Dr. Sanjay Pandeya NEPHROLOGIST

Transcription

1 Dr. Sanjay Pandeya NEPHROLOGIST HALTON HEALTHCARE SERVICES, OAKVILLE, ON JOSEPH BRANT HOSPITAL, BURLINGTON, ON [ADJ] ASSISTANT PROFESSOR, MCMASTER UNIVERSITY

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3 Approach to Hematuria DR. SANJAY PANDEYA MD. FRCPC.

4 Case 1 37 year old female Married with 2 children Healthy Investigations on insurance physical Informed that she has blood in her urine on routine urinalysis Makes an appointment with her family physician Normal BP, normal renal function, no proteinuria

5 Objectives Evaluation of the patient with isolated microscopic Management, Prognosis and when to refer patients with microscopic hematuria

6 AMH and Risk of Malignancy Screening AMH + Ix AMH + detailed Ix Avg High

7 AMH and Other Conditions Calculi BPH Urethral Stricture 7.1 Low High

8 Etiology

9 Major causes by age and duration Schematic representation of the major causes of hematuria in relation to the age at which they usually occur (horizontal axis), transience or persistence (vertical axis), and frequency (blue implies more frequent).

10 Definition: Presence of red or brown urine Usually only takes less than 1 ml blood/l Initial test is centrifuge results Red sediment = hematuria Red supernatant Heme positive = myoglobin, hemoglobin Hem negative = other Gross hematuria

11 Approach to Patient with Red/Brown Urine

12 Heme negative red urine Medications Food dyes Metabolities Doxorubicin Beets (in selected patients) Bile pigments Chloroquine Blackberries Homogentisic acid Deferoxamine Food coloring Melanin Ibuprofen Iron sorbitol Nitrofurantoin Phenazopyridine Phenolphthalein Rifampin Methemoglobin Porphyrin Tyrosinosis Urates

13 [Asymptomatic] Microscopic hematuria [AMH] Definition: Ø Usually accidental finding from UA or urine dipstick Ø 3 or more RBCs/hpf on two microscopic urinalysis without recent exercise, menses, sexual activity or instrumentation Ø No "safe" lower limit below which significant disease can be excluded Ø Often asymptomatic Ø The degree of hematuria does not correlate with the seriousness of the underlying cause of the bleeding.

14 Evaluation Transient or Persistent First approach is to repeat an abnormal U/A 1/3 will be normal on next urinalysis Transient hematuria generally related to infection, fever, exercise, sexual activity, menses

15 Diagnosis of AMH Urine Microscopy is the gold standard for detection of microscopic hematuria Dipsticks for heme are as sensitive as urine sediment examination, but result in more false positive tests due to the following False positives: Semen is present in the urine after ejaculation An alkaline urine with a ph greater than 9 or contamination with oxidizing agents used to clean the perineum. The presence of myoglobinuria.

16 Evaluation The evaluation should address the following three questions Is the hematuria transient or persistent? Are there any clues from the history or physical examination that suggest a particular diagnosis? Does the hematuria represent glomerular or extraglomerular bleeding?

17 Evaluation The evaluation should address the following three questions Is the hematuria transient or persistent? Are there any clues from the history or physical examination that suggest a particular diagnosis? Does the hematuria represent glomerular or extraglomerular bleeding?

18 Evaluation - CUA

19 Evaluation - Urological

20 Evaluation CUA and AUA Guidelines Once benign causes have been ruled out, the presence of asymptomatic microhematuria should prompt a urologic evaluation. Recommendation (Evidence Strength Grade C) At the initial evaluation, an estimate of renal function should be obtained (may include calculated egfr, creatinine, and BUN) because intrinsic renal disease may have implications for renal related risk during the evaluation and management of patients with AMH.

