hey Paul I'm excited to tell you that we are launching a curbsiders patreon have you heard about this I I did because I worked with you but tell me more about it all right Paul well we want to be able to keep offering this great free content and we're doing things like upgrading our website we offer transcripts now for episodes recording new seasons of our mini-series teach and addiction medicine the digest is growing at staff and Paul now we're on video people could see us as we're talking right here what a treat for our listeners that's right so with cashlac admitting privileges they're going to get all episodes ad free that's the whole back catalog plus future episodes and twice monthly there's gonna be bonus episodes where me and you recap a show and answer some listener questions so people should sign up today at patreon.com curbsiders and uh you get a whole lot of more of Paul America's PCP all right Paul this this part is going to be humiliating but uh as always Paul I wanted to start off with something and uh Dr fine I apologize for this up front but uh uh Paul you know I I was looking at my urine the other day to see to see if I was if I was healthy or not and you know the conclusion no Paul it was unclear um two laps by the way for the decision thank you the curbside podcast is for entertainment education and information purposes only and the topics discussed should not be used or prevent any diseases or conditions for the more they use the same expressed on this podcast and affiliate Outreach programs if indeed there are any in fact there are none pretty much we aren't responsible you should always do your own homework [Music] this is ay podcast so welcome back to the curbsiders I'm Dr Matthew Frank wado here with my great friend Dr Paul Nelson Williams Paul how how are things going great I'm good nervous um but glad to actually be doing a live event so nice to everyone here thank you so much and uh Paul would you remind it people what is it exactly that we do on the curbside is of course we're going to talk to our great guest Dr Derek fine about hematuria but what is it that we generally do on this show sure as a reminder we are the internal medicine podcast we use expert interviews from your clinical pearls and practice changing knowledge and we have the great doctor Derek fine with us to talk us through some of the evaluation for hematuria and I'll let you tell us a little bit about our guest today all right so Dr Derek fine he is self-described as a Hopkins lifer he's been there since medical school he uh was recently Clinical Director of nephrology here he's a professor of medicine he has a focus on HIV kidney disease and lupus and you know without that part I think we should just jump right into this and uh maybe get to know our guests a little bit what do you think absolutely okay so Derek first question uh an easy question I think what is a hobby that you have outside of medicine then we're going to start you know ramping it up uh after that so I don't know if any major Hobbies where I do something a lot I would say it changes over time my big hobby is my family I work hard I love my work so it's sort of my hobby and I get pleasure out of my work I kind of don't feel I need a whole lot extra but um recently I've I've with YouTube I've gotten into chess again I was a ever chess player as a kid and my son and I watch YouTube videos and we're trying to learn some new openings so and we have like a Wednesday night call where we discuss some chess games and things so I'd say that's become a little hobby that's a good game and the YouTube videos you're watching are these chess matches or tutorials or what what does this entail exactly yeah I sort of thank God I didn't have YouTube as a teenager because I actually would have probably just watched videos all day it's unbelievable what's out there um people who are Masters teaching you how to do things and uh you know strategies and then just watching games the world championships and so it's nice to to just watch the games and have commentary at the side and the computer telling you who's going to win and it's kind of fun we got a chess board for Christmas and I made the mistake of my wife and I could beat the kids pretty handily because they had never played it even though I hadn't played in a long time and then I like made the mistake of showing my sons that there's like different openings in that YouTube can teach you them and now like my 10 year old can beat everybody in the house and he's like because he's very tricky to begin with and now like he found Jess is a tricky game so that's good yeah um Paul anything you want to ask before we get to the case sure and I'd love to ask any favorite advice or feedback that you've received or given during your career or training I think there's a couple things that stand out um one is my father always told me you know Derek find something that you're passionate about and you'll become good at it I thought that was good advice I sometimes don't follow that and then I get in trouble um and then my former Chief once gave he actually gave this Grand rounds Paul schill and he said you know pick up the phone and the advice was when someone calls you pick up the phone because you never know what's on the other side that could sort of change your life and I think or change a patient's life and and I think that's come true many times all right terrific advice so Paul I think let's let's get to a case because we I want to spend plenty of time on the clinical aspect of this so why don't you read us a case from everyone's favorite Hospital which is a real place at least in our hearts our cash back Memorial so our case from cash like Hospital we're going to talk about Mr Jones he's a 40 year old gentleman who follows with you for Primary Care um you being us collectively his past history is noteworthy for high blood pressure he's on five milligrams of amlodipine he has obesity with the body mass index of 31 has some tobacco use you're a little bit surprised to see him since he just saw about four months ago when your visits are mostly consist of counseling in yearly follow-up um at that last visit he noted some low back pain so you recommended NSAIDs because that's what we do um maybe we forgot to give a duration or limitation in any case he shares with you that he's been seeing blood in his urine for the past two weeks and he is understandably alarmed by this so Derek before we get too deep into the case and how you even sort of conceptualize the workup of hematuria I'd like to ask um we like to start with definitions and hopefully we can agree that hematuria is blood in the urine but is there anything else that we should be thinking about and I guess other I would follow how much blood do you have to see before you even we start to be concerned or so yeah let's just start tell us about hematuria that's why I'm