Transcript File

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:
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–
–
–
–
–
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:
–
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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