21 Evaluation Investigations Urine culture if positive, administer antibiotics and repeat urinalysis Urine cytology greater sensitivity for carcinoma of the bladder [90%]; less than 65% if upper tract malignancy CUA at initial investigation easy test to perform; non-invasive; inexpensive, it is a recommended investigation for lower tract assessment that at initial investigation AUA following a negative work up or those with other risk factors for carcinoma in situ (e.g., irritative voiding symptoms, current or past tobacco use, chemical exposures), cytology may be useful. Other: CBC, PTT, INR Electrolytes, creatinine Urine ACR Repeat U/A

22 Etiology of MH Kidney Malignancy vascular disease (malignant hypertension, AVM, nutcracker syndrome, renal vein thrombosis, sickle cell trait/disease, papillary necrosis) infec?on (pyelonephri?s, TB, CMV, EBV) Hypercalciuria hereditary disease (polycys?c kidney disease, medullary sponge kidney) Urinary Tract malignancy (prostate, ureter, bladder) BPH Nephrolithiasis Coagulopathy *** Trauma

23 Evaluation - Urological Guideline Upper Tract (imaging) Lower Tract (cystoscopy) CUA All > 40 * AUA All > 35 * UK All All * Consider in younger patients if risk factors

24 Evaluation Upper Tract Imaging Ultrasound Lower diagnostic yield and is less sensitive for urothelial transitional cell carcinoma Less sensitive for small renal tumors Cheaper and safe Availability Sensitivity of U/S < 1 cm 1-2 cm 2-3 cm > 3 cm Sensitivity

25 Evaluation Upper Tract Imaging IVP Detect TCC of kidney or ureter Less sensitive [61% versus 100%] and specific [ 91% versus 97%] compared to CT especially for lesions >3cm = 1 year of background radiation exposure Sensitivity of Imaging Sensitivity Specificity CT IVP

26 Evaluation Upper Tract Imaging CT Urography Considered preferred initial imaging with unexplained hematuria Multi-phasic computed tomography (CT) urography (without and with intravenous contrast), including sufficient phases to evaluate the renal parenchyma to rule out a renal mass and an excretory phase to evaluate the urothelium of the upper tracts Detects calculi, small lesions = 2-3 year of background radiation exposure May be contraindicated if allergy, significant kidney disease

27 Evaluation Upper Tract Imaging CUA Although there are numerous studies describing the application of these modalities in this setting there are no comparative studies that can help establish an evidence-based policy with update pending Depends on availability, cost, local issues

28 Evaluation Upper Tract Imaging Alternative AUA recommendations MR urography MRI with retrograde pyelogram U/S with retrograde pyelogram

29 Evaluation - Imaging

30 Evaluation Lower Tract Cystoscopy CUA all patients over 40 y.o. AUA all patients over 35 y.o. Exception in high risk patients Smoking history Occupational exposure to chemicals or dyes (benzenes or aromatic amines), such as printers, painters, chemical plant workers History of gross hematuria History of chronic cystitis or irritative voiding symptoms History of pelvic irradiation History of exposure to alkylating agents (cyclophosphamide) History of a chronic indwelling foreign body History of analgesic abuse, which is also associated with an increased incidence of carcinoma of the kidney

31 Follow-up and Recommendatoins Follow up The combination of negative radiologic examination, cytology, and cystoscopy is usually sufficient to exclude malignancy in the urinary tract However, approximately 1% of older patients with an initially negative evaluation will, at 3 to 4 years, have a detectable urinary tract malignancy

32 Follow-up and Recommendatoins Recommendation (CUA) Initial and then periodic urine cytology and UA should be performed in patients at high risk for malignancy (at 6, 12, 24 and 36 months) Recommendation (AUA) For persistent AMH, repeat U/A annually If two negative annual U/A, no need for further f/u If persistent, repeat evaluation within three to five years should be considered

33 Case 1 37 year old female Married with 2 children Healthy Investigations on insurance physical Informed that she has blood in her urine on routine urinalysis Makes an appointment with her family physician Normal BP, normal renal function, no proteinuria

34 Isolated Microscopic [Glomerular] Hematuria When persistent hematuria is essentially the only manifestation of glomerular disease, one of three disorders is most likely IgA nephropathy, in which there is often gross hematuria, and sometimes a positive family history but without any clear pattern of autosomal inheritance Alport syndrome (hereditary nephritis), in which gross hematuria can occur in association with a positive family history of renal failure, and sometimes deafness or corneal abnormalities. Thin basement membrane nephropathy (also called benign familial hematuria), in which gross hematuria is unusual and the family history may be positive (with an autonomic dominant pattern of inheritance) for microscopic hematuria but not for renal failure.