asking so I think of the time the definitions change but currently most believe that three or more raid cells in the urine is is hematuria and one time of three is enough to prompt a workup for hematuria a grossey mature is just visible hematuria yeah I think microscopic hematuria is one of those Banes of if you're well any doctor really gen but usually the general internist it's like our responsibility to follow it up everyone else can be like oh yeah we saw some hematuria tell your PCP about it right so uh I'm I'm curious to to get your advice on this but what else what else do we need to know about the history here we've given you some that he's he's chewing down NSAIDs but what else do you want to know about Mr Jones so so usually I start off you know I'm gonna get the call can you see this patient and then I'm gonna say I think you need to call the urologist okay that most of the calls again are actually Urology and then it turns out 80 or more of of the time if there's hematuria it's it's not a Nephrology issue and I guess we'll get into when it becomes a Nephrology issue and hopefully someone's already done some work up that'll say actually no you need to see this patient because this is is one of your problems not a Urologic one so that's the way I'm sort of first looking at it am I dealing with something that's neurological nephrologic um if it's grossly mature it's always pretty serious and much more likely to be cancer but I always worry about malignancy is really the first thing I think of could this be malignancy and then obviously as a nephrologist I'm going to think is it something that has to do with the glamoronephritis or something up in the kidney I think a lot of the time you're Guided by symptoms or if someone says I burn when it burns when I pee and I've got hematuria it's easy right so if they come with symptoms that very quickly guides you down a pathway that's going to probably get you to the diagnosis pretty quickly so most of the time it's asymptomatic and that's the bane of your existence right it's not the same but yes it's the it's the asymptomatic stuff where it's like where did this come from and okay this patient could have cancer and how do I get to at least rule that out and and then move on to the other diagnoses that are maybe less you know less concerning than a cancer although glomerular nephrite is pretty pretty concerning too and we're talking a little bit before we started about sort of I know I think some of the Urology guidelines differentiate between higher risk and low risk and high risk I think being high risk malignancy so in the patient's history what factor is going to make you think oh gosh I should really be worried about cancer I know obviously anyone can have malignancy but what what risk factors traditionally would infer cancer risk in this patient population so the first thing is if you have grocery mature and they're clots it's much more likely Urologic and those patients should really get a serious Urologic workout for malignancy the things um you know older patients and it depends on how old you are what old is but some places say older than 35 is enough to consider high risk the American neurological association their guideline has different age groups I think it's sometimes easier just to sort of have one cut off um I think 35 40 is probably a reasonable cut of say above that I'm a little more worried about building and see smokers and people with certain environmental exposures pains dies um I don't know how prevalent those are but you can ask and if someone says yeah I'd do hair dye all the time maybe they're using some some chemical um the aristocic acid which is in some herbs um very uncommon now but but there were some outbreaks of kidney failure from that that could cause bladder cancer um so I'm going to get some of these exposures and you know certainly if there's grocery material that immediately puts you high risk um age old and 35 smoking history those are the easy ones that are going to take me down the path of I'm going to be having more aggressive Urologic workup if it's not nephrologic oh you looked like you were gonna ask something no that's just my face um it's always lightly confused I any any physical symptoms so you mentioned clots being particularly concerning I feel like we traditionally ask about back pain or flying pain specifically anything any any other sort of localizing symptoms before we sort of move deeper into our evaluation well if we're thinking certainly on the Urologic side anything that might suggest you know pain or obstruction um flank pain bladder pain to Syria the the usual symptoms you would think about you know if you're thinking about UTIs kidney stones you know system bleeding in the kidney and when it comes to the diseases I take care of I'm looking for systemic symptoms so if I'm thinking things like lupus vasculitis I'm looking at primary renal type syndromes thinking the anchovasculars GBM disease if there's I see my favorite rheumatologist in the room you taught me most Rheumatology then I know um you know I'm gonna go head to toe you know this is one of a red eye and pain when they look at the light and I'm thinking uvi's there's something systemic going on do they have a rash they have a malar rash ulcers sort of thinking through the lupus type of um rashes palpable purpura moving the water vasculitis so I think a good exam is is going to at least guide you and then lab testing will guide you um and then you know kidney box you don't know it's going to be the way it's going to go I wanted to share an anecdote that might set up the next part of this Paul so what one uh we had a sponsor a while back that was like sending us a lot of produce I don't know if you remember that and they were sending it was like it was one of those like slightly imperfect Foods uh ones I don't think I got those okay anyway I should have looped you in on that one but uh they were for some reason they were sending me like bunches and bunches of Beats and I have like this I was raised like not to waste anything so I was eating a lot of beets and it was horrific like beat Yuri Paul seems to be a real thing so I'd like to talk about other things that can cause baby pseudo gross hematuria and uh thank sorry about the too much information everybody but beat urea I can attest it's a real thing so so the first time I saw a case of beturia was in high school so I grew up in South Africa and there's certain Rivers you were told don't swim in those Rivers because there could be bilhousie and we kind of knew that people can cause blood in the urine so one of my high school friends got red urine and we all thought he had bulhas yeah and he said no I just ate too many beats so that was actually the first time I mean I have a kid who gets beaturia so there's something genetic not all people will get it maybe if you eat a you know bucketful