75. Haematuria Flashcards
Urinary calculus.
a) Most common composition, and other types
b) Proteus organisms often lead to what calculi ?
c) Effect of loop and thiazide diuretics on renal calculi
d) 3 common loci for stones
a) - Calcium , eg. calcium oxalate
- Uric acid - radiolucent (cannot be seen on XR); associated with low urine pH
- Struvite (infective - usually related to proteus)
- Cystine - inborn errors of metabolism
b) Magnesium ammonium phosphate (ie. struvite /staghorn)
c) - Loop - reduces renal calcium réabsorption to lower serum calcium (hence useful in hypercalcaemia) but leads to hypercalciuria (so increases risk of renal calculus)
- thiazides- increases renal calcium réabsorption, leading to hypocalciuria (hence useful in reducing risks of renal calculus formation)
d) - PUJ
- Mid-ureter where they cross pelvic brim/ internal iliac vessels
- VUJ
Index conditions.
- Renal calculi
- Urinary tract infection (UTI)
- Urinary tract malignancy
- Glomerulonephritis (GN)
- Bleeding disorders including anticoaglulants
- Rhabdomyolysis
Definitions.
a) VH
b) NVH
c) NVH may be split into… (2)
d) “Significant haematuria”
a) Visible/ macroscopic/ gross haematuria.
b) Non-visible/ microscopic/ dipstick haematuria
c) Symptomatic (s-NVH) and asymptomatic (a-NVH)
d) Significant haematuria is defined as:
- Any single episode of VH.
- 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.
Symptoms associated with haematuria.
Symptomatic non-visible haematuria associated symptoms include:
- LUTS: hesitancy, frequency, urgency, dysuria, etc.
- systemic: fever, rigors, etc.
Aetiology.
a) Common causes
b) Infective
c) Malignant
d) Traumatic
e) Inflammatory
f) Structural
g) Haematological
h) Toxin causes
a) UTI, bladder tumours, urinary tract stones, urethritis, benign prostatic hypertrophy (BPH) and prostate cancer
- Benign causes: incidental, benign familial haematuria
b) Infection: cystitis, tuberculosis, prostatitis, urethritis, schistosomiasis, infective endocarditis.
c) Tumour: renal carcinoma, Wilms’ tumour, carcinoma of the bladder, prostate cancer, urethral cancer or endometrial cancer.
d) Trauma: renal tract trauma due to accidents, catheter or foreign body, prolonged severe exercise, rapid emptying of an overdistended bladder (eg, after catheterisation for acute retention).; Surgery: invasive procedures to the prostate or bladder.
Genital bleeding, including child abuse; menstruation; Münchhausen’s syndrome or fabricated or induced illness by carers
e) Inflammation: glomerulonephritis, Henoch-Schönlein purpura, IgA nephropathy, Goodpasture’s syndrome, polyarteritis, post-irradiation.
f) Structural: calculi (renal, bladder, ureteric), simple cysts, polycystic renal disease, congenital vascular anomalies, medullary sponge kidney
g) Haematological: sickle cell disease, coagulation disorders, anticoagulation therapy.
h) Toxins: sulfonamides, cyclophosphamide, non-steroidal anti-inflammatory drugs.
Clinical/ laboratory features suggesting a renal cause
Clincal.
- Hypertension
- Renal mass
- Known previous renal problems
Biochemical.
- Altered renal function tests
- Proteinuria
- Glomerular red cells (red cells with irregular contours and shape) in the urine
Other causes of dark urine (non-haematuria)
- Haemoglobinuria: dipstick-positive but no red cells on microscopy.
- Myoglobinuria.
- Food - eg, beetroot.
- Drugs - eg, rifampicin, nitrofurantoin, senna.
- Porphyria: urine darkens on standing.
- Bilirubinuria: obstructive biliary disease
Investigations.
a) Transient causes to exclude
b) Initial investigations to perform
c) Indications for nephrology referral (non-cancer)
d) Tertiary investigations
a) UTI, exercise-induced haematuria, myoglobinuria, and menstruation
b) - Bedside: measure BP, urine dip for infection, blood and PCR/ACR (proteinuria), DRE in men (?prostate Ca)
- Bloods (Urea and creatinine [eGFR], FBC, clotting)
- Imaging: cystoscopy (2-week wait), USS
- Special tests: red cell microscopy (GN - red cell casts)
c) - Urological cause excluded (and not cancer)
- Signs of renal disease (reduced GFR, HTN, proteinuria, etc.)
- Intercurrent infection (usually URTI) in <40 year old
d) Cystoscopy, USS, XR/CT KUB (rarely, renal biopsy)
Monitoring of patients with haematuria (if investigations reveal no pathology).
a) Symptoms
b) Tests
a) - Voiding LUTS.
- Visible haematuria.
b) - Significant or increasing proteinuria.
- Progressive renal impairment (falling eGFR).
- Hypertension (the development of hypertension in older people may have no relation to the haematuria)
NICE two-week referral guidelines.
a) Bladder or renal cancer
b) Bladder cancer only
c) Endometrial cancer
d) Prostate cancer
a) Aged > 45 with:
- Visible haematuria without UTI; or,
- Visible haematuria that persists or recurs after successful treatment of UTI
b) Aged > 60 with:
- Non-visible haematuria, AND…
- dysuria or raised WCC
c) Women aged > 55 with:
- Visible haematuria, AND…
- Low Hb levels OR thrombocytosis OR high blood glucose levels OR unexplained vaginal discharge
d) Visible haematuria, AND…
- Abnormal PSA, OR malignant-feeling prostate on DRE.
