForrenaltractmalignancy

AmericanUrologicalAssociaIon:•  Age>35•  Smoking•  OccupaIonalexposure•  ChroniccysIIsorirritaIvevoiding•  PelvisirradiaIon•  Exposuretocyclophosphamide•  Chronicindwellingforeignbody•  Analgesicabuse(paracetamolRR1.28,NSAIDsRR1.25)–  meta-analysisof20observaIonalstudies(Choueirietal,IntJCancer2014)

•  Grosshaematuria

UrinaryTractMalignancy•  ProspecIvecohortstudyof4414membersofamanagedcareorganizaIonwithunexplained,asymptomaIcmicroscopichematuria

! 111cancerswereidenIfied(2.5percent);100werebladdercancers,and11wererenalcancers

! Prevalenceofmalignancywas11.2%amongpaIents50yearsorolderwhoalsohadahistoryofgrosshematuriaplusatleastoneaddiIonalriskfactor(smoking,male,rbc>25)

! <50yearswithoutgrosshematuria,cancerprevalenceratewas0.2%

UrinaryTractMalignancy•  Studyof1930paIents(meanageof58years,62percentmale)whowerereferredtoahematuriaclinic

! 12percenthadbladdercancer,0.7percenthadkidneyanduppertracttumors

! 61percenthadnocauseidenIfied50–59years60–69yearsSex Gross Microscopic

Male 20.4% 1.9%

Female 8.9% 1.9%

Sex Gross Microscopic

Male 28.9% 7.9%

Female 21.5% 4.5%

UrinaryTractMalignancy•  1034paIentswithmicroscopichematuria•  Evaluatedbyultrasound,IVP,urinarycytology,andcystoscopy.

! Incidenceofmalignancy(bladder,kidney,orprostate)was2.4percent

! Kidneystonesorglomerularorotherintrinsicrenaldisease-20%

! 78percenthadeithernoidenIfiablecause! NeithercytologynorIVPreliablydetectedallofthetumors

Imaging•  Unexplainedhematuria(glomerularbleedingisexcluded)

•  Imagingofkidney,ureter,bladdercombinedwithcystoscopy(bladderandurethrallesion)

•  CTUwithorwithoutcontrast(preferrediniIal)•  IVPorUSreplacedbyCTU•  USpreferredforpregnantwomen•  MRUlessdata•  Cystoscopy–enIrebladdercanbevisualised+prostateandurethra

UnexplainedHematuria•  NoDxfromhistory,urinalysis,imagingsorcystoscopy

•  MildglomerulopathyandpredisposiIontostonedisease

•  Glomerulardisease–assowithproteinuria,rbccasts,renalinsufficiency

•  Persistentglomerularhematuria(isolated)–IgA,Thinbasementmembrane,mesangioprooliferaIve,Alportsyndrome

•  PosInfecIousGNandexerciseareothercausebuttypicallytransient

RarecondiIons

•  Hereditaryhemorrhagictelangiectasis•  RadiaIoncysIIs•  schistosomiasis•  AVM•  Nutcrackersyndrome•  Loinpain-hematuriasyndrome

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TakeHomeMessage

•  Transientmicroscopichematuriainhealthyyoungadultsarecommon

•  IdenIfyriskfactorsareimportantforgrossormicroscopichematuriainpaIentsabove35yearsforurinarytractmalignancy

•  DecreasedeGFRandproteinuriaareimportantriskfactorforprogressiverenaldisease