you'll get it got to be honest it kind of turned me off to eating beets quite colorful and while we're on the topic of pseudohe Materia because I think this is what we're we don't have to focus in just on Beats even though they're level to talk about and apparently we're sponsored in some way by them any I do have some medications behind us but any other any other potential exposures that you think about so the um Rifampin would be one actually had a lupus patient recently who had a a positive TB test and needed immunosuppression they put on Rifampin and a urine turned red and everyone thought her lupus was out of control turned out was Rifampin sort of more an orangey red color um Pyridium twice twice up there so it must be the most important really important but I have seen Pyridium although I don't know how often people are using maybe you guys use Pyridium but yeah patients can buy it over the counter so a lot of patients will call me and tell me they're already taking it am I am I mistaken about that isn't that what the I think there's some over-the-counter for like people that have mbci I think it has iridium in it and they they're you know someone does have weird colored urine I'm I'm looking at their drugs because they are various colors you might see from propofol apparently cause all different colors but I would hope that we know for a patient was doing outpatient propofol um all right what about I feel like oftentimes hematuria might be minimized in the setting of anticoagulation so if someone is taking Warfarin or a doact is is should we should we be reassured by that should be alarmed by that what does that tell us if anything no there's no evidence that anticoagulation should cause hematuria so if you have hemature and anticoagulation you have to work it up and that person might be lucky actually because it unmasked something that was early so they should undergo the same workup you know unless there's obvious trauma or something that you can attribute that you maturity to like any other patient they should be worked up yeah I seem to have I don't know if you've had this patient in your practice but I have I've had at least like three or four old men that either they said they went on a long like bumpy car ride or a cycle ride and then they came with hematuria or they held it for a really really long time and then they said they had human Sharia so I it was hard to even convince them to get a work up because they're like oh I think I know why this happened I was like I don't know if that's a thing like I so exercise it in Juicy maturity is a real thing um I've seen it a few times people run a marathon and if it's smushing the red cells in the foot and then you get hemoglobin area um or if it's shaking the bladder around yeah but but very well described if someone says to me look I I just ran a marathon I have hematuria I'm first going to check the CK actually but you're right um the other cause of uh pigment in the in the urine but um I would probably not do a CT immediately on a patient like that Paul should we go to the next part of the case we should all right so do we a little bit more history Mr Jones tells us he's been having intermittent hematuria for about the past two weeks and then it has progressed to be fairly consistent so now he's having it almost all the time he's without dysuria he's not having flank pain there are no fevers or chills to make us think this might be a cystitis he has no history of kidney stones to his knowledge he denies new sexual partners he's been without recent strenuous exercise so unfortunately no marathons for Mr Jones um other than some lumbar back pain which is chronic and he does say well I did have a cold a couple weeks back he otherwise feels reasonably well so we have a little bit more history maybe not as thorough as we could have taken um considering we think about rheumatologic stuff but does any of this help at all does this any of this start to form a differential for you not yet I think I'd need some Labs at this point um he did take non-steroidals um if you have chronic long-term non-steroids you can get petlery necrosis he's got some back pain um back pain could be kidney pain it depends where it is um and you know could have a stone I guess but bilateral you know sort of lower back pain generally that's not the case so at this point I'm thinking I need some more testing I need to focus it a little um and figure out if I'm actually dealing with something that's something a nephrologist should take care of or not all right let's say we do an examination because we are excellent doctors uh he is normal intensive in the office he does not have any obvious rashes or a lesions this cardiac exam is not exciting as long as you're clear to auscultation no lower extremi edema you check a point of care your analysis in the office and it is indeed cloudy it is red but we do the point of carrier analysis there is indeed blood we can look see it just looking at it but the dipstick shows three plus blood Trace protein no glucose pH is 6.5 the specific gravity is 1.022 no ketones and neuroblinogen is 0.2 milligrams per deciliter so one of the the Frameworks that I've heard about thinking about hematuria and what you've alluded to is sort of separating glomerular from non-glomerular causes so as we we have this point of carrier analysis does that change anything for you and then I guess where would you go from here so the problem with your analysis is that you're in protein is not accurate enough so Trace protein could be 500 milligrams could be zero could be two grams um it really depends on the concentration of the urine which here is 1.022 relatively concentrated on the specific gravity um it's helpful it's not three plus protein certainly if it's three plus I believe it if it's zero it's probably not a lot but in between the the your analysis isn't accurate enough so I'm going to need to get a qualification with you know albuminario proteinuriate direct measurement to get me included it's maybe reassuring I just not very comfortable with the trace protein as a nephrologist um so I'm not yet ready to say this is definitely a urologist's problem um so I think we need a little more information then we have just on this your analysis but clearly there's there's blood in here and we need to move to the next next level can you speak to the the difference between the urine protein creatinine ratio and the urine albumin creatinine ratio and the I guess the reliability of either those do you have because as a first test do you recommend one or the other I mean traditionally I've said just get a urine protein quinine ratio we know that you're in albumin somewhere around 60 of the protein creatine ratio albumin is probably a little more sensitive and more accurate um the proteinuria tends to be less accurate much lower levels um I think the lb manure is going