​Kembara Xtra - Medicine - Hematuria

​Kembara Xtra - Medicine - Hematuria 
Introduction 
Gross (visible) or microscopic (invisible), symptomatic or asymptomatic blood in the pee


Epidemiology 
Prevalence
Gross: 0.13% in children; asymptomatic microscopic hematuria (AMH): 0.4–4.1%. Adults: 0.9-17% AMH
Pathophysiology and Etiology 
Exercise-induced trauma that resolves 24 hours after the activity stops
Injuries to the kidneys, bladder, or ureters as a result of abdominal or pelvic surgery, indwelling catheters, or foreign bodies. Physical or sexual abuse.

Neoplasms: benign tumors or urologic malignancies
- Urinary endometriosis (suspect in females with cyclic hematuria)
Infectious and inflammatory factors
- UTI is the most typical adult hematuria cause.
- Renal diseases include acute and chronic tubulointerstitial nephritis brought on by medications, infections, and systemic illnesses, as well as radiation nephritis and cystitis. Glomerular illness
Goodpasture syndrome (autoimmune, pulmonary hemorrhage-associated antiglomerular basement membrane illness) Lupus nephritis, IgA nephropathy, and Henoch-Schönlein purpura
Membranoproliferative glomerulonephritis (GN), poststreptococcal, or quickly progressing GN  Visceral abscesses and endocarditis in Wegener granulomatosis
- Syphilis, TB, schistosomiasis, and other illnesses
Congenital/familial causes - Cystic disease: polycystic kidney disease, solitary renal cyst - Benign familial hematuria or thin basement membrane nephropathy (autosomal dominant) Hyperuricosuria Drugs that cause calculi such as acyclovir Metabolic causes - Stones (85% have hematuria) Hypercalciuria Hypercalciuria Alport syndrome (80% X-linked; hematuria, proteinuria, hearing loss, abnormalities of the cornea) - Fabry disease, also known as vascular kidney disease and an X-linked recessive inborn metabolic defect. - Nail-patella syndrome (autosomal dominant; hematuria in 33%; nail and patella hypoplasia) - Renal tubular acidosis type 1 (autoimmune or autosomal dominant).
Hematologic reasons, such as bleeding disorders like hemophilia
- Renal papillary necrosis (Sickle cell trait)
Hemangioma and arteriovenous malformations (rare) are two vascular causes.
- Renal parenchymal congestion and constriction of the left renal vein characterize the Nutcracker syndrome. - Renal artery/vein thrombosis - Kidney artery emboli
Chemical causes include aminoglycosides, cyclosporine, analgesics, oral contraceptives, Chinese medicines, cyclophosphamide, aspirin, sulfa medications, and penicillins.
Obstruction caused by posterior urethral valves or strictures
- Any form of hydronephrosis
- Benign prostatic hyperplasia: Discard any further hematuria-causing factors.
Additional causes (Most frequently in young women using oral contraceptives) Leg discomfort and hematuria

Risk factors include: smoking; occupational exposures to petrochemicals, rubber, or dye manufacturing; pelvic radiation; chronic infection, particularly with calculi; recent upper respiratory infection; positive family history of stones, GN, or cancer; and chronic indwelling foreign body.

Introducing Historical Considerations
UTI with burning, urgency, and frequency; glomerular origin with dark cola-colored urine; clots with extraglomerular hemorrhage; and lupus, vasculitis, and Henoch- Schönlein purpura with arthralgias and rash. 
Upper respiratory infection (URI) recently: poststreptococcal GN, membranoproliferative GN; concurrent URI: IgA nephropathy; excessive vitamin use: stones; pyelonephritis; flank pain; infarction;
Running a marathon: traumatic, rhabdomyolysis; traveling: schistosomiasis, tuberculosis
Weight loss and/or painless hematuria: malignancy
Family history includes von Willebrand disease, thin basement membrane disease, sickle cell disease, polycystic kidney disease, and Alport disease (hereditary nephritis).
Even brief instances of visible hematuria (VH) in the urine are linked to an OR of 7.2 for urologic malignancies.

Considerations for a clinical examination include elevated blood pressure, edema, and weight gain due to glomerular disease.
Fever indicates infection; palpable kidney indicates polycystic kidney disease; and in the genitalia, look for lesions or meatal erosion.

