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Hematuria
GLMS23Feb2019
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Case1• 23yearsoldmanotherwisehealthy
• Nofamilyhistoryofkidneydisease• Foundtohavemicroscopichematuriaonmedicalcheckupforjoiningarmy(2occasions)
• HasbeenundergoingrunningforhisfitnessforarmyselecIon
• Fitlookingandmuscular• BP130/75mmHg,Pulse64permin,Height1.8m,Weight80kilo
• NormalphysicalexaminaIon
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Case1
• Urinemicroscopyshowsrbc>100,wbc<10,nilepithelialcell
• SpoturineAlbumin/CreaInineraIo4(<2.3)• eGFR>90ml/min/1.73m2
WhatinvesIgaIonsnext?
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Case2
• 28yearsoldman,fitandhealthy,regulargymgoer• Presentedtoemergencydepartmenta\ersustaininggroininjurywhileplayingindoorsoccer
• Fatherhashypertensionnilelse• NilregularmedicaIons• Non-smoker,socialalcohol• Ayearago,eGFR>90ml/min,UrineAlbumin/CreaInineraIo4.6(2.3),nourinemicroscopyavailable
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Case2
• Xray–nobonyinjury,dischargedonpainreliefwithGPfollowup
• BP145/90mmHg,P102permin,anxious• WasgivenBrufenandParacetamol• Urinemicroscopyrbc>100,wbc15,Albumin/CreaInineraIo110
• eGFR84ml/min/1.73m2atImeofpresentaIontoED• Review1weeklaterwithrepeatlabsatregularGP
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Case2
• AnxiouswithhissituaIon• BP146/87mmHg,Pulse88permin• NormalphysicalexaminaIonapartfromminorpainfulhip
• eGFR76ml/min/1.73m2,Urinemicroscopyrbc>100,2++protein,ACR146
! Whatnext?
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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.
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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
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Roleofrenalbiopsy• Presenceofriskfactorsforprogressivediseasesuchasproteinuriaand/oranelevaIonintheserumcreaInineconcentraIon
• Kidneybiopsyisnotusuallyperformedforisolatedglomerularhematuria
• Mostcommonfindingsareanormalbiopsy,IgAnephropathy,thinbasementmembranedisease,mildnonspecificglomerularabnormaliIes,andhereditarynephriIs(Alportsyndrome)
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TransientorPersistentHematuria• CommonprobleminadultsProspecIvecohortstudyincluding2,421,585members(ofallages)! 967,297(40percent)hadasymptomaIcmicroscopichematuria
! SecondurinalysiswasposiIveformicroscopichematuriain643,304(66percent)
! Approximatelyone-thirdofindividualswithaniniIallyposiIveurinalysishadtransienthematuria
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TransientorPersistentHematuriaStudyevaluated1000youngmenwhohadyearlyurinalysesbetweentheagesof18and33years! Hematuriawasseenin39percentonatleastoneoccasion
! 16percentontwoormoreoccasions! NoobviouseIologycanbeidenIfiedinmostpaIentswithtransienthematuria
! Fever,infecIon,trauma,andexercisearepotenIalcauses
! CanoccurwithUTI(pyuria)
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RiskFactorsForrenaltractmalignancy
AmericanUrologicalAssociaIon:• Age>35• Smoking• OccupaIonalexposure• ChroniccysIIsorirritaIvevoiding• PelvisirradiaIon• Exposuretocyclophosphamide• Chronicindwellingforeignbody• Analgesicabuse(paracetamolRR1.28,NSAIDsRR1.25)– meta-analysisof20observaIonalstudies(Choueirietal,IntJCancer2014)
• Grosshaematuria
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UrinaryTractMalignancy• ProspecIvecohortstudyof4414membersofamanagedcareorganizaIonwithunexplained,asymptomaIcmicroscopichematuria
! 111cancerswereidenIfied(2.5percent);100werebladdercancers,and11wererenalcancers
! Prevalenceofmalignancywas11.2%amongpaIents50yearsorolderwhoalsohadahistoryofgrosshematuriaplusatleastoneaddiIonalriskfactor(smoking,male,rbc>25)
! <50yearswithoutgrosshematuria,cancerprevalenceratewas0.2%
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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%
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UrinaryTractMalignancy• 1034paIentswithmicroscopichematuria• Evaluatedbyultrasound,IVP,urinarycytology,andcystoscopy.
! Incidenceofmalignancy(bladder,kidney,orprostate)was2.4percent
! Kidneystonesorglomerularorotherintrinsicrenaldisease-20%
! 78percenthadeithernoidenIfiablecause! NeithercytologynorIVPreliablydetectedallofthetumors
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Imaging• Unexplainedhematuria(glomerularbleedingisexcluded)
• Imagingofkidney,ureter,bladdercombinedwithcystoscopy(bladderandurethrallesion)
• CTUwithorwithoutcontrast(preferrediniIal)• IVPorUSreplacedbyCTU• USpreferredforpregnantwomen• MRUlessdata• Cystoscopy–enIrebladdercanbevisualised+prostateandurethra
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UnexplainedHematuria• NoDxfromhistory,urinalysis,imagingsorcystoscopy
• MildglomerulopathyandpredisposiIontostonedisease
• Glomerulardisease–assowithproteinuria,rbccasts,renalinsufficiency
• Persistentglomerularhematuria(isolated)–IgA,Thinbasementmembrane,mesangioprooliferaIve,Alportsyndrome
• PosInfecIousGNandexerciseareothercausebuttypicallytransient
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RarecondiIons
• Hereditaryhemorrhagictelangiectasis• RadiaIoncysIIs• schistosomiasis• AVM• Nutcrackersyndrome• Loinpain-hematuriasyndrome
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TakeHomeMessage
• Transientmicroscopichematuriainhealthyyoungadultsarecommon
• IdenIfyriskfactorsareimportantforgrossormicroscopichematuriainpaIentsabove35yearsforurinarytractmalignancy
• DecreasedeGFRandproteinuriaareimportantriskfactorforprogressiverenaldisease