to be helpful and it's going to tell you if there's glomerular protein and so I think over the years I've leaned more towards checking albino although I frequently get both because I called the poor man's u-pep okay right because if you've got a big difference between the two I'm thinking okay this is going to tell me there's tubular proteins in here and I'm sort of going down a different path with that so I don't think there's a for me I often will get both because they'll come back quickly and the u-pep may take a while but I think the lb manure will give you glomerular protein and nowadays if you're looking at chronic kidney disease and risk stratification the album malaria is a much better measure so I think most nephrologists now at least chronically are following that lab as well but generally you're going to get the same information as a screening test and it's going to be better than a dipstick okay and I I'd like to talk a little bit more about the urinalysis that we're actually um joking before this presentation we typically don't see cast reported but I feel like there's lots of parts of your analysis that I just cheerfully ignore and just hope that they're not actually ever gonna become relevant to things like crystals um I just I'd rather just not know um so I guess could you sort of talk us a little bit from some of the specifics about the urinalysis that might be particularly helpful so you mentioned obviously the protein albumin stuff would be very useful but are there other things that I should not be ignoring in terms of your analysis that might be helpful or help guide or differential at all so a couple of points I'll make and some for the audience here is so for example our your analysis in our lab will report the number of cells per ML and then it'll report per high power field if you do the math they're just dividing the number of cells per ml by about five I couldn't figure out somewhere between 5.5 and 5.6 and they may be factoring the specific gravity you get to but no one's actually looking anymore um it's just automated so don't think someone looked at that urine now there may be other places that do look but that takes like a whole two people to to look at urines all day if you're in a big hospital and I think that that's very costly so most of it is just done automated with an automated measure so you can't trust that someone's ever looked at a urine that you sent to a lab I don't think labcorp's got someone sitting in a lab looking at you and but maybe they do that someone will like yeah it's okay it's important because it it you think someone's looked and they haven't and and I've found in my own experience the lab will I've never seen a lab pick up a red tail cast and so this week I had a patient in the hospital with a that they said they saw granular cancer I thought that was really impressive except we looked and they were Red Cell cast so you can't trust the lab what is helpful is raid cells right there no red cells you probably don't have a red cell cast and you can move on if there are red cells doesn't really help you unless you look at it yourself and that's often difficult for folks so if you see red cells just assume they might be casts in there because the lab's not going to pick them up yeah once in a while on a urinalysis I'll see Highland casts or granular cast reported maybe occasionally some like calcium oxalate crystals like Paul said I I wish they wouldn't do it all that all that information but I see what I do yeah so the crystals are non-specific you know everyone is I don't know we frequently see you oxalate cast you know I mean sorry Chelsea Crystal look quite common almond um you know I think you just look at that in the context if someone had a kidney stone and they have that well they probably have calcium oxalate stones or at least there's calcium oxide in the urine I don't also don't make a lot of the the crystals um usually we're seeing them when the specific gravity is really high because that's when things precipitate in the urine so more often they're not they're a clue that this is just very concentrated urine and you'll see that because you probably ordered a protein Cranium ratio at the same time and the creatinine is really high in the urine so they're it's probably based on that mostly in Highland cast the exact same thing they're going to just be telling you that this is concentrated urine should we give him some more studies here Paul we should I do want to ask and I I don't know if you can speak this at all I stumbled across the three tube tests in a couple of papers as I Was preparing for this and it's not something I'd ever heard about is that anything that we're actually doing in practicality urologists might be this is where you massage the prostate and you get urine before during and afterwards something like that um I remember back in med school which is a long time ago for me a urologist telling me they don't do them even this was 30 years ago so they probably do still do them but I would defer to a urologist which begs the question what was Paul Reed just an ancient textbook um all right so we get some urine micro back from the lab zero to five wbc's RBC is greater than 20 uh epithelial cells 0 to 10 some calcium oxy crystals of course a few bacteria without growth So based on this information uh we'll say Matt decides that Mr Jones's hematuria is likely non-glomerular and refers the patient to Nephrology or not Nephrology Urology so in your your experience recognizing that you know Nephrology is your world but since you're an or expert in hematuria what does the Urologic look like in terms of working something like this up so for convince this is non-glomerular bleeding we send the patient Urology where might they go from here and what would the guidelines tell us to do and and often the the intern is starting to work up anyway you know it doesn't get to Urology until you've done some of these studies and well they show up in my clinic and I say okay I'm going to do the urologist a favor and get the work I've done before they see Urology so sort of what is that work up and I think that does depend somewhat on the risk um so if you look at some sort of basic if you want to just keep it simple I've got risk factors I'm older than 35 I'm a smoker maybe I've got exposures um it's grossy maturia I'm going to start with imaging um and generally the best test is a CT with contrast it's CT eurography it's going to pick up masses it's going to pick up tumors it's going to pick up Stones sorry tumors and mass or the same thing sorry cysts masses and Stones you'll pick those all up and you'll see um anatomical abnormalities um you'll see things along the the ureters and if you go down into the pelvis you may even see masses in the bladder obviously lateral thickening things that might clear you in but the CT is the best study the Urology