Things not to miss - Glomerulonephritis

A 56 years old male patient presented to a GP with a history of hematuria for two days duration. There was no associated dysuria or features of bladder outflow obstruction. The hematuria was persistent and the urine was uniformly red in colour. He was a smoker. Physical examination was unremarkable.

The GP reviewed the patient with followed investigations.

WBC - 8
Hb - 10.1
MCV - 80
Plt - 145

S. Cr - 1.4mg/dL

UFR
RBC - Field full
Pus cells - 5-10
Protein - 1+

As the reports were almost normal he suspected a carcinoma of the bladder and sent the patient to a urologist with a referral letter.

Urologist arranged an ultrasound KUB which was normal. He planned a cystoscopy which was performed in a weeks time. It did not show any evidence of a malignancy.

Investigations were repeated.

WBC - 10.5
Hb - 9.4
MCV - 80
Plt - 130

S. Cr - 4.5mg/dL

UFR
RBC - field full
Pus cells - 10-20
Protein 1+

The management team was alarmed, and the patient was immediately referred to a nephrologist.

Nephrologist immediately had a look at the urine under the microscope.

90% of the cells were dysmorphic. There were RBC casts.

Diagnosis? Rapidly progressive glomerulonephritis.

The patient was admitted and IV methyl prednisolone was started. Renal biopsy was done on the next day, which confirmed the diagnosis. S. Cr rose up to 9.1 requiring dialysis. Etiological investigations were consistent with renal vasculitis.

Despite aggressive management with steroids and immunosuppressives, kidneys never recovered. The patient had to undergo lifelong dialysis.




Lesson

In any patient with hematuria consider Nephrological causes. A cancer can wait a week. But a week is more than enough for a nephrological disease to cause irreversible renal damage.



When to suspect a nephrological cause for hematuria

• Presence of dysmorphic red cells.
• In any patient with hematuria, ask specifically for dysmorphic cells in the urine examination.
• Look for casts.
• Casts
• Casts also indicate a nephrological cause.
• Read about various types of casts and what diseases cause them.
• Protein
• Significant proteinuria indicated glomerular pathology
• Abnormal creatinine
• Never ignore a mildly elevated level of S. Creatinine. The next report in 24 hours might show a creatinine some five times higher than the initial value!
• Other supportive evidence
• Clinical features
• Respiratory symptoms
• Rashes
• Arthritis
• Eye disease etc.
• Abnormal Hb, Platelets
• High ESR/ CRP

Remember,

Many renal diseases require prompt diagnosis and aggressive treatment to prevent development of irreversible renal failure!


Acknowledgement : Dr. AWM Wazil, Consultant Nephrologist (And a great teacher!)