View
228
Download
0
Category
Preview:
Citation preview
8/13/2019 2008.04.01 Curry - Hematuria
1/33
8/13/2019 2008.04.01 Curry - Hematuria
2/33
8/13/2019 2008.04.01 Curry - Hematuria
3/33
HEMATURIA: Brenner and RectorThe Kidney
8/13/2019 2008.04.01 Curry - Hematuria
4/33
HEMATURIA: Rakel and BopeConns Current Therapy, 2008
Microscopic hematuria in a patient with an apparent UTIshould be carefully observed and should disappear aftertherapy of the UTI. If the microscopic hematuria
disappears, then the physician can safely assume it wasrelated to the UTI. Particularly in elderly patients, if themicroscopic hematuria persists after eradication of theUTI, then the patient should be investigated for abladder or renal source of the microscopic hematuria.
(p. 668)
8/13/2019 2008.04.01 Curry - Hematuria
5/33
8/13/2019 2008.04.01 Curry - Hematuria
6/33
P.T.:A Hard Case
53 YO man who works in highway construction presentsto various physicians over a one year period withmicroscopic hematuria associated with intermittentburning dysuria.
He smokes one PPD and has mild controlled HBP. He is diagnosed with cystitis and bladder infections,
given various antibiotics with varying relief.
He develops gross painful hematuria and after a failure
of antibiotics is referred to a urologist. What do you think he is most likely to have?
8/13/2019 2008.04.01 Curry - Hematuria
7/33
P.T.:A Hard Case
53YO manwho works in highway constructionpresentsto various physicians over a one year period withmicroscopic hematuriaassociated with intermittentburning dysuria.
He smokesone PPD and has mild controlled HBP. He is diagnosed with cystitis and bladder infections,
given various antibiotics with varying relief.
He develops gross painful hematuria and after a failure
of antibiotics is referred to a urologist.= risk factors for bladder CA
8/13/2019 2008.04.01 Curry - Hematuria
8/33
P.T.:A Hard Case continued
He is diagnosed with adenocarcinoma of the bladder andhas transurethral resection.
His symptoms resolve and he does well for about sixmonths, but they recur and require cystectomy and an
ileal conduit. He comes to you to see what else can be done.
Over the next year he develops multiple areas of longbone pain with metastases on imaging.
He becomes unable to care for his aging mother. Spinal metastases result in paraplegia.
Five years after diagnosis, he dies with home hospice.
8/13/2019 2008.04.01 Curry - Hematuria
9/33
M.P.:An Easier Case?
48 YO AAF sees you for routine examination and healthmaintenance. She has HBP controlled with HCTZ.
Her BP is normal. General examination is normal, pelvicexam is normal, and there is no edema.
UA shows 5 RBC/hpf, 0-2 WBC, no proteinuria
Creatinine 0.8 mg/dL
How should she be evaluated?
8/13/2019 2008.04.01 Curry - Hematuria
10/33
8/13/2019 2008.04.01 Curry - Hematuria
11/33
Causes of heme-negative red urine
Medications: Doxorubicin, Chloroquine,Deferoxamine, Ibuprofen, Iron, sorbitol, Nitrofurantoin,Phenazopyridine, Phenolphthalein, Rifampin
Food dyes: Beets (in selected patients), Blackberries,Food coloring
Metabolites: Bile pigments, Homogentisic acid,Melanin, Methemoglobin, Porphyrin, Tyrosinosis, Urates
2008 UpToDate www.uptodate.com
8/13/2019 2008.04.01 Curry - Hematuria
12/33
CAUSES OF HEMATURIA BY AGE
2008 UpToDate
8/13/2019 2008.04.01 Curry - Hematuria
13/33Cohen R and Brown R. N Engl J Med 2003;348:2330-2338
8/13/2019 2008.04.01 Curry - Hematuria
14/33
REPORTED CAUSES OF ASYMPTOMATIC MICROSCOPIC HEMATURIA
Highly SignificantBladder cancer
Renal cell carcinomaCA prostateUreteral calculusRenal calculusHydronephrosisRenal artery stenosisRenal lymphomaRenal transitional cell CAUreteral trans.call CAMetastatic carcinomaAbd. aortic aneurysmRenal parenchymal ds.
