saima usman. haematuria common finding incidental defining haematuria visible haematuria non visible...
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SAIMA USMAN
HAEMATURIACommon finding Incidental
DEFINING HAEMATURIA
Visible haematuria Non visible haematuria (dipstick and
microscopic)
Indication for urine dipstik testing
Lower urinary tract symptoms Upper urinary tract symptomsDiagnosis of hypertensionDiabetes(at least annually)Newly detected renal dysfunction(e
GFR<60ml/min)Suspected multisystem disease with possible
renal involvement.
Innocent haematuriaHaemoglobinuriaMyoglobinuriaMenstruationSexual intercourseAcute intermittent porphyriaFood :beet root, black berries, rhubarbDrugs:
nitrofurantoin,senna,rifampicin,phenolphthalein,chloroquine,doxorubicin
Chronic lead or mercury poisoning
HAEMATURIAUTI 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 HAEMATURIAPRE RENAL
CAUSES
Bleeding diathesisAtrial fibrillationInfective
endocarditisScurvy
PurpuraLeukaemiaThrombocytopeniahaemophilia
CAUSES OF HAEMATURIARENAL CAUSESNEPHROLOGICAL
IgA nephropathyGlomerulonephritisPolyarteritis nodosaGood pasture’s
syndromeAcute pyelonephritis
Polycystic kidney disease
Haemolytic uremic syndrome
Alport’s syndrome
Causes of haematuriaUROLOGICAL GENERALIZEDMalignancy Benign tumourTraumaCalculusPKDRenal vasculature
problemsMedullary sponge kidney
Renal toxinsSLE
CAUSES OF HEMATURIAPOST RENAL CAUSES
URETERIC
CalculusCarcinoma Papillomaschistosomiasis
BLADDER/PROSTATICTumourBPHProstatic cancerCalculusCystitisInjury/FBPurpuraSchistosomiasis
CAUSES OF HAEMATURIAURETHRAL
Acute urethritisCalculusInjuryCarcinomaPapillomaUrethral meatal ulcerF.B
Approach to haematuriaThorough history including Urinary symptomsRecent history (trauma/muscle injury/causes
of factitious haematuria/exercise/foreign travel)
Systemic features (fever, weight loss) other symptoms(bleeding,bruising)
Co-morbidityDrug historyOccupationFamily history
EXAMINATION
General
Anaemia , wt. loss , skin colour, bruising/bleeding
Vital signsPulse rate, blood pressure, temp.
CardiovascularSigns of infective endocarditis, murmur
RespiratoryLung signs (rare)
Abdominal
Palpable masses, distended bladder
Rectal examinationProstatic enlargement-BPH/cancer
INVESTIGATING HAEMATURIA
Urine MCS To exclude UTI .Red cell cast indicates glomerulonephritis
Urine albumin:creatinine ratio Perform if proteinuria on dipstick of 1+ or more. 24 hrs protein collection is rarely necessary
Full blood count Anaemia, signs of infection, thrombocytopenia
ESR/PV Raised in infection or malignancy
U&Es For renal function and eGFR
INVESTIGATING HAEMATURIA
Clotting screen Remember that haematuria in those on anti coagulants can occur with normal clotting screen
PSA Not in context of UTI that may give a false high reading. Measure 4-6 weeks later.
Kidney ,Ureter and Bladder X-ray To look for stones
Ultrasound scan To 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 CRITERIAURGENT (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 CRITERIAUROLOGY
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 CRITERIANEPHROLOGY
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 establishedAnnual assessment(while haematuria
persists)of BP, eGFR and ACR/PCRRe 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.
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