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A 62 year old male patient with longstanding type 2 diabetes attends the diabetic clinic. His clinic

appointment has been brought forward due to worsening of his renal function over the past 18 months. He

adheres to a good diet and his weight is unchanged. His glycaemic control has been stable for the past 4

years.

His medications include: gliclazide 160mg BD, pioglitazone 45mg OD, ramipril 5mg OD and aspirin 75mg

OD. He was previously on metformin which was stopped recently due to deteriorating renal function.

On examination he displays central obesity. His blood pressure is 161/98 mmHg. There is pitting oedema

to his mid calf on both legs. He reports occasional polyuria if he misses his gliclazide tablets and

remembers one episode of frank haematuria in the past month. He is otherwise asymptomatic.

Blood tests from last week reveal:

Sodium 141 mmol/l

Potassium 4.8 mmol/l

Urea 12.4 mmol/l

Creatinine 186 µmol/l

Estimated glomerular filtration rare (eGFR) 34 ml/min/1.73m2

Blood tests from 6 months ago:

Sodium 136 mmol/l

Potassium 4.6 mmol/l

Urea 9.0 mmol/l

Creatinine 144 µmol/l

Estimated glomerular filtration rare (eGFR) 46 ml/min/1.73m2

What is next most important investigation?

Urine albumin:creatinine ratio

Cytoscopy

Question 5 of 31



Renal biopsy

Renal ultrasound

Computer tomography (CT) scan of abdomen and pelvis

This patient is at an increased risk of bladder cancer due to their history of pioglitazone use. Unexplained

frank haematuria should prompt urgent referral to urology for cystoscopy. His pioglitazone should be

stopped as per MHRA guidance

(http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON125962). Further investigation of his

worsening renal function can then follow.

Haematuria

The management of patients with haematuria is often difficult due to the absence of widely followed

guidelines. It is sometimes unclear whether patients are best managed in primary care, by urologists or by

nephrologists.

The terminology surrounding haematuria is changing. Microscopic or dipstick positive haematuria is

increasingly termed non-visible haematuria whilst macroscopic haematuria is termed visible haematuria.

Non-visible haematuria is found in around 2.5% of the population.

Causes of transient or spurious non-visible haematuria

urinary tract infection

menstruation

vigorous exercise (this normally settles after around 3 days)

sexual intercourse

Causes of persistent non-visible haematuria

cancer (bladder, renal, prostate)

stones

benign prostatic hyperplasia

prostatitis

urethritis e.g. Chlamydia

renal causes: IgA nephropathy, thin basement membrane disease

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Spurious causes - red/orange urine, where blood is not present on dipstick

foods: beetroot, rhubarb

drugs: rifampicin, doxorubicin

Management

Current evidence does not support screening for haematuria. The incidence of non-visible haematuria issimilar in patients taking aspirin/warfarin to the general population hence these patients should also be

investigated.

Testing

urine dipstick is the test of choice for detecting haematuria

persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples

tested 2-3 weeks apart

renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should

also be checkedurine microscopy may be used but time to analysis significantly affects the number of red blood

cells detected

NICE urgent cancer referral guidelines

of any age with painless macroscopic haematuria

patients under the age of 40 years with normal renal function, no proteinuria and who are

normotensive do not need to be referred and may be managed in primary care

aged 40 years and older who present with recurrent or persistent urinary tract infection associated

with haematuriaaged 50 years and older who are found to have unexplained microscopic haematuria

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A 31.6%

B 26.7%

C 12.1%

D 23.7%E 5.9%

26.7% of users answered this question correctly

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