1. Serving Up Advice: A Waiter With Hematuria COPYRIGHT © 2016, ALL RIGHTS RESERVED From the Publishers of

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3. Consult Guys: Greetings from Las Vegas. I am one of your loyal fans from the very beginning and its one of your early shows that has led me to seek your sage advice about one of my patients. I remember several years ago you presented a Stumper of a patient who developed green urine during surgery. With your usual skill and tact you reasoned that the patient’s green urine was a result of a metabolite of propofol anesthesia. Its been almost 3 years since I viewed this and I remember it like it was yesterday. So today I am writing to ask your advice about another urine abnormality – microscopic hematuria. My patient is a 65 year old man who was recently found to have atrial fibrillation. Because of his thromboembolic risk I started anticoagulation with warfarin. Initial warfarin titration was difficult and early on his INR rose to 5. At that time he had one episode of a scant red tinge to his urine. It was painless, cleared quickly and has not recurred. We’ve been maintaining his INR at around 2 and he’s done well. To follow up on what I suspect was one self limited episode of gross hematuria I recently obtained a urine analysis. It revealed no wbc, but he did have 3 rbc/hpf. It was otherwise normal. I repeated the UA and the microscopic evaluation revealed 1 rbc/hpf. Consult Guys: Greetings from Las Vegas. I am one of your loyal fans from the very beginning and its one of your early shows that has led me to seek your sage advice about one of my patients. I remember several years ago you presented a Stumper of a patient who developed green urine during surgery. With your usual skill and tact you reasoned that the patient’s green urine was a result of a metabolite of propofol anesthesia. Its been almost 3 years since I viewed this and I remember it like it was yesterday. So today I am writing to ask your advice about another urine abnormality – microscopic hematuria. My patient is a 65 year old man who was recently found to have atrial fibrillation. Because of his thromboembolic risk I started anticoagulation with warfarin. Initial warfarin titration was difficult and early on his INR rose to 5. At that time he had one episode of a scant red tinge to his urine. It was painless, cleared quickly and has not recurred. We’ve been maintaining his INR at around 2 and he’s done well. To follow up on what I suspect was one self limited episode of gross hematuria I recently obtained a urine analysis. It revealed no wbc, but he did have 3 rbc/hpf. It was otherwise normal. I repeated the UA and the microscopic evaluation revealed 1 rbc/hpf.

4. Copyright © 2016 His history is significant for hypertension. He is a non-smoker. He’s been a waiter for years and still works full time. He has no urinary symptoms and has never had a urinary tract infection. His physical exam is unremarkable except for atrial fibrillation with controlled ventricular response. So mentors of the internet here is where I need advice. I suspect that the one self limited episode of hematuria was due to his elevated INR. Follow up urine microscopic evaluation revealed only 3 rbc/hpf and then when repeated 1 rbc/hpf. Hgb 13.5 Cr 0.8 INR 2.0 I am content to leave the evaluation at that but with your expertise in urine color abnormalities I need your advice. Thanks- Vince from Vegas His history is significant for hypertension. He is a non-smoker. He’s been a waiter for years and still works full time. He has no urinary symptoms and has never had a urinary tract infection. His physical exam is unremarkable except for atrial fibrillation with controlled ventricular response. So mentors of the internet here is where I need advice. I suspect that the one self limited episode of hematuria was due to his elevated INR. Follow up urine microscopic evaluation revealed only 3 rbc/hpf and then when repeated 1 rbc/hpf. Hgb 13.5 Cr 0.8 INR 2.0 I am content to leave the evaluation at that but with your expertise in urine color abnormalities I need your advice. Thanks- Vince from Vegas

5. Urothelial Cancer Risk Factors Smoking 50% Occupation 50% Incidence increasing  Increasing faster in women Risk factors  Male  Age > 50  Chemical / dye exposure  Analgesic abuse  Urologic disease  Urinary symptoms  Occupation Copyright © 2016

6. Chimney Service Industry 2012 5,000 chimney sweeps

7. U.S. Waiters and Waitresses 2014 Bureau of Labor Statistics 2.45 million

8. *Culclasure TF, Bray VJ, Hasbargen JA. The Significance of Hematuria in the Anticoagulated Patient. Arch Intern Med. 1994;154(6):649-652.

9. The Significance of Hematuria in the Anticoagulated Patient Anticoagulation clinic (warfarin) Asymptomatic micro hematuria: > 5 rbc/hpf No difference prevalence compared to un- anticoagulated controls ( 3.2% vs 4.8%) 81% of hematuria patients with urologic disease Message: asymptomatic micro hematuria often not benign in the anticoagulated patient

10. *Van Savage JG et al. Anticoagulant Associated Hematuria: A Prospective Study. The Journal of Urology. 1995; 5:1594 – 1596.

11. Anticoagulant Associated Hematuria: A Prospective Study Only 6 patients with microscopic hematuria  3 nephrolithiasis  1 glomerulonephritis  2 BPH / prostatitis

12. *Hurlen M et al. Occult bleeding in three different antithrombotic regimes after myocardial infarction. Thrombosis Research. 2006; 4:433 – 438.

13. Occult bleeding in three different antithrombotic regimes after myocardial infarction A WARIS-II subgroup analysis 29 (10%) with microscopic hematuria Incomplete evaluation  4 with known urologic disease  2 bladder cancer  1 urinary tract calculus Their conclusion  Only macroscopic bleeding during treatment with anticoagulants – antithrombotics is clinically relevant

14. *Davis R et al. Diagnosis, Evaluation and Follow-Up of Asymptomatic Microhematuria (AMH) in Adults: AUA Guideline. The Journal of Urology. 2006; 6: 2473 – 2481.

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17. High-Value Care Advice ACP and Annals of Internal Medicine Gross hematuria – even if episodic – is serious. Ask for it during routine review of symptoms and in patients with asymptomatic micro hematuria.  Refer for urologic evaluation Confirm blood positive urine dipstick with microscopic evaluation.  Microscopic hematuria > 3 rbc/hpf Copyright © 2016

18. High-Value Care Advice ACP and Annals of Internal Medicine Consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause. Pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy. Do not use screening urinalysis for cancer detection in asymptomatic adults. Do not obtain urine cytology or other urine based molecular markers for bladder cancer detection in the initial evaluation of hematuria.  Miss up to 43% of bladder cancers  False positive up to 26% Copyright © 2016

19. Advice from The Consult Guys The patient is at risk for urothelial carcinoma.  Male  Age > 50  Occupation  Episode of gross hematuria  Follow up microscopic hematuria Urology referral  Cystoscopy  Upper tract imaging (CT urography) Copyright © 2016

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