SAQ. How to evaluate a 30 years female with visible haematuria?

D/D:

• • Menstruation, Infection (cystitis, pyelonephritis)
  • SLE with LN, Vasculitis
  • GN : especially IgA nephritis
  • ADPKD

• • Stone, Trauma, Tumor

• • HTN
  • Drugs
  • Bleeding disorders
  • Haemoglobinuria/myoglobinuria (causes)

SAQ. A 25-year-old lady with arthralgia, skin rash and haemoptysis. Urine R/M/E reveals protein (++) and haematuria.

1. a) What are the possible differentials? 
2. b) What other history do you want to take to reach a diagnosis? 

Possible differentials are: 

1.  SLE with LN
2. Systemic vasculitis, HSP
3. RA with pulmonary involvement 
4. Sarcoidosis 
5. Systemic Sclerosis 
6. Disseminated TB 

Evaluation of hematuria

(source: synopsis of nephrology)

History:

• Intense exercise, abdominal trauma, menstruation, recent bladder catheterization
• Fever, abdominal pain, dysuria, frequency  ——————– → UTI
• Passage of clots in urine ——————– →extraglomerular cause of hematuria.
• Periorbital puffiness, weight gain, oliguria, dark-colored urine, edema or hypertension  ———– → glomerular cause (painless hematuria)
• Recent throat or skin infection   ——————— → postinfectious glomerulonephritis.
• Joint pains, skin rashes, prolonged fever, anemia, weight loss, hemoptysis   ——————— → CTD, vasculitis, HSP

• Bleeding from other sites, anemia   —————→ bleeding diathesis

• Drug history:  ————– →intake of certain drugs or toxic substances

• Family history of kidney disease:

• Alport syndrome, collagen vascular diseases, urolithiasis, polycystic kidney disease

General Examination:

• Periorbital puffiness, peripheral edema
• BP 
• Skin survey: purpura

Systemic examination:

Abdomen:

• palpable kidneys 
• genitalia

Fundoscopy:

• hypertensive retinopathy 

Investigation:

The laboratory tests ordered for the assessment of hematuria should be according to the clinical history and the physical examination. The helpful tests are:

Patients with hematuria may usefully be classified into one of the following four groups:

1. Gross hematuria
2. Symptomatic microscopic hematuria 
3. Asymptomatic microscopic hematuria with proteinuria 
4. Asymptomatic microscopic (isolated) hematuria

Management:

Principles of treatment:

• Hematuria is a sign and not itself a disease; treatment should be directed at the process causing it.
• Asymptomatic (isolated), persistent hematuria usually does not require treatment.
  • follow up yearly
• Treatment of the cause
  • surgical intervention: stone, tumor, PUJ obstruction