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The full report is titled “Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians.” The authors are M. Nielsen and A. Qaseem, for the High Value Care Task Force of the American College of Physicians.
This article was published at www.annals.org on 26 January 2016.
Hematuria as a Marker of Occult Urinary Tract Cancer. Ann Intern Med. 2016;164:I-34. doi: 10.7326/P16-9007
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Published: Ann Intern Med. 2016;164(7):I-34.
Published at www.annals.org on 26 January 2016
Hematuria is the medical name for blood in the urine. Blood is sometimes found when a doctor tests your urine. This is usually a small amount of blood that is only noticeable with a microscope or special test. This is called microscopic hematuria. Other times, blood may be visible in the urine. This is called gross hematuria.
Blood in the urine can be caused by some common problems, such as urinary tract infections, kidney stones, injuries, or certain medicines. Other more serious causes can be kidney diseases, including cancer. Blood in the urine can come with or without pain.
Testing for blood in the urine is usually a painless urine test. Follow-up testing to find the cause of blood in the urine can be more complex. One test to check for problems causing blood in the urine is a computed tomography (CT) scan of the urinary tract, which includes the kidney and bladder. Another test, called cystoscopy, involves inserting a thin tube with a camera into the bladder to check for problems. These tests can cause side effects, such as discomfort, anxiety, and even life-threatening reactions. They are also costly for patients. It is important that these tests are only done when needed.
The authors looked at research and clinical guidelines related to blood in the urine. This information was used to develop advice for clinicians and patients.
•During routine office visits, clinicians should ask patients if they have seen blood in their urine. This is especially important for any patients who have previously had blood in the urine.
•Clinicians should not use routine urine tests as a way to screen for cancer in adults with no symptoms.
•If a patient's urine test shows microscopic blood in the urine, clinicians should confirm this result by looking at the sample under a microscope. If blood in the urine is confirmed and there is no known cause, clinicians should consider referring the patient for additional tests. Patients on antiplatelet or anticoagulation medicines may have greater risk for blood in the urine. Clinicians should still consider referring patients with confirmed blood in the urine for additional tests, even if they are taking these medicines.
•If a patient has visible blood in the urine (gross hematuria), clinicians should refer that patient to a specialist in urology.
•Clinicians should not test for abnormal cells or signs of bladder cancer in the urine as the next steps when blood in the urine is found.
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Robert S. Brown, MD
Nephrology Division, Beth Israel Deaconess Medical Center, Boston, MA
February 8, 2016
What is high-value care for hematuria that is only microscopic?
While I applaud Nielsen, Qaseem and the American College of Physicians Task Force in promoting guidelines for care in the management of patients with hematuria (1), I take issue with advice that needs to be more nuanced for those with microscopic, rather than gross, hematuria. First, while occult cancer may be the most serious concern in those with gross hematuria, glomerular disease with its attendant risks of chronic kidney disease and premature death is another serious condition in those with microscopic hematuria, particularly in the office practice of patients not referred to specialty clinics. A careful urinary sediment examination looking for red blood cell casts or >5% acanthocytes which have almost 100% specificity for glomerular disease (2–4) is a noninvasive way to spare patients from unnecessary imaging or cystoscopy. So rather than a mere peripheral mention on Figure 1, examination of red blood cell morphology should be added to their “High-Value Care Advice 3: Clinicians should confirm hemepositive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults”. Second, “High-Value Care Advice 5: Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause” is unbalanced. It suggests that urologic referral is needed for cystoscopy and imaging. I would argue that many physicians feel competent to consider whether ultrasound, CT scanning or magnetic resonance imaging is appropriate, and almost always such imaging should precede cystoscopy. Moreover, since there is little evidence to support cystoscopy in patients under 40 years of age that have only microscopic hematuria without risk factors for bladder cancer (5), urologic referral of such young patients is usually unnecessary. 1. Nielsen M, Qaseem A. Hematuria as a Marker of Occult Urinary Tract Cancer: Advice for High-Value Care From the American College of Physicians. Ann Intern Med. 2016 Jan 26; doi:10.7326/M15-1496.2. Köhler H, Wandel E, Brunck B. Acanthocyturia--a characteristic marker for glomerular bleeding. Kidney Int. 1991 Jul;40(1):115–20. 3. Kitamoto Y, Tomita M, Akamine M, Inoue T, Itoh J, Takamori H, et al. Differentiation of hematuria using a uniquely shaped red cell. Nephron. 1993 Jan;64(1):32–6. 4. Nagahama D, Yoshiko K, Watanabe M, Morita Y, Iwatani Y, Matsuo S. A useful new classification of dysmorphic urinary erythrocytes. Clin Exp Nephrol. 2005 Dec;9(4):304–9. 5. Niemi MA, Cohen RA. Evaluation of microscopic hematuria: a critical review and proposed algorithm. Adv Chronic Kidney Dis. 2015 Jul;22(4):289–96.
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