Ureteric stones (nephrolithiasis)
a) Stone types
b) Risk factors
c) Presentation
d) Differentials - common? - important ones to rule out?
e) Investigations (sensitivity)
f) Management -? (admit who?)
g) Indications for nephrostomy
a) Calcium oxalate (most common), struvite (ammonium magnesium phosphate; may be staghorn), uric acid, cystine
b) - Renal abnormalities (eg. horseshoe kidney, medullary sponge kidney)
- Hypertension, FHx of stones
- Crystal formation - dehydration, gout, Crohn’s, hypercalcaemia/ hypercalciuria, diuretics, Sarcoid
c) - Renal colic (loin to groin) - quick onset and severe
- Urinary - haematuria, dysuria, UTI sx
- Systemic - nausea and vomiting, may result in pyelonephritis (fever, rigors, sepsis)
d) - Common: pyelonephritis, MSK pain
- AAA rupture, ectopic, appendicitis, pancreatitis, testicular torsion
e) - Bedside: urine dip (pH test, infection, blood in 85%, protein, glucose, + MSU), pregnancy test (?ectopic)
- Bloods: FBC, CRP, U+Es/creatinine, calcium, phosphate, magnesium and uric acid (latter 2 may indicate stone composition)
- Imaging: non-contrast CT KUB scan gold-standard (sensitivity 98%) - patients are laid prone
- Children/pregnancy - USS first line
- Special tests: stone analysis
- F/U test - may do XR to see whether confirmed stone has passed
f) Admission criteria.
- Fever/ infection signs
- Solitary kidney or kidney disease
- Inadequate pain relief or persistent pain.
- Dehydration, or severe nausea/vomiting
- Anuria.
- Pregnancy.
- > 60 an diagnostic certainty (eg. cannot exclude AAA)
Further management.
- NSAIDs for pain - IM/PR diclofenac
- Anti-emetics
- Conservative (if < 5 mm) - spontaneous expulsion (takes ~ 1 - 3 weeks in 80%)
- Medical expulsion - add alpha-blocker (eg. tamsulosin) or CCB
- Surgical (20%) - shock-wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy or open surgery
g) Nephrostomy:
- Ureteric obstruction leading to severe hydronephrosis
Stone analysis
a) In who?
b) How?
a) - First-time stone formers.
- Recurrent stones
b) Urinating through a tea strainer, a filter paper such as a coffee filter or a gauze
Ureteric stone prevention
a) Conservative.
- HYDRATION - increase fluid intake to maintain urine output at 2-3 litres per day.
- Reduce salt intake, and dietary animal protein
- Reduce oxalate intake (chocolate, rhubarb, nuts)
- Reduce urate-rich foods (alcohol, offal and certain fish, red meat).
- Drink regular cranberry juice: increases citrate excretion and reduces oxalate and phosphate excretion
- Maintain calcium intake at normal levels (lowering intake increases excretion of calcium oxalate).
b) Medication:
- thiazide diuretics (for calcium stones),
- allopurinol (for uric acid stones)
- calcium citrate (for oxalate stones).
Glomerulonephritis.
a) What is it?
b) Most common causes in children
c) Most common cause in adults (aged 16 - 35)
d) Spectrum of disease
e) Investigations
f) Antibodies if secondary cause suspected (what test MUST be done in adults > 50?)
g) Management
a) A range of immune-mediated disorders causing inflammation in the glomerulus/other parts of the kidney
b) - Post-strep GN (nephritic)
- Minimal change nephropathy (nephrotic)
- HSP (nephritic)
c) IgA nephropathy (idiopathic; nephritic)
d) - Asymptomatic haematuria/proteinuria
- Nephrotic syndrome - HOP
- Acute nephritis - haematuria, HTN
- Progressive GN (rapidly progressive or chronic) - leads to end-stage renal failure
e) - Bedside: urine dip (protein, blood, etc.), BP (?HTN), BM (?diabetes)
- Bloods: FBC, CRP, U+Es/creatinine, protein/albumin, glucose, ASOT (?post-strep), clotting
- Imaging: renal USS
- Special tests: urine microscopy (?red cell casts), 24h urine collection, ACR, renal biopsy
f) - Adults > 50: myeloma screen (serum and urine protein electrophoresis)
- ASOT (?post-strep)
- ANA/anti-dsDNA (?SLE)
- ANCA (?vasculitis)
- Anti-GBM (?Goodpasture’s)
- HBsAg (Hep B)
g) General.
- Monitor BP, urine haematuria/proteinuria, serum albumin and eGFR
- Lower BP if required through ACE inhibition
- Fluid and salt restrict in nephrotic (+/- protein supplementation)
Medical.
- Diuretics for oedema (spiro and furosemide)
- Steroids / other immunosuppressants (eg. cyclophosphamide)
- Statins for hyperlipidaemia
- Antiplatelet/anticoagulant
- Last resort measures: IVIg and dialysis
IgA nephropathy.
a) Cause
b) Other IgA renal disease in children
c) Presentation
d) Investigations
e) Management
a) Idiopathic
b) HSP
c) - Haematuria (often brown/red urine)
- Usually coexistent infection (eg. URTI, gastroenteritis)
- May have loin pain
- May have HTN
d) - Urine dipstick +/- microscopy
- Bloods: FBC, CRP, U+Es, creatinine, clotting, etc.
- If uncertaintly - renal biopsy
- If > 50: myeloma screen
e) - Monitor BP, eGFR and urine
- ACE inhibitors
- Corticosteroids +/- cyclophosphamide
- ESRD - dialysis or transplant
