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 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 Atrial fibrillation Infective endocarditis Scurvy Purpura Leukaemia Thrombocytopenia haemophilia
CAUSES OF HAEMATURIA RENAL CAUSES NEPHROLOGICAL IgA nephropathy Glomerulonephritis Polyarteritis nodosa Good pasture’s syndrome Acute pyelonephritis Polycystic kidney disease Haemolytic uremic syndrome Alport’s syndrome
Approach to haematuria Thorough history including Urinary symptoms Recent history (trauma/muscle injury/causes of factitious haematuria/exercise/foreign travel) Systemic features (fever, weight loss) other symptoms(bleeding,bruising) Co-morbidity Drug history Occupation Family history
INVESTIGATING HAEMATURIA Urine MCSTo exclude UTI.Red cell cast indicates glomerulonephritis Urine albumin:creatinine ratioPerform if proteinuria on dipstick of 1+ or more. 24 hrs protein collection is rarely necessary Full blood countAnaemia, signs of infection, thrombocytopenia ESR/PVRaised in infection or malignancy U&EsFor renal function and eGFR
INVESTIGATING HAEMATURIA Clotting screenRemember that haematuria in those on anti coagulants can occur with normal clotting screen PSANot in context of UTI that may give a false high reading. Measure 4-6 weeks later. Kidney,Ureter and Bladder X-rayTo look for stones Ultrasound scanTo 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 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.