Asymptomatic%20Microscopic%20Hematuria%20in%20Adults:%20Summary%20of%20the%20AUA%20Best%20Practice%20Policy%20Recommendations

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Asymptomatic Microscopic Hematuria in
AdultsSummary of the AUA Best Practice Policy
Recommendations

• Am Fam Physician 2001631145-54

Supervisor ????? Reporter ????? Date 96/4/10
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Introduction

• Gross hematuria warrants a thorough diagnostic
  evaluation
• Microscopic hematuria
• gt3 RBC/ hpf (2/3 freshly voided, clean-catch,
  midstream urine specimen)
• Minor finding in normal person
• Pt w/ urologic malignancies

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Introduction

• Prevalence of asymptomatic microscopic hemauria
  0.19 21
• Hematuria categories
• Life-threatening
• Significant requiring treatment
• Significant requiring observation
• Insignificant

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Risk Factors for Significant Diseasein Patients
with Microscopic Hematuria

• Smoking history
• Occupational exposure to chemicals or dyes
• (benzenes or aromatic amines)
• History of gross hematuria
• Age gt40 years
• History of urologic disorder or disease
• History of irritative voiding symptoms
• History of urinary tract infection
• Analgesic abuse
• History of pelvic irradiation

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Initial Evaluation of Asymptomatic microscopic
Hematuria

• Significant proteinuria total protein excretion
  of gt 1g/day or gt0.5g/day
• Red cell casts pathognomonic for glomerular
  bleeding
• gt 80 dysmorphic urinary red blood cell
  variation in size and shape red blood cell,
  glomerular in origin

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Primary renal diseases

• Glomerular disease
• Lupus erythematosus
• Vasculitis
• Malignancy
• Infection (hepatitis, endocarditis)
• Glomerulonephritis
• Interstitial renal diseases drug induced

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Initial Evaluation of Asymptomatic microscopic
Hematuria
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Urologic Evaluation of Asymptomatic Microscopic
HematuriaLow Risk patient
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Urologic Evaluation of Asymptomatic Microscopic
Hematuria High Risk patient
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Advances in the management of gout and
hyperuricaemia

• Scand j Rheumatol 200635251-260

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Introduction

• Acute gouty arthritis one of the most painful
  experiences
• Management
• Terminate the acute attack
• Preventing the recurrence of acute attacks
• Reverse the complications of diseases
• Eliminating sodium urate crystals deposited in
  the joints and kidneys
• Preventing or reversing the commonly associated
  conditions of hypertriglyceridaemia, obesity,
  hypertension, alcoholism

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Acute gouty arthritis

• Management
• Past
• Warm the joint to dissolve the crystals
• Joint was pulled and bent to mobilize
• Present time
• Ice pack with pretreat with anti-inflammatory
  agents
• Medication dont correct hyperuricaemia
• NSAID
• Colchicine
• Corticosteroid preparation
• Corticotrophin (ACTH)
• The sooner the better

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Acute gouty arthritis NSAID

• Preferred over colchicine more favourable
  side-effect profile, in creased duration of
  action
• Take until symptoms resolve completely
• COX1 COX2
• Indomethacin 100mg ? 50mg q6h
• Ibuprofen
• Naproxen sodium 500mg q8-12h
• Diclofenac 50mg q8h
• COX2
• Celecoxib
• Etoricoxib

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Acute gouty arthritis NSAID

• Adverse effect
• Nausea
• Diarrhea
• Headaches
• Dyspepsia
• Confusion
• Fluid retention
• Increase BP
• Elevation Cr
• Increase the risk of MI

• Relative Contraindication
• CHF
• Renal insufficiency
• Active peptic ulcer disease
• GI bleeding
• Concurrent aspirin
• ? Add Proton pump inhibitors

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Acute gouty arthritis Colchicine

• Direct against factors prominent in
  crystal-induced inflammation
• Most effective first 10 12 hours of attack
• Dosage
• Oral 0.6mg q1-2 1.0mg ?0.5mg q2-6h 1.0mg tid
  until
• Joint symptoms resolve
• Pt taken 10 doses without relief
• GI side effects develop

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Acute gouty arthritis Colchicine

• Low therapeutic index
• Therapeutic plasma concentration
• 0.5 3.0 ng/ml
• Toxic dosage 3.0ng/ml
• Side effect GI
• Increase peristalsis
• Abdominal discomfort
• N/V
• Diarrhea

