From the Guidelines
The patient should be referred to a nephrologist promptly for comprehensive evaluation and management of suspected medical renal disease, given the presence of proteinuria, hematuria, and renal insufficiency. The key findings in this patient include elevated blood pressure (140/94 mm Hg), impaired kidney function (elevated BUN of 24 mg/dL and creatinine of 1.7 mg/dL), and urinalysis showing proteinuria (+2) with hematuria (20-30 RBCs/hpf) without evidence of infection (negative leukocyte esterase and nitrites) 1. This combination of hypertension, reduced kidney function, proteinuria, and hematuria is characteristic of glomerular pathology. According to the AUA/SUFU guideline, patients with these features should be referred to a nephrologist for evaluation of medical renal disease, which can cause hematuria 1.
The next steps should include a 24-hour urine collection to quantify protein excretion, serum complement levels, antinuclear antibody testing, anti-neutrophil cytoplasmic antibody testing, anti-glomerular basement membrane antibodies, and hepatitis serologies to determine the specific cause 1. A kidney biopsy may be necessary for definitive diagnosis. Treatment will depend on the underlying cause but may include blood pressure control with ACE inhibitors or ARBs, immunosuppressive therapy for certain types of glomerulonephritis, and supportive care. The American College of Radiology also recommends a thorough history, physical examination, and laboratory analysis of blood and urine for the evaluation of patients with acute kidney injury or chronic kidney disease 1.
Given the patient's presentation, it is essential to prioritize the evaluation and management of medical renal disease to prevent further kidney damage and improve outcomes. The patient's symptoms and laboratory results suggest a high risk of medical renal disease, and prompt referral to a nephrologist is necessary to ensure timely and appropriate management 1.
From the Research
Patient's Condition
The patient's vital signs are:
- Temperature: 37.2 C (99 F)
- Blood pressure: 140/94 mm Hg
- Pulse: 80/min
- Respirations: 16/min The physical examination shows no abnormalities.
Laboratory Results
The laboratory results are as follows:
- Serum chemistry:
- Blood urea nitrogen: 24 mg/dL
- Creatinine: 1.7 mg/dL
- Urinalysis:
- Specific gravity: 1.016
- Protein: +2
- Blood: moderate
- Leukocyte esterase: negative
- Nitrites: negative
- White blood cells: 1-2/hpf
- Red blood cells: 20-30/hpf
Possible Causes and Treatments
The patient's urinalysis results show proteinuria (+2) and hematuria (moderate blood), which may indicate kidney disease or other underlying conditions 2.
- The presence of proteinuria may be treated with ACE inhibitors, which have been shown to reduce proteinuria and slow the progression of renal insufficiency 3, 4.
- However, the use of ACE inhibitors in patients with chronic kidney disease requires careful consideration of the potential risks and benefits, including the risk of hypotension, renal function impairment, and hyperkalemia 5.
- Combination therapy with ACE inhibitors and statins may also be effective in reducing proteinuria and improving renal function in patients with advanced renal disease 6.
Further Evaluation
The patient's condition warrants further evaluation to determine the underlying cause of the proteinuria and hematuria, and to assess the risk of malignancy or other complications 2.
- This may include additional laboratory tests, imaging studies, and referral to a nephrologist or urologist for further evaluation and treatment.