recommendation would say if it's a low risk patient so they have this intermediate risk where you again where you could do an ultrasound and then the low risk if you want you get an ultrasound are generally going to get an ultrasound on everybody who's got hematuria if I really don't have a good alternative explanation for that hematuria and then if that Imaging is negative they're going to need a cystoscopy because bladder cancers are not uncommon and that's where the money is now I'll get asked something about you cytopathology my view on that is if the cytopathology is positive they're going to get a sister and if it's negative I'm still going to get a system so and and it's not in the guidelines either but the urologist will get cytopathology and by the time they see neurologist there's good reasons why they would be doing that but I'd leave that to their evaluation yeah it's not a test I order but I at least the Urology groups at Cash lack seem to to order that test fairly often yeah Paul did you have a slide of of the workup of easy to read slide I do I do yeah I thought so for reference this is an up to date I find it very helpful so if you don't have um if you don't absorb this talk I think you can just sort of look and basically I think the important thing here let me just point I think there's referral over here somewhere um so that's probably the most useful thing um if you do go up to date the two biggest boxes in there are the ones that you need to look at the wrist probably you can work out yourself you probably know it already and my role on this show and in life has always been sort of asked the really obvious questions but truly I don't I'm asking because I I'm um lightly confused with ultrasonography what are we looking for specifically I feel like there's so much stuff that it might potentially miss like what are the things we're potentially gonna catch with ultrasonography if we're going to start with that so the easy ones are assists if the messes are big enough you'll you'll see those you'll see hydronephrosis um if there's obstruction you possibly see a stone you won't always see a stone because it could be low um you'll see anatomical abnormalities you'll see if someone has two kidneys that's that's fun it's a good place to start the other referral uh one kidney where did that come from um so it gives you some reason the ultrasounds these days have good definition of the vascular arterial venous flow um but the resolution on a CT is is far greater you're going to pick up the small cancers that you may want to know about now uh you're going to pick up you know the the system hemorrhagic versus not and things like that so Sony CT is better energy and ultrasound's a good screen a low low risk patient you just want to make sure there's nothing major going on it it'll get you helpful information and easy to do and no radiation exposure right is is there a big difference between for you the patient with uh Ace like asymptomatic like microscopic hematuria and gross hematuria as far as like the the Urologic the Imaging work up the cystoscopy so having grocery material immediately puts you in that high risk category so you're going to get the CT in the system um from a general standpoint grocery material is probably more serious in in the nephrologic world too because it means more of your your glomerular capillaries are bleeding right so question I often ask Med students is how come you can have a patient with hematuria but no proteinuri right like red cells are way bigger than protein and it's just when you're premature it's actually bleeding you know the little calories that are popped and so if you see a lot of blood it means a lot of calories have popped and so it's generally going to signify more serious disease so yeah it does it does up the anti if I'm if I'm seeing gross immature yeah so the ultimate workup is pretty much the same same workout though but it's just your your more heightened you're more Vigilant about the person with gross human cherry and more worried for something more yeah I might make a phone call instead of just sending some labs and and putting it in the computer and waiting six weeks for them to be seen yeah okay so let's let's say for the for now because we're gonna get to the glomerular bleeding obviously but um while we're here in your logic categories let's say we've done all our due diligence they've gotten the cystoscopy and they've got Imaging and all this stuff comes back Stone Cold normal for the most part so no cancers sure that's good news but the patient's still peeing blood which I I've had we I've had cases like this so where what's some of the more exotic stuff that we would go from here if we if we're still thinking this is non-glomerular but we need to figure them out why else might be having grocery material right so firstly there are some nephrologic like the mild IGA nephropathy or there's a disease called thin Basin membrane disease you can argue if it's if it's a disease or not but they can present with hemature without proteinuria so once you've done all your work up you circled back to those type of diseases they generally aren't causing a well they can cause persistent immature but not gross immaturia it with those diseases um so if if I've got someone who's got recurrent growth immature I've certainly had those sort of patients what sort of things am I thinking of um papillary necrosis um I might check a sickle screen in in the appropriate patient um because there's susceptibility there um I might think of vascular abnormalities so looking at doing angiography the CT or an actual angiogram if someone's really got grossy material um you know I've there are people that we never make a diagnosis generally the grossly mature patients we're figuring it out the the asymptomatic micromaterial one episode or two episodes probably half the time you you never really find anything but with the grocery matures I'm probably gonna keep looking at for things and and avms and battery necrosis are going to start showing up on my my list of of considerations so if you still don't find anything I think this comes up a lot too the patient with one episode of grossey Materia and you don't find anything on the workup or with asymptomatic hematuria um how often do you need to follow it up like if it if it happens again and or if it just doesn't happen again but they had that one incidence like how long do we have to follow this and worry about it right so the AOA guidelines and the low risk patients say you can check it again in a year I mean I I like six month intervals because a year later I've forgotten about everything but I would say six to 12 months you want to check again and you know if it is recurrent then you you sort of move to the more serious work up if it's someone with asymptomatic or you didn't do a big one yeah and so you might follow this just