Moderately SignificantRenal calculus
Bacterial cystitisVesicoureteral refluxInterstitital cystitisBladder diverticulumBladder calculusUreteropelvic junction obstr.Radiation cystitisPapillary necrosisRenal parenchymal diseaseAtrophic kidneyRenal AV fistulaRenal contusionBladder neck contracture
Symptomatic BPHUrethral stricture/meatal stenosisPolycystic kidneyProstatitisBladder papillomaMycobacterial cystitisPyelonephritis
InsignificantAsymptomatic BPH
UrethrotrigonitisRenal cystDuplicated collecting systemCystoceleNeurogenic bladderProstatic calculusUreteroceleBladder neck polypsUrethral polypsCystitis cystica/glandularisBladder varices/telangiectasiaScarred kidneyTrabeculated bladder
Urethral carunclePseudomembranous trigonitisUrethritisPelvic kidneyCaliceal diverticulumExercise hematuriaVerumontanitis
Adapted from Urol Clin N Am 1998; 25(4):661
8/13/2019 2008.04.01 Curry - Hematuria
15/33
Cohen R and Brown R. N Engl J Med 2003;348:2330-2338
Findings in Urinary Sediment
Hematuria(Crenated RBCs arenonspecific.)
RBC Cast= glomerular
Dysmorphic RBCs(acanthocytes)
suggest glomerular
8/13/2019 2008.04.01 Curry - Hematuria
16/33
URINALYSIS IN ACUTE KIDNEY INJURY
Prerenal Normal or hyaline casts
Intrarenal
Tubular cell injury Muddy-brown, granular, epithelial casts
Interstitial nephritis Pyuria, hematuria, mild proteinuria,granular and epithelial casts, eosinophils
Glomerulonephritis Hematuria, marked proteinuria, redblood cell casts,granular casts
Vascular disorders Normal or hematuria, mild proteinuria
Postrenal Normal or hematuria,granular casts,pyuria
from Goldman: Cecil Medicine, 23rd ed.
Copyright 2007 Saunders, Chapter 121
EVALUATION OF
8/13/2019 2008.04.01 Curry - Hematuria
17/33
Cohen R and Brown R.N Engl J Med 2003;348:2330-2338
EVALUATION OFMICROSCOPIC HEMATURIA
8/13/2019 2008.04.01 Curry - Hematuria
18/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
IV pyelogram
Ultrasound
Non-contrasted CT
Four phase contrasted helical CT
8/13/2019 2008.04.01 Curry - Hematuria
19/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
IV pyelogram
Mostly outdated
OK for stone disease if CT not available
Ultrasound Non-contrasted CT
Four phase contrasted helical CT
8/13/2019 2008.04.01 Curry - Hematuria
20/33
8/13/2019 2008.04.01 Curry - Hematuria
21/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
IV pyelogram Mostly outdated
OK for stone disease if CT not available
Ultrasound
Good option in pregnancy, children, acute renal failure Similar sensitivity/specificity to non-con CT
Operator-dependent
FUTURE: US contrast (bubble study)
Non-contrasted CT Best for stone disease
Not as sensitive for renal or other tumors
Four phase contrasted helical CT
8/13/2019 2008.04.01 Curry - Hematuria
22/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
IV pyelogram Mostly outdated
OK for stone disease if CT not available
Ultrasound
Good option in pregnancy, children, acute renal failure Similar sensitivity/specificity to non-con CT
Operator-dependent
FUTURE: US contrast (bubble study)
Non-contrasted CT Best for stone disease
Not as sensitive for renal or other tumors
Four phase contrasted helical CT: BEST/RISKIEST/$$$
8/13/2019 2008.04.01 Curry - Hematuria
23/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
IV pyelogram
Ultrasound
Non-contrasted CT
Four phase contrasted helical CT
Most sensitive and specific (0.92/0.94)
Involves contrast exposure approx. 15 X annual baseline
Most expensive current option
8/13/2019 2008.04.01 Curry - Hematuria
24/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
Four-sequence helical CT Pre-enhancement: calculi or parenchymal
calcifications in the genitourinary tractArterial early corticomedullary: vascular tumors, such
as renal cell carcinoma, inflammatory conditions,infarcts and vascular anomalies, such as a retro-aorticleft renal vein or the nutcracker phenomenon
