HAEMATURIARMO Teaching Whanganui DHB

Mr Christophe CHEMASLE27th June 2013

Before Starting

•Macroscopic haematuria is exceptionally (= rarely) lethal (1 personal case)

•Catheterisation is to be avoided at all cost unless the patient is in retention

•It is OK to discharge the patient and send a referral to the urologists (provided the patient is stable and does not need blood transfusion)

Terminology

• Visible Haematuria (VH). Referred to as ‘macroscopic haematuria’ or ‘gross haematuria’.Urine is coloured pink or red (or, on occasion like cola in acute glomerulonephritis). Requires consideration of rare causes of discoloured urine (myoglobinuria, haemoglobinuria, beeturia, drug discoloration – rifampicin, doxorubicin)

• Non-Visible Haematuria (NVH). Otherwise referred to as ‘microscopic haematuria’ or ‘dipstick positive haematuria’.

• Symptomatic Non-Visible Haematuria (s-NVH). LUTS (Lower Urinary Tract infections eg dysuria, urgency). Flank Pain.

• Asymptomatic Non-Visible Haematuria (a-NVH). Incidental detection in the absence of LUTS or upper urinary tract symptoms.

Definition of Positivity

• Urine dipstick of a fresh voided urine sample, containing no preservative, is a sensitive means of detecting haematuria.

• Community based urine samples sent for microscopy have a significant false negative rate; Routine microscopy for confirmation of dipstick haematuria is not necessary.

• Whilst the sensitivity of urine dipsticks may vary from one manufacturer to another, significant haematuria is considered to be 1+ or greater. Trace haematuria should be considered negative.

• There is no distinction in significance between non-haemolysed and haemolysed dipstick-positive haematuria. 1+ positive for either should be considered of equal significance.

What is significant haematuria?

• Any single episode of VH or Any single episode of s-NVH (in absence of UTI or other transient causes).

• Persistent a-NVH (in absence of UTI or other transient causes). Persistence is defined as 2 out of 3 dipsticks positive for NVH.

• Transient causes that need to be excluded are: Urinary tract infection (UTI), Exercice induced Haematuria, Menstruation

• The presence of haematuria (VH or NVH) should not be attributed to anti-coagulant or anti-platelet therapy and patients should be evaluated regardless of these medications.

Initial Investigations

• Exclude UTI and/or other transient cause.

• Plasma creatinine/eGFR.

• Measure proteinuria on a random sample. Send urine for protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) on a random sample

• Blood pressure

Urological Referral

• All patients with visible haematuria.

• BUT patients <40 yrs with cola-coloured urine and an inter-current upper respiratory tract infection will have an acute glomerulonephritis, and a nephrology referral may be considered more appropriate.

• All patients with s-NVH (any age).

• All patients with a-NVH aged ≥40 yrs.

Nephrological Referral

• For patients who have had a urological cause excluded, or have not met the referral criteria for a urological assessment ,

• If there is concurrent: declining GFR, Stage 4 or 5CKD, significant proteinuria, Hypertension and <40y years old, visible haematuria with intercurrent upper respiratory tract infection

• If criteria not met, patient should be followed in primary care

Long term monitoring

• Patients should be monitored for the development of:

• voiding LUTS

• visible haematuria

• significant or increasing proteinuria

• progressive renal impairment (falling eGFR)

• hypertension

MACROSCOPICMACROSCOPIC14 negative (1 on Warfarin)10 bph7 stones (5 kidney 2 ureteric)5 TCC5 UTI (from which 2 urethritis and 1 prostatitis)2 RCC2 filling defects (1 negative URS 1 pending)1 PCa1 Berger’s Disease1 post radiation cystitis

70.8 % are explained

MICROSCOPICMICROSCOPIC12 negative6 uti5 kidney stone3 TCC3 interstitial cystitis3 bph2 referred to nephrology1 polycythaemia1 malignant retroperitoneal fibrosis1 Urethral Caroncula1 CT pending

65.7% are explained

TAKE HOME MESSAGETAKE HOME MESSAGE

Regardless of haematuria type, TCC accounts for 10%

Delaying diagnosis because patient has only has one episode of macroscopic haematuria can have dramatic consequences

Thank you