annually um as far as I saw some maybe some writing about like if you did the whole workup and you didn't find anything maybe three to five years later you might even do another cystoscopy and another imaging test if they keep having it I don't I don't think I've had a patient like that maybe I'm missing them but that seems like that's not going to be a common thing you need to do yeah it's not going to be very common and certainly if they've Recon grocery material there's something going on there yeah I think I have one patient with confirmed thin basement membrane disease and she has persistent microscopic hematuria and we're we cheerfully just follow that she's doing fine right so that would be and then the question with those people is do biopsy them and they don't really need biopsies but sometimes it gives everyone a piece of mind that you've ruled that out yeah we all sleep better the next day all right Paul what's next we have more more of a case here we do so oopsy doodle is literally written in the script here because I'm an excellent educator while our patient is at the Urology appointment the urine protein comes back and the patient has severe albuminuria so we look at the part of the urinalysis that we usually ignore and the lab notes erythrocyte casts so we call the patient we leave a frantic voicemails the patient's undergoing cystoscopy saying hey I actually think that you should see a nephrologist instead so Mr Jones goes to Nephrology completely bewildered um someone angry just primary care doctor so I might ask so now now our patient is squaring your hands now we have a patient who has grossing Materia but now albuminuria so we're much more solidly in glomerular bleeding so what what might your workup look like and how how might you address this particular patient now that he's landed on your doorstep so I assume woke up much of the worker was done earlier so the most important is what's is the albumin in the urine and what's my serum cranial what's my GFR right if I've got a creatinine that's going up and I'm not obstructed I'm really worried about a a renal process right proteinuria is going to glue me in and then systemic symptoms hypertension this patient had hypertension was new generally that's not going to end with your Urologic diseases um and those are the big ones that they're going to sort of very quickly lead me down the Nephrology Pathways you can make both appointments at once and but we're really looking at kidney Funk if the cranium is going up and then the question is they're rapidly Progressive glomerulonephritis that's going to be obviously a the most serious of the the nephrologic uh issues and the differential is pretty similar if it's rapidly Progressive or not you still go through the same diseases it's just more likely some than others if it's rapidly Progressive yeah so this person this would be somebody so if we're the primary care we have somebody with uh hypertension albuminuria new gross hematuria we should be very worried and get them to you quickly especially if the crat needs Rising yeah no I would say that it requires urgent evaluation if the credit means Rising you know if they've had hemature for six months and the credit means the same as it was six months earlier they probably don't need to see me tomorrow right um but but certainly these are serious diseases that can if you don't catch them early you you lose kidney so you know time is kidney yeah and so they they do need a very uh rapid evaluation you want to get into the workup for yeah no I feel like we we could at least even help if we were better doctors we would we would have done a fairly thorough work before sending them to you so I guess I'd like you to sort of if you just talk us through what what reasonable Baseline Labs you might check in this patient and I I think some of this might need your order them because it's an up-to-date but if you could even sort of talk us through what you're looking for with these things specifically that would also be really helpful right so you know I think the the way to approach it is say what could this patient have and and this would really apply to our rapidly Progressive gns or just gns in general so you know hematuria with proteinuria I've probably got it I'm in the glomerular nephritis realm but you know we do see him mature with proteinuri in our sort of nephrotic type of disease as well which um are probably going to be possessed somewhat with with these Labs as well so if I'm thinking glomerular nephritis I'm the way that you're going to actually divide them up that makes a little bit easier otherwise it just is like a blur like all these diseases I'm going to send these labs and hopefully I hit it right um so I think I've sort of three big groups right the one is the easiest one anti-gbm um and if it involves the lung we call good pastures it doesn't involve the lung is just kidney we call anti-gbm disease and these diagnoses are all made on immunofluorescence really like when you start putting them in the three categories so I've got my anti-gbm disease I've got my anchor gns or my Palestinian right when you do the immuno operations there's not a lot of immuno there isn't there shouldn't be antibodies there and then we have our immune complex gns right that's your big three families the anti-gbns are usually pretty easy to know because if they found over rapidly Progressive renal failure it's probably not that throw that away um anchor gns um contrary to popular belief they don't have to be rapidly Progressive we have many patients with you know anti-mpo antibodies and they've been around for a year and they kind of didn't get blown off but it was like well I don't think I think it's just a bystander and the cranium's rising slowly you do biopsy and yeah there's one Crescent not it's not a full moon and chrysantic GN um so we can't rule them out by a non-rapidly progressive disease and that's why that the workup tends to be similar for Rapid versus non-rapid but then I've got my Anchorage ends and fairly simply I'm going to send off anchor antibodies which is really anti-npo and anti-pr3 antibodies and think about if you have both presents the same time think about drug type of induced anchor gns and then my immune complex gns which are that's where you get a whole list and and one way then to divide that up is looking at complement levels and um my low compliments versus normal complement disease and it's not that hard to to remember because when we have hyper complementinia they're really just three big families one is my infection related gns um one is lupus and then one is the sort of this mpgn family which you see with things like hep C you can see the monologue these there's a whole differential diagnosis for for mpgn but that's like the big the big three they can have normal compliments you've always got to include them anyway and then