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Five-minute Practitioner: April 2009

Only got five minutes? Then just read these key points on haematuria, CKD and palliative care

Only got five minutes? Then just read these key points on haematuria, CKD and palliative care

Haematuria

Non-visible haematuria (NVH) is detected by oxidation of organic peroxide by haemoglobin on a urine dipstick of a fresh voided urine sample, containing no preservative. Routine microscopy for confirmation of dipstick haematuria is not necessary. Significant haematuria is considered to be 1+ or greater and trace haematuria should be considered negative.

A UTI should be considered if nitrite and leukocyte are also positive on dipstick. Urinalysis should be repeated following treatment of a UTI to ensure haematuria is not persistent.

In patients taking anticoagulant or antiplatelet drugs, the presence of haematuria (VH or NVH) should not be assumed to be caused by the drugs and these patients should also be evaluated.

If haematuria is detected the following steps should be followed. Establish if it is transient or persistent and whether VH or NVH is present. Ask if there are any clues from the history or physical examination that suggest a particular diagnosis. Measure blood pressure. Check serum creatinine and estimated glomerular filtration rate (eGFR). Quantify proteinuria on a random urine sample for albumin:creatinine ratio (ACR) or protein:creatinine ratio (PCR).

Referral for urological evaluation including renal imaging and cystoscopy is appropriate for patients with: a single episode of VH (any age); s-NVH (any age); a-NVH aged ?40.

Haematuria in the absence of proteinuria should be followed up annually with repeat testing for haematuria, proteinuria/albuminuria, eGFR and blood pressure monitoring as long as the haematuria persists. Those who develop abnormalities of these parameters should be referred to a nephrologist.

CKD

The prevalence of CKD stages 3-5 in the UK has been estimated at 8.5% based on a large primary care study. The prevalence increases dramatically with age, and is also thought to be increasing year by year. Only a minority of patients diagnosed with CKD will progress to established renal failure while a substantial proportion will die of cardiovascular disease.

Although eGFR remains an estimate, changes in eGFR in an individual are a reliable marker of a change of renal function. eGFR tends to become less reliable at extremes of body type and is not valid for those under 18.

The MDRD equation used to calculate eGFR was originally validated on white and black Americans and seems to equate well to the UK's white population. Data from the USA showed that creatinine values underestimated renal function in those of African and Caribbean descent by an average of 21% and also overestimated renal function in women by 26%; hence there are corrections for these factors in the abbreviated MDRD formula.

Once kidney disease has been established the priority is to determine whether this is an acute or chronic process and then define the risk progression. Those risk factors that are modifiable, for example hypertension, become therapeutic targets to slow progression. Progressive renal disease requiring referral to specialist services is defined as: a decline in eGFR > 5 ml/min/1.73m2 within 1 year or > 10 ml/min/1.73m2 within 5 years.

Patients with uncontrolled hypertension warrant referral as do those with CKD stage 4 or 5, or with suspected rare or genetic kidney disease. Those with suspected renal artery stenosis, complex disease, or where management of complications is difficult, will also require specialist intervention.

Palliative care

Three-quarters of patients wish to die at home, but less than a quarter currently do so. A concerted effort in primary care can increase the chances of a terminally ill patient fulfilling this wish. In one practice, a focus on developing an integrated nursing team whose members are all skilled in palliative care has led to an increase from 30% of patients who wished to dying at home a decade ago to a current figure of over 50%.

Good inter-professional liaison is essential. Regular practice meetings to review patients should occur. Patient-held continuation cards in which all professionals involved can write notes are invaluable. Liaison between the primary care team, patient, relatives and carers, outside agencies and secondary care is essential to the success of domiciliary palliative care.

Practice nursing teams are pivotal in providing support and care for patients. Macmillan nurses have specialist training in palliative care and, while they do not provide hands-on care, they are skilled in counselling, support and symptom control. Marie Curie have diversified to provide broader palliative care and many PCTs have contracts with them. One particular advantage is that they can provide overnight nursing care.

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