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.
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
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.
Hematuria as a Marker of Occult Urinary Tract Cancer. Ann Intern Med. 2016;164:I–34. doi: 10.7326/P16-9007
Download citation file:
Published: Ann Intern Med. 2016;164(7):I-34.
Published at www.annals.org on 26 January 2016
Nephrology, Urological Disorders.
Results provided by:
Copyright © 2018 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use