35 Case 2 45 year old female New to your practice Noticed tea coloured urine Recent upper respiratory illness Background history of multiple urinalyses where she always has blood in her urine Smoker Family history: Father - bladder cancer U/A shows hematuria and proteinuria (ACR 150)

36 Evaluation - Nephrological

37 HISTORY AND PHYSICAL

38 Evaluation - History Abdominal or flank pain (obstr due to calculi, clot, less so CA) Dysuria, frequency, urgency (infx, less so CA) Strenuous exercise or trauma Menstruation cycle (if cyclical think UT endometriosis) Recent URI/ sore throat (IgAN or other GN) Skin rashes/ skin infection Diarrhea (especially bloody) Joint pains/swellings (GN) Medications/toxins (GN) h/o sickle cell disease or sickle trait Travel (TB or parasitic infx)

39 Family history Hematuria Early hearing loss HTN Stones Renal disease Dialysis or transplant Sickle cell trait Coagulopathy

40 Evaluation - Medications Substances and Medications Affecting Urine Color Artificial food coloring Beets Berries Chloroquine Furazolidone Hydroxychloroquine Nitrofurantoin Phenazopyridine Phenolphthalein Rifampin

41 Evaluation - Medications Interstitial nephritis Captopril (Capoten) Cephalosporins Chlorothiazide (Diuril) Ciprofloxacin (Cipro) Furosemide (Lasix) NSAIDs Olsalazine (Dipentum) Omeprazole (Prilosec) Penicillins Rifampin (Rifadin) Silver sulfadiazine (Silvadene) Trimethoprim- sulfamethoxazole (Bactrim, Septra) Papillary necrosis Hemorrhagic cystitis Urolithiasis Acetylsalicylic acid (aspirin) NSAIDs Cyclophosphamide (Cytoxan) Ifosfamide (Ifex) Mitotane (Lysodren) Carbonic anhydrase inhibitors Dichlorphenamide (Daranide) Indinavir (Crixivan) Mirtazapine (Remeron) Ritonavir (Norvir) Triamterene (Dyrenium)

42 Evaluation Physical Vital sign: BP, T, HR Skin: Rashes, evidence or trauma, bruising Abdomen for masses, tenderness (flank, suprapubic), bruits CVS: irregular irregular Edema (especially periorbital) Joint erythema, swelling, warmth Paleness, jaundice Inspection of external genitalia and prostate

43 Glomerular v. non-glomerular

44 Evaluation - Glomerular v. Non Hypertension Renal Impairment Systemic Disease CTD Urine Studies Extraglomerular Glomerular Color (if macroscopic) Red or pink Red, smoky brown, or "Coca- Cola" Clots May be present Absent Proteinuria <500 mg/day May be >500 mg/day RBC morphology Normal Dysmorphic RBC casts Absent May be present

45 Evaluation - Glomerular v. Non Clots represent extraglomerular bleeding Associated proteinuria Color of urine Red cell casts or dysmorphic red blood cells

46 Nephrology Referral Consider a refer to nephrology for further evaluation if suspected glomerular etiology Considerations: Serology Biopsy Therapy including immunosuppressive therapy Referrals (Urology, Rheumatology) Ongoing follow- up

47 Serology Quantitative IgA (IgG/IgM) Serum immunoelectrophoresis ANA, DNA Ab, ENA C3, C4 RF panca, canca testing, anti-gbm antibody * Cryoglobulins Hepatitis and HIV Serology VDRL * $$

48 Evaluation Renal biopsy In cases of isolated microscopic hematuria, there is no role for a renal biopsy as the renal prognosis is excellent, and management would not change. This should be reevaluated if there are other findings to suggest an underlying glomerulonephritis [i.e. proteinuria, renal impairment]

49 Case 2 45 year old female New to your practice Noticed tea-coloured urine Recent upper respiratory illness Background history of multiple urinalyses where she always has blood in her urine Smoker Family history: Father - bladder cancer

50 AMH -Key Points Confirm persistent hematuria Baseline testing: bloodwork and urine Reversible causes and signs of GN, systemic disease Imaging U/S or CTU depending on availability Cystoscopy Follow-up: CUA and AUA Serology when indicated

51 AMH -Key Points Referral to Urology Concerning finding on imaging Patient > 40 y.o. (35 y.o. in AUA) or less if risk factors Referral to Nephrology If concerns of underlying GN Not needed if normal renal function (including no decline), no hypertension or proteinuria May need for insurance (Case 1)

52 Serology

53 Questions??? DR. SANJAY PANDEYA MD. FRCPC.