on the normal complement immune complex I'm thinking IGA Inox online purple and that's sort of that's really it for the you're going to hit it 90 of the time you're going to get your diagnosis in that group and then there's a whole lot of mimickers um of of an RPG and so HIV nephropathy can give you a rapid loss of kidney function generally no hematuria though so it may not make it to this lecture um hep C related disease is usually on the list it's an MPG and generally or cryoglobulins can can also cause renal failure the other mimickers would be um myeloma you have rapid renal failure again you should not see immature but people with myeloma can there's a whole lot of other diseases for another day that monotronal demography is associated with their 10 different renal diseases it's not always just the amyloid or the casts um Scleroderma can cause you know your thrombic micro angiopathy um would also give you rapidly Progressive renal failure and there you're looking at you know someone's got a hemolytic anemia thrombocypenia so they're the sort of mimicker groups that don't quite fit into my gns but can look very similar so we have to work all those up as well but so the basic here is the C3 C4 is going to narrow you down to some of those hyper complementing diseases as post-infectious GN Ana anti-double-stranded DNA generally lupus anchors um our vasculitis and drug-induced um anti-gbm as I said clinically usually pretty obvious HIV for HIV in a property but HIV can also cause immune complex disease hippie hip C hippie usually we're getting membranous nephropathy not usually causing a GN but it can our s-pep and free light chains is you know looking for monoclonomyopathies um and the various diseases that can be related so that's sort of knowing what you're looking for makes a lot easier for me to understand why I'm getting those those particular tests so sorry that's a really nice way to break it down I I like that a lot I feel like I don't know about you Matt you don't have to admit this but I will just because I'm used to him living yourself in the show but like I feel like compliments fall solidly in the same rhombus crystals where it's one of those things where like I fire it off I'm like I hope that comes back normal um so but now I actually have a framework so that's really helpful yeah this I I think I learned that I think I learned this kind of stuff for step one and then like immediately forgot it I'll never have to worry about that again so just just keep in mind normal compliments you can still see all these diseases so for example in post-infectures only 75 of folks have low complement lupus depends you know membranous lupus is 50 and proliferative is 90 low complement so negative doesn't rule it out positive is really helpful this is going to take you down a different pathway it sounds like we're going to need your help regardless once we get to this point but it's nice to have some sense of what's going on I think it inspires confidence in the patient when they you know when you have some at least passing familiarity with what what's what what is happening to them and the workup that's happening so thank you for that that's good you're gonna make you're gonna make Paul and I look like competent primary care doctors and the audience as well uh Paul what's what's next I at some point we might have time for audience questions but I I think for sure we're in the home stretch I would like it's probably easier to ask at this point so a patient who's presenting to you um with glomerular bleeding is there what would be the instances where you wouldn't get a biopsy I guess like where would you be so reassured that I don't have to I don't need tissue for the diagnosis I think if there's very little proteinuria and they have stable disease and we know that they've had hematuria for a long time so that would make me think something like thin-based membrane or or it's a very low level IGA um you know the debates if you you know what are you doing someone who they've got pulmonary involvement they've got anchor Titus through the roof and they've got renal faded you Bob see those folks you know that gets a little bit there are a lot of people who won't I'm I'm a big believer and put a needle in it but for many reasons not only diagnostic confirmation but you know what happens that you don't do it and then two months later they're not getting better and they're like oh now I've got to get above seem you don't know what we've started with and that's going to make a huge difference into what you may do next um you know so generally I'm getting a biopsy for most of these processes I'm trying to figure out what's going on but there are you know there are times when you you don't obviously a patient doesn't want it you're not going to do it and if they have high risk of of bleeding um and there are patients where you know you you're about to do a biopsy and they say Hey you know did I tell you about that hematoma I had spontaneously in my service muscle last week and I say no you didn't but maybe you should go back to your room and not get a kidney box obviously times when you're not going to do a box it's just too risky in general the risk is low I'm telling my patients you've got a one in a hundred chance less than one in a hundred of needing an admission if it's an outpatient procedure and you things you get admitted for would be an angiogram because the bleeding hasn't stopped um blood transfusion or humidity having instability and these are pretty uncommon and um but real risk benefit you know is huge much of the time so it's usually a pretty easy decision but there are some times that you're not going to do a biopsy the last question I have for you and I don't know that we have to spend a whole ton of time on this is I I feel like in my reading I've seen that patients with renal transplants and hematuria is kind of fall into a different category I can tell you as a primary care doctor if I have a patient with renal transplant hematuria like it's they're just going to Nephrology too it's sweet like that work Up's easy for me but for you does that change the way you think about things or what what do you worry about differently for for a patient who might be transplanted it sometimes it does depend what the Baseline disease was so some diseases occur so I'm going to be thinking about that rejection will be on my list so that is something that's seriously [Music] um unusual infections so like BK virus although those are usually associated with Rising creatinines as well so I don't do a lot of transplant my go-to it's a transplant biopsies are much less dangerous because the kidney is right there and you can put your finger um so much lower threshold to put a needle in it although nowadays the transplant guys are sending off these DNA free DNA things um I'm not I I'm not quite there yet I like putting needles