Multiple Diagnoses 
Menstrual/vaginal hemorrhage, rectal bleeding, and medications like phenazopyridine and rifampin can cause urine to become orange or crimson, which might be mistaken for hematuria.

Laboratory Results 

A hematuria risk index may help in stratifying patients who need more extensive testing and are at risk for urothelial cancers. VH, age greater than 50, male gender, family history of urological malignancies, and smoking are high-risk markers.
Initial examinations (lab, imaging)

Guidelines suggest investigating AMH using upper urinary tract imaging and cystoscopy if acute cystitis/UTI has been ruled out; none advocate cytology or urine markers for initial AMH evaluation.

 Urine dipstick (specificity: 65–99%; sensitivity: 91–100%) False negatives are uncommon, however they can be brought on by large doses of vitamin C.
Alkaline urine (>9), semen, free hemoglobin (hemolysis), and myoglobin (rhabdomyolysis) are examples of false positives. - Heme-negative red urine: The dipstick may become discolored by food dyes, beets, blackberries, rhubarb, porphyria, rifampin, phenytoin, or phenazopyridine, making interpretation challenging.
Any proteinuria greater than 2+ raises suspicions of glomerular disease.
It is generally advisable to perform a microscopic urinalysis to quantify RBCs and validate dipstick results.
- The American Urological Association (AUA) defines clinically significant microscopic hematuria as having less than 3 RBCs per HPF on a correctly obtained urine sample when there is no clear benign etiology (1).
- If the dipstick is positive but the microscopic examination is negative, three further tests should be performed. Exclude fictitious or nonurinary causes, such as menstruation, mild trauma, exercise, improper collection method, or chemical/drug causes, through cessation of activity/cause and a repeat urinalysis, and move forward with a workup if someone tests positive.
– Pathognomonic for glomerular origin are RBC casts and dysmorphic cells.
Renal function tests (eGFR, BUN, creatinine), albumin, and electrolytes to assess the hazards of contrast-enhanced imaging and to distinguish intrinsic renal disease (1)[C]
Significant proteinuria (>500 mg/day), red cell casts, dysmorphic RBCs, elevated creatinine, and an albumin:creatinine ratio 30 mg/mmol are all signs of renal disease.
Urine culture if infection or pyuria is suspected
Multidetector CT urography (MDCTU); specificity 92%, sensitivity 95%
According to the American Urological Association (AUA) and the American College of Radiology (ACR), the initial imaging procedure of choice in non-pregnant persons without radiation or contrast allergy who have unexplained hematuria (1) – Normal does not exclude the necessity for a cystoscopy, especially in those at high risk.
- The presence of calculi on a noncontrast image does not rule out the requirement for a contrast phase or another diagnosis.
In adult patients with acute flank discomfort who suspect stone involvement, noncontrast CT is preferred as the first line of treatment.
- If the US is negative, perform an unenhanced helical CT on any children suspected of having stone disease.
- In children with traumatic hematuria, perform contrast-enhanced CT of the abdomen and pelvis.
Renal and bladder ultrasound (RBUS) is best for distinguishing between cystic and solid masses and is sensitive to hydronephrosis. US at the point of care may help patients avoid CT when there is a suspicion of stones.
- US can be used as the first line of treatment in patients who cannot have CTU or who have a low risk of developing cancer. - No radiation or iodinated contrast exposure and cost-effective.
- Sensitivity and NPV for upper tract urothelial cancer were 14.3% and 99.7%, while for renal cancer they were 85.7% and 99.9%.
- Low sensitivity for renal masses smaller than 3 cm - The main drawback is that transitional cell carcinoma in the urothelium cannot be adequately evaluated.
MRU has a high sensitivity/specificity for renal parenchyma but is less useful for detecting stones or the collecting system. - May be used in patients who are ineligible for MDCTU
MRI is least cost-effective yet has sensitivity for renal masses comparable to that of CT.
- Limited capacity to accurately identify calcifications of the urinary tract
- For patients who cannot tolerate MDCTU or MRU, it can be coupled with retrograde pyelogram (RPG).