Nephrographic phase: hypervascular andhypovascular lesions such as infarcts, inflammatorylesions of the medulla and certain neoplastic lesions
Excretory phase: transitional cell carcinoma,medullary sponge kidney, caliceal diverticula, andlesions of the ureter and urethra
FUTURE: MR Urography
8/13/2019 2008.04.01 Curry - Hematuria
25/33
MICROSCOPIC HEMATURIA:IMAGING OPTIONS
IV pyelogram
Ultrasound
Non-contrasted CT
Four phase contrasted helical CT
FUTURE: MR Urography
RADIATION DOSE IS BECOMING MAJOR CONCERN
Patients with recurrent stones can get up to 10 CTs infive years = threshhold associated with CA breast
Litigation trends
8/13/2019 2008.04.01 Curry - Hematuria
26/33
MICROSCOPIC HEMATURIA:WHEN TO REFER
8/13/2019 2008.04.01 Curry - Hematuria
27/33
8/13/2019 2008.04.01 Curry - Hematuria
28/33
MICROSCOPIC HEMATURIA:WHEN TO REFER
With proteinuria/casts/renal insufficiency:possible renal Bx
Lesion on CT
Positive urine cytology: Cystoscopy +/- moreimaging
Neg imaging, neg cytology but >50 yo or other
risk for CA bladder: Cystoscopy(AUA recommends >40 yo)
Cohen R and Brown R. N Engl J Med 2003;348:2330-2338
8/13/2019 2008.04.01 Curry - Hematuria
29/33
MICROSCOPIC HEMATURIA:PATIENTS ON ANTICOAGULANTS
243 pts on warfarin in 2-yr prospective study Hematuria incidence on warfarin (3.2%) same as controls (4.8%)
G-U disease found in 81% of patients with >1 episode of microscopichematuria
Causes of hematuria did not vary between groups (mostly infection,
also bladder CA, cysts, pap. nec.) Arch Int Med 1994;154:649 30 pts new onset gross or microscopic hematuria on anticoagulation
6 microscopic, 24 gross
9/30 = 30% had sig. disease (stones, bladder CA)J Urol 1995;153:1594
These observations indicate that hematuria in an anticoagulatedpatient should generally be evaluated in the same fashion as inother patients unless there is evidence of bleeding from multiplesites with markedly abnormal coagulation studies. (Rose, UTD)
8/13/2019 2008.04.01 Curry - Hematuria
30/33
UNEXPLAINED MICROSCOPIC HEMATURIA:POSSIBLE CAUSES
Glomerular (50%): IgA Nephrop., thin B. memb. Ds. Nutcracker Syndrome(Left Renal Vein compressed
between aorta and SMA) Left RV and gonadal varices Hematuria, left flank pain can be intermittent Can have nephrotic range proteinuria Dx by CT or MRA
Loin Pain-Hematuria Syndrome Hypercalciuria/Hyperuricosuria: thiazide or allopurinol
can cure Factitious Hematuria: usually gross Exercise Hematuria March Hematuria Undiagnosed
8/13/2019 2008.04.01 Curry - Hematuria
31/33
MICROSCOPIC HEMATURIA:IS SCREENING INDICATED?
The U.S. Preventive Services Task Force (USPSTF)recommends AGAINST screening for Bladder Cancer
Bladder CA 2-3 X more in men
Smoking increases risk, about 50% occur in smokers
Unusual before age 50
UA, cytology, bladder tumor antigen (BTA) or nuclear matrixantigen (NMP22) can detect silent tumors
Low prevalence of bladder CA makes PPV of tests low.
Occupational exposure not addressed (chemicals in dye andrubber industries)
USPSTF: AHRQ June 2004. http://www.ahrq.gov/clinic/
8/13/2019 2008.04.01 Curry - Hematuria
32/33
M.P.:An Easier Case?
48 YO AAF sees you for routine examination and healthmaintenance. She has HBP controlled with HCTZ.
Her BP is normal. General examination is normal, pelvicexam is normal, and there is no edema.
UA shows 5 RBC/hpf, 0-2 WBC, no proteinuria
Creatinine 0.8 mg/dL
How should she be evaluated?
8/13/2019 2008.04.01 Curry - Hematuria
33/33
SELECTED REFERENCES
1. Cohen R and Brown R. Clinical practice: Microscopic hematuria.N Engl J Med 2003; 348:2330.
2. Grossfeld, BD, Wolf, JS Jr et al. Asymptomatic microscopichematuria in adults: Summary of the AUA best practice policyrecommendations. Am Fam Physician 2001; 63:1145.
3. Lang, EK, Macchia, RJ et al. Computerized tomography tailoredfor the assessment of microscopic hematuria. J Urol 2002;167:547.
4. Rose, BD and Fletcher RH. Evaluation of hematuria in adults.UpToDate; July 17, 2007.
Recommended