Microscopic haematuria Not visible, but when you find it ...

Microscopic haematuria
Not visible,

but when you find it, what next?

Dr David MAKANJUOLA
Renal unit

St. Helier hospital

Upper vs lower urinary tract bleeding

Urinalysis
Urine
microscopy
Urine cytology

Hb
Hb

Orthotolidine
Peroxidase

Hb
Hb

Hb
Orthotolidine
Peroxidase

Hb False positives:
Hb Haemoglobinuria,
myoglobinuria,
Hb Betadine,
Orthotolidine very dilute
Peroxidase alkaline urine

False negatives: Hardly any



ABNORMAL URINE
SEDIMENT IN
GLOMERULAR
HAEMATURIA

Case history

• 22 year old Afro-Caribbean male
• Microscopic haematuria noted on registration

with new GP.
• No proteinuria
• Normal creatinine (90µmol/l)
• Blood pressure 120/70mmHg

• No haematuria on dipstick testing at subsequent
review in GP surgery.

Haematuria

Management should include
•Check serum creatinine in all patients
•Check for proteinuria in all patients
(quantify protein/creatinine ratio if positive)

Visible (macroscopic) Invisible (microscopic) Microscopic haematuria
haematuria haematuria without with prot/creat ratio
proteinuria, >50mg/mmol
GFR>60ml/min/1.73m2

Major causes of haematuria by age and duration

From Up To Date
Schematic representation of the major causes of haematuria in relation to the age at which they usually occur
(horizontal axis), transience or persistence (vertical axis), and frequency (blue implies more frequent).

Haematuria

Management should include
•Check serum creatinine in all patients
•Check for proteinuria in all patients
(quantitate protein/creatinine ratio if positive)

Visible (macroscopic) Invisible (microscopic) Microscopic haematuria
haematuria haematuria without proteinuria, with prot/creat ratio
>50mg/mmol
Usually fast track GFR>60ml/min/1.73m2
Urology referral for Refer to nephrology
imaging and cystoscopy, Age >40, usually refer to Lower levels of
unless strong pointers to Urology (recommended age proteinuria, manage
acute renal disease may vary locally) as Stage 1/2 CKD
Age <40, or >40 with negative
Refer to nephrology if urological investigations,
urological investigations manage as Stage 1/2 CKD
negative

Haematuria

Management should include
•Check serum creatinine in all patients

Microscopic haematuria•Check for proteinuria in all patients
(quantitate protein/creatinine ratio if positive)

with GFR<60ml/min/1.73m2

Visible (macroscopic) Invisible (microscopic) Microscopic haematuria

haematuria without proteinuria, with prot/creat ratio
GFR>60ml/min/1.73m2 >50mg/mmol
(+/-prot/creat ratio >50mg/mmol)haematuria
Usually fast track

Urology referral for Age >40, usually refer to Refer to nephrology

imaging and cystoscopy, Urology (recommended age Lower levels of

unless strong pointers to proteinuria, manage
as Stage 1/2 CKD
Refer to renal team.acute renal disease
may vary locally)
Age <40, or >40 with negative

Refer to nephrology if urological investigations,
urological investigations manage as Stage 1/2 CKD

negative

Case history

• Plan - manage as stage 1/2 CKD.

• Poor attender at surgery.

• Develops flu-like illness with abdominal pain.

• Gives history of intermittent flank pains, but
no dysuria or history of renal stones.

Case history

• Haematuria on dipstick testing on this occasion,
but also, protein 1+, nitrites and leucocytes +ve.

• BP 150/110mmHg

• MSU sent. Form given for blood tests.

• Commenced on Trimethoprim

Case history

• Blood tests while on antibiotics show the

following:

• Hb 15 Urea 6.5

• WBC 13.5 Creatinine 135

• Platelets 225 Potassium 5.3

• CRP 68

• MSU – WCC > 100, RBC +
• Coliforms, sens to Trimethoprim, Amoxycillin

A digression……… Trimethoprim inhibits the
secretion of creatinine
CREATININE (~10-15%) into the tubules and can
reversibly increase the
serum creatinine up to 10-
15%.

UREA
(variable %)

Case history

• Blood tests repeated 1 week after the course

of antibiotics show the following:

• Hb 15 Urea 6.5

• WBC 6.5 Creatinine 150

• Platelets 225 Potassium 5.3

• CRP 5

• Urine dipstick – blood 2+

AKI - classification

Stage Serum creatinine (SCr) criteria Urine output criteria

1 increase ≥ 26 μmol/L within 48h
or
increase ≥1.5 to 1.9 X reference
SCr

2 increase of ≥ 2 to 2.9 X reference
SCr

3 increase of ≥3 X reference SCr
or
increase of ≥354 μmol/L
or
commenced on renal
replacement therapy (RRT)
irrespective of stage

AKI - classification

Stage Serum creatinine (SCr) criteria Urine output criteria

1 increase ≥ 26 μmol/L within 48h <0.5 mL/kg/hr for > 6
or consecutive hrs
increase ≥1.5 to 1.9 X reference
SCr (<30mls/h in a 60kg person)

2 increase of ≥ 2 to 2.9 X reference <0.5 mL/kg/ hr for > 12 h
SCr (<30mls/h in a 60kg person)

3 increase of ≥3 X reference SCr <0.3 mL/kg/ hr for > 24 h

or or

increase of ≥354 μmol/L anuria for 12 hrs

or (<20mls/h in a 60kg person)

commenced on renal replacement

therapy (RRT) irrespective of stage

Acute Kidney Injury (AKI)

• The reference serum creatinine should be the
lowest creatinine value recorded within 3
months of the event.

• If a reference serum creatinine value is not
available within 3 months and AKI is
suspected, repeat the serum creatinine
within 24 hours.

Case history

• Auto-immune screen –ve
• Hb electrophoresis normal
• Vasculitis screen –ve

• Abdominal ultrasound scan shows multiple cysts
in both kidneys, as well as some cysts in the
liver.

• Family history – no known FH of CKD, but his
father died in his 40s of a stroke.

Polycystic kidneys

Polycystic kidneys - Epidemiology

• Common – occurs in 1 in every 400-1,000 live
births.

• Family history - can be negative in up to 25%
of cases:

– New mutation
– Adopted individual
– Affected parent died without PKD being noted

Polycystic kidneys - Genetics

• Autosomal dominant (adult) PKD
• PKD 1 – abnormality on chromosome 16

• PKD 2 – abnormality on chromosome 4

• In PKD 2, development of cysts and also, of
ESRD tends to occur later in life and it tends
to have a less severe phenotype than PKD1.

Polycystic kidneys - Clinical features (Renal)

• Haematuria – macro and microscopic.

• Proteinuria – usually <1g/day (PCR
100mg/mmol)

• Hypertension

Polycystic kidneys - Clinical features (Renal)

• Renal stones in up to 20% (50%urate stones)
• Flank and abdominal pains

• Renal cancers –

– often bilateral, and
frequently present with
a fever.

– diagnosis difficult.

Polycystic kidneys - Clinical features (Extra-renal)

Cerebral aneurysms

IN SUMMARY…..

Non-visible haematuria

• Patients with asymptomatic transient micro-haematuria and negative
urologic work up, but who may be at risk for malignancy should be
followed up with annual urinalyses.

• After two consecutive negative urinalyses, this follow-up may be
stopped.

• If gross hematuria occurs at any time after the initial evaluation, the full
evaluation should be repeated.

• If hypertension, proteinuria, an increase in serum creatinine, or evidence
of glomerular bleeding develops in a patient who has been evaluated for
haematuria, the patient should be re-evaluated for renal disease.