in things well wrap up the case so Mr Jones ultimately undergoes renal biopsy he is diagnosed with lupus nephritis shockingly he now follows with Nephrology and Rheumatology he heals you as a diagnostic wizard so happy ending sort of uh for Mr Jones so we'll end there for our particular case and I guess I if maybe before questions why don't we ask you um Derek any any major take-home points like our our internists out there or to to take away from this talk like the really big picture stuff that you'd like them bring home yeah I think the big picture is think Urology and cancer to start do a very quick very easy to decide whether you need a nephrologist involved lb manoria look at the cranium those are normal you're probably okay for now um and and go on the Urologic realm grossy material you know always take that seriously and as you guys probably say in your podcast I was going to say I haven't listened to it a whole lot but um um you know do good history right like it's going to get you like 80 of the way just talking to the patient so I didn't really talk about that but that is it's probably more than on the show before yeah I'm sure it has and Paul and I have been disappointed that you actually have to talk to your patient yeah yeah so I think talking to your patient and doing a history is probably going to get you a whole lot further than in physical because chances are the thing you find on physical they're going to tell you it's there right yeah like I've got this funny purple thing on my leg that doesn't blanch yeah and then you tell you are you medical like why do you think that what you use the word doesn't Blanche yeah my husband's a nurse or something you know that sort of thing and but you know most of the time the history is going to get you most of the information uh any any questions yes okay so the question is you get a disconnect between the the urine dipstick and the urine microscopy and and do you have to further investigate that yeah I think you need to assume that they have hematuria because the urine could have been sitting around in you know in that little box outside the office for three hours and the red cells just exploded and the hemoglobin still there but the red cells aren't so I would say you could assume until proven otherwise that there are red cells maybe try get a fresher sample and see if they're red cells and then think about myoglobin you know could is it someone who just exercised you know do they have some myopathy or something but I think you have to just assume that hematuria on a dipstick is is or he pigment on a dipstick is hematuria so you would repeat at a minute I would repeat it yeah okay good question any other yes good question so it's if someone has lived uh outside the U.S where we're recording this anything else that should be high on your list I mentioned bill has here earlier so schistosomiasis would be uh something that and you know I don't know where it's endemic but in I know in Africa certainly North Africa southern Africa but not not the Vol River and that which is just outside Johannesburg you can swim in that one at least they told me that and I I haven't got bladder cancer so I think I was okay um obviously if you see a acute onset of of dark urine there's uh plasmodium philosopherum and massive hemolysis would be something we've actually had a case or two here over the years at this hospital with someone traveled and to be honest not a lot else comes to mind from a dream TB yeah now you know we always hear about TB and with white cells in the urine check a TV I think people have TB with white ceiling urine are usually pretty sick you know if they're like asymptomatic they probably don't have TB causing pyurio immaturia but yeah I guess that that is on the differential diagnosis it might even be on that slide that's got a thousand dollars okay oh so the question is if if we don't see anything and the workup's negative but we think maybe a small stone is passed how do we handle that situation you know if you've done your work up and you don't find anything they they probably you know isn't something serious going on or something that's going to be life-threatening at least in the near future um I think that's as good an explanations any other it makes you feel better it makes the patient feel better that okay I've at least got some you don't say these are the things that could do this and then you move on and you just keep an eye on them and put it on your past medical history at the top that he mature that wasn't well described and wasn't there was no underlying diagnosis and then keep an eye on it and if it comes back that maybe something will present later if it's something bad you'll know it'll come back um but I that certainly does happen people can have asymptomatic kidney stones um that cause immature or asymptomatic you know trauma and I don't mean to call you out but your look of existential pain at that question made me feel better primary care doctor the exact same feeling uh one last question yeah very very good question for the person who's been exposed to a Foley catheter recently how long can we blame the hematuria on that the phone is out now I I don't know the answer but I'd say if a month later they still have it then you worry about it so when they discharge have them follow up and get get a check in four weeks and but still there it's probably something you need to work up all right well great thank you audience for such great questions uh maybe a round of applause for a fantastic expert [Applause] and uh I'll ask Paul uh if you if y'all would sit for 30 seconds through an outro pod you want to get us to it sure that's the most humiliating part um this has been another episode of the curb cider is bringing you a little knowledge food for your brain hole Yeah yummy did someone in the audience try to say it too yes thank you it's catching on hungry for more join our patreon oh this is so embarrassing and get all our episodes out free plus twice monthly bonus episodes at patreon.com curbsiders you can find show notes at the curbsideers.com and sign up for our mailing list to get our weekly show notes in your inbox plus our curb shutters digest with Recaps the latest practice changing articles guidelines and news and internal medicine and uh you can find the show on YouTube Spotify Apple podcast you can send your comments and feedback to ask herbsiders gmail.com uh a special thanks to Dr Paul Nelson Williams America's primary care physician uh for writing and producing this episode and uh to our whole team our our technical production is done by pod paste Elizabeth Frodo runs our social media Chris the chu Manchu is the moderator on our Discord Stuart Brigham composed our theme music and with all that until next time I've been Dr Matthew Frank watto and as always our main Dr Paul Nelson Williams thank you so much [Music] foreign