From the Guidelines
The best course of action for a 77-year-old female with diabetes and hematuria is immediate medical evaluation by a healthcare provider, preferably within 24-48 hours. This patient should not delay seeking care as hematuria in an elderly diabetic patient can indicate several serious conditions requiring prompt attention. The evaluation should include a complete urinalysis, urine culture, blood tests including kidney function (creatinine, BUN), and possibly imaging studies such as ultrasound or CT scan of the urinary tract. While waiting for the appointment, the patient should maintain good hydration by drinking 6-8 glasses of water daily, continue taking all prescribed diabetes medications as directed, and monitor blood glucose levels closely. The patient should also document when the blood in urine was first noticed, its appearance (bright red or tea-colored), any associated symptoms like pain during urination, frequency, urgency, or fever, and bring this information to the appointment. Hematuria in diabetic patients can result from urinary tract infections (more common in diabetics), kidney disease related to diabetes (diabetic nephropathy), kidney stones, or potentially bladder or kidney cancer (for which age is a risk factor) 1. Diabetic patients are particularly vulnerable to urinary tract complications due to elevated glucose levels creating favorable conditions for bacterial growth and potential damage to blood vessels in the kidneys from long-term diabetes.
Some key considerations for the evaluation of hematuria include:
- Clinicians should include gross hematuria in their routine review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria 1.
- Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating further evaluation in all asymptomatic adults 1.
- Clinicians should refer for further urologic evaluation in all adults with gross hematuria, even if self-limited 1.
- Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause 1.
Given the potential for hematuria to be a sign of serious underlying conditions, it is crucial to approach this symptom with a high level of vigilance and to pursue thorough evaluation and referral as necessary, as supported by the guidelines and evidence from studies such as those published in the Annals of Internal Medicine 1.
From the Research
Patient Profile
- 77-year-old female
- Diagnosed with Diabetes Mellitus
- Presence of blood in urine (hematuria)
Clinical Significance of Hematuria
- Hematuria may indicate nondiabetic renal disease in diabetic chronic kidney disease (CKD) 2
- Associated with an increased risk of end-stage renal disease, particularly in patients with early diabetic CKD 2
- Microscopic haematuria is noted in diabetic nephropathy and is associated with albuminuria 2, 3
Diagnostic Considerations
- Urinary biomarkers, such as transferrin, type IV collagen, and N-acetyl-beta-D-glucosaminidase, may be useful in detecting incipient nephropathy and risk assessment of cardiovascular disease 4
- Metformin, a common treatment for type 2 diabetes, has been shown to reduce pro-inflammatory mediators in blood and urine, but its effect on renal function is unclear 5
Management of Diabetes in Older Adults
- Older adults with diabetes are often asymptomatic and at higher risk of vascular disease 6
- Diagnosis and management of diabetes in older adults should take into account the increased likelihood of metabolic syndrome, dysfunctional insulin secretion, and peripheral insulin resistance 6
- Cost-effective care of older adults with diabetes is crucial, considering the high prevalence of diabetes in this population 6
Potential Next Steps
- Further evaluation of the patient's kidney function and urinary biomarkers to determine the underlying cause of hematuria
- Consideration of metformin or other anti-diabetic medications to manage the patient's diabetes and reduce inflammation
- Regular monitoring of the patient's blood sugar levels, blood pressure, and kidney function to prevent progression of diabetic nephropathy 2, 3, 5