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Acute gouty arthritis Colchicine

• Careful use
• Elderly
• Renal insufficiency
• Axonal neuromyopathy ?rhabdomyolysis with renal
  failure
• Liver disease
• Systolic congestive heart failure

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Acute gouty arthritis Corticosteroids

• For refractory gout, intolerant of NSAIDs or
  colchicine
• Relatively poor drug for acute gout
• Use in higher doses for acute gout 20 60 mg
  /day
• Route
• IV methylprednisolone 125mg/day
• IM triamcinolone diacetate 60mg ,
  methylprednisoloneacetate 40mg repeated q1 4 D
• Intra-articular route

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Acute gouty arthritis Corticosteroids

• Rebound flare-up
• Gradually tapered
• Side effect
• Fluid retention
• Electrolyte shifts
• Glucose intolerance
• DM
• Elevated BP
• Increased susceptibility to infection

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Acute gouty arthritis ACTH

• IM or Gel (25 80 IU)
• More effective than corticosteroids
• Induce endogenous corticosteroid production by
  the adrenal glands
• Interferes with the acute inflammatory response
  through local activation of melanocortin
  receptor-3

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Preventing further attacks

• Untreated gout with urate-lowering drug
• 62 recurrence within 1 yr
• 78 recurrence by 2 yr
• 89 by 5 yr
• Enlarging tophi ?destructive inflammatory
  response ? destroy cartilage and bone

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Preventing further attacks

• Treatment goal
• Serum urate level lt 6.8mg/dl
• Optimal lt5.0 mg/dl
• Urate-lowering therapy
• Timing After first attack of the acute gouty
  arthritis controversial
• Use up to 2 to 3 weeks after acute gouty
  arthritis flare

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Preventing further attacks

• Urate-lowering therapy
• Might precipitate an acute attack
• Start with low dose, increase dose every 12 wk
• Add low dose of colchicine or NSAIDs daily for
  prophylactic agents 85
• several weeks prior to starting the
  urate-lowering agent for a period of at least 3
  months
• Maintain until target serum urate levellt5.0mg/dl

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Control of hyperuricaemia

• Urate-lowering medications lifelong usage
• Target serum urate level lt6.8mg/dl
• Optimal serum urate levellt5.0mg/dl
• Medication
• Uricosuric agents
• Xanthine oxidase inhibitors

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Control of hyperuricaemia

• Uricosuric Agents
• Indication
• lt60y/o,
• CCrgt80mL/min,
• 24hr urinary uric acid excretion lt800mg,
• (-) renal stone hx
• Alkalinization of the urine decrease the risk
  of forming uric acid calculi

Probenecid Sulfinpyrazone
Maintenance dosage 500mg 3g /day( Bid/tid) 300 400mg /day(tid/qid)
SE Rash, GI sym, hypersensitivity
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Control of hyperuricaemia

• Xanthine oxidase inhibitors
• Indication
• larger quantities of urinary uric acid excretion
• Hx of nephrolithiasis
• Failure of uricosuric agent use
• Allopurinol
• 50mg 800mg /day
• Effective in renal failure? dosage adjust
• 50mg 100mg/day ? increased dosage accordingly

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Ancillary factors

• Alcohol consumption
• Beer largest risk
• Moderate wine drinking did not increase the risk
• Diet
• Dietary Purine restriction lower urate level
  only 6mmol/L
• Restricts calories and CHO, increase protein and
  unsaturated substantial reductions in urate level

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Ancillary factors

• Reduction of body weight and regular physical
  exercise
• Hyper TG fenofibrate ( uricosuric effects)
• Hypertension
• Thiazides rise urate levels
• Angiotensin-receptor-blocking agent losartan
  lower urate level

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Asymptomatic hyperuricaemia

• High serum urate levels (-) symptoms
• Not indication for specific urate-lowering drug
  therapy
• Cause should be determined
• Hyperuricaemia V.S. renal V.S. Cadiovascular
  disease
• Urate independent risk factor for cardiovascular
  mortality (NHANES I,16yrs)
• Insulin resistance V.S. hyperuricaemia
• Management
• Non-pharmacological dietary
• Lifestyle modifications

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The End

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