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Case 3 – Alan Hays • Consultation 1 Doctor : • You have not seen 38 yr old Alan Hays, a roofer, before, as he is a new patient. • The nurse picked up microscopic haematuria at his new patient medical and asked him to come in to discuss this with you. Case 3 – Alan Hays • Consultation 1 Patient : • You are Alan Hays, aged 38, a roofer. You moved house recently, and joined the practice, at your new pt medical the nurse found blood in your urine, and asked you to book in with the doctor. • You are fit and well, completely asymptomatic. You live with your 35 yr old girlfriend, Donna. You have taken up running with a couple of mates to try to get fitter. You smoke 10/day and drink 15 pints beer per wk. Microscopic/ Invisible haematuria • Visible haematuria (VH) = macroscopic haematuria/ gross haematuria • Invisible haematuria (IH) = microscopic haematuria or ‘dipstick positive haematuria’ • Significant haematuria is defined as: – any single episode of VH – any single episode of symptomatic NVH (in absence of UTI or other transient causes). – persistent asymptomatic -IH (in absence of UTI or other transient causes) : defined as 2 out of 3 dipsticks positive (≥1+, not trace) for IH Microscopic/ Invisible Haematuria – what it isn’t • Transient microscopic haematuria: – UTI – Exercise related (repeat ≥ 3d after exercise) • Spurious microscopic haematuria: – – – – – – Menstrual contamination Sexual intercourse Foods (esp. beetroot, blackberries and rhubarb) Rhabdomyolysis Drugs (doxorubicin, chloroquine, rifampicin) Chronic lead or mercury poisoning. Case 3 – Alan Hays • Consultation 2 Doctor: • Alan has come back to see you to discuss a second urine test, which shows 1 + blood only. • He has just been on holiday for a week to Tenerife, where he had a good rest. He feels great, but is a bit anxious now about his test result. Case 3 – Alan Hays • Consultation 2 – patient: • You were asked to bring in a further urine sample 1 wk later, and the receptionist called to ask you to book in with the doctor again to discuss the result. • If asked to be examined your BP is 122/73 How risky is it? • 2 – 13% of the population may have IH but < 1.5% of these have significant pathology. • Urine dipstick testing is highly sensitive (97%) and moderately specific (75%) for the detection of haematuria • Visible haematuria is associated with cancer in 8-25% of cases, • IH assoc with cancer in only 2.6% • < 0.5% of people aged under 50 years investigated for asymptomatic invisible haematuria have cancer • Data suggest that invisible haematuria detected on dipstick screening has a sensitivity of < 3% and a positive predictive value of 0.2% for cancer • Invisible haematuria =20 times more likely to develop end stage renal failure than those without: but the absolute risk is low: 34 v 2/100 000 person years! Testing • Presence of haematuria (VH or IH) should not be attributed to anti-coagulant or anti-platelet therapy and patients should be evaluated regardless of these medications. • Population screening is considered justified in Japan but no other country has a national programme • Regard two out of three positive dipstick tests as confirmation 1+ or more NOT trace Assessment • SYMPTOMS: – – – – visible haematuria, loin pain, Dysuria Pelvic pain • Also ascertain – Risk factors for urinary tract cancer (smoking; exposure to chemicals used in leather, dye, and rubber manufacturing; cyclophosphamide treatment). – A family history (Alports, Polycystic kidneys) • Examine – Blood pressure – Abdominally UTI • Exclude UTI and/or other transient cause • If UTI then treat and test again after proof of clearance – 2 out of 3 positive means IH • Remember recurrent UTI can be a sx of bladder cancer or in men 35-50 with sx. chronic prostatitis • Check urine for blood again in a week or more Tests • Plasma creatinine/eGFR. • Measure Proteinuria: Send urine for albumin:creatinine ratio (ACR) on a random sample (according to local practice). • Sickle cell disease/ trait • (Urothelial cancers are detected by cystoscopy rather than imaging, imaging alone can provide false reassurance and should not be undertaken) • (N.B. 24 hour urine collections for protein are rarely required. An approximation to the 24 hour urine protein or albumin excretion (in mg) is obtained by multiplying the ratio (in mg/mmol) x10.) Management 1 • So if after all the above there is no UTI, 2 out of 3 positive dipstick test, normal clinical examination and normal/ stable eGFR then: • 3 possible routes: 1. Urology Referral 2. Nephrology referral 3. Continued Observation Urological referral • All patients with a-IH aged ≥ 35-40 yrs or even younger if smokers/ other risk factors for bladder cancer • NICE says urgent if >60 yrs • (Asymptomatic visible haematuria (any age)).* • (Sustained symptomatic IH (any age)). Cystoscopy and imaging of upper renal tract – CT USS X • There is no high quality evidence that asymptomatic IH for urinary tract cancer improves outcome compared with investigating visible haematuria only. IH becomes VH in 3 months of bladder cancer recurrences • * N.B. Some patients <40 yrs with cola-coloured urine and an inter-current (usually upper respiratory tract) infection will have an acute glomerulonephritis, and a nephrology referral may be considered more appropriate if clinically suspected. Nephrological referral 1)Any Age: • eGFR < 30 mL/min/1.73m (CKD 4 and5) • A sustained > or = 25% ↘ in eGFR and a change in category or a sustained ↘of ≥15 mL/min/1.73m2 2) Under 40: • Urinary ACRof ≥30 mg/mmol (2 measurements) • BP > 140/90 • eGFR < 60 • Visible haematuria coinciding with intercurrent (usually upper respiratory tract) infection • Concern about rare or genetic causes of haematuria Nephrology referral risks and benefits: • Benefits of interventions to slow progression of kidney disease (BP control, Salt restriction, RAS blockade to reduce proteinuria) do not vary with renal histology • Most conditions diagnosed by renal biopsy in patients with a-IH (IgA and thin BM nephropathy) are not amenable to disease specific treatment; even membranous nephropathy treatment only benefits those with proteinuria or a progressive reduction in renal function Nephrology referral • Kidney biopsy provides a tissue diagnosis but carries important risks, including life threatening bleeding • NB Hypertension is a common unrelated comorbidity in older patients Observation in Primary Care • • • • Most patients with IH wont meet the referral criteria Monitoring for as long as the haematuria persists Consider USS of renal tract if not referring and >CKD3 Most are likely to have glomerular haematuria (IgA disease and thin basement membrane nephropathy) • Annual assessment of – – – – blood pressure Dipstick test of urine for IH estimated glomerular filtration rate urinary ACR • The 1% risk of missed urological cancer in patients already investigated once for asymptomatic invisible haematuria does not justify repeat urological testing • https://www.nice.org.uk/guidance/cg182/res ources • http://www.bmj.com/content/349/bmj.g6768