Tests in the Future & Special Considerations
Other tests may be ordered depending on the probable cause. These include prothrombin time (PT)/international normalized ratio (INR) testing for warfarin-treated patients, antineutrophil cytoplasmic antibody (ANCA), C3, C4, and antistreptolysin O (ASO) titers.
Think about genetic testing for patients who may have familial hematuria.
Voided urine cytology (sensitivity 43.5%, specificity 95.7%, positive predictive value 47.6%, and negative predictive value 94.9%) - Not advised for routine evaluation of AMH; however, it may be used in cases where a person has strong risk factors for urinary malignancy 
There is not enough data to support the routine use of urine tumor markers. 
Patients with VH had a higher risk of developing cancer than those with nonvisible hematuria (13.8% vs. 3.1%).
The VH's overall positive predictive value for bladder/renal cancer in people over 15 years of age is 5.1%; risk rises with age and with being a man.
VCUG in kids with recurrent UTIs necessitating workup


Other/Diagnostic Procedures

The best method for evaluating the bladder, particularly minor urothelial lesions, is flexible cystoscopy (sensitivity 62%; specificity 43-98%); the NPV for bladder cancers is 99%.
– The AUA advises cystoscopy in addition to imaging for all patients with hematuria who are under 35 years old and for all patients with risk factors for bladder cancer regardless of age.

Renal biopsy: Although it is uncommon, it may be required to diagnose GN or to address the growing renal insufficiency.
In addition to US or noncontrast investigations in patients who are not candidates for contrast or MRI, RPG is reserved when MDCTU is ambiguous. - Needs a cystoscopy since it is sensitive to minor lesions of the supravesicular collecting system
Ureteroscopy and pyeloscopy are used to visualize lesions that may be present in the supravesical collecting system. These procedures may also involve cystoscopy and anesthesia.
- Potential harm to the collection system
pregnant women's issues
For pregnant patients, US is the first imaging modality of choice. Alternatives include using MRI or US together with MRU or RPG.
Child Safety Considerations
Think about familial reasons, hyperuricemia, GN, Wilms tumor, child maltreatment, and hypercalciuria.

● The AAP advises against starting a workup for hematuria in a juvenile patient before performing another probe urinalysis. The most frequent diagnoses on renal biopsy in individuals with chronic ASM are hypercalciuria (30-35%), hyperuricemia (5-20%), and glomerulonephritides, including IgAN and thin basement membrane disease.
Hematuria that is gross or symptomatic requires a thorough workup. Consider UTI, hypercalciuria, family causes, masses, stones, or cysts if the RBCs are eumorphic. Obtain a urinary Ca:Cr ratio, US, urine culture, and family history. Urine Ca:Cr ratio >0.2 (mg/mg) in children >6 years of age is suggestive of hypercalciuria. Consider a renal consultation if your RBCs are dysmorphic, especially if you have proteinuria, high blood pressure, edema, or a favorable family history.
Renal US is reserved for situations of suspected trauma (with contrast) or stones (without contrast), while CT is used to diagnose the majority of congenital and malignant diseases.

First Line of Medicine
The first step in treating hematuria is to address its underlying cause. Drugs that produce hematuria should be stopped.


Referral Urology referral for stones, vascular/anatomic malformations, or nutcracker syndrome Nephrology referral for proteinuria, red cell casts, increased serum creatinine, and albumin:creatinine ratio 30 mg/mmol

Further Treatments 
If endometriosis is causing hematuria and has symptoms, surgery to remove it is recommended.

Constant Care 
Specialist close follow-up is advised depending on the underlying reason. When necessary, primary care doctors are crucial in determining secondary causes of hematuria and ensuring multidisciplinary care.

Patient Follow-Up Monitoring
Even though recent research indicates that no further testing is necessary for patients with AMH following thorough initial negative examinations (imaging, cystoscopy), until symptoms or frank hematuria appear, some specialists still advise routine urinalyses. In these patients, the AUA advises annual urinalyses until two consecutive negative results are obtained, and if hematuria is chronic, to consider a repeat workup in three to five years.

diet Extra fluids for clotting or stones

Poorer for malignant tumors and some types of nephritis; generally great for common causes of hematuria; persistent AMH is linked to a higher risk of end-stage renal disease in patients between the ages of 16 and 25.

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