What is the best approach to manage a 72-year-old male with resolved gross hematuria, now presenting with microscopic hematuria, proteinuria, and hypertension?

From the Guidelines

The best approach for a 72-year-old male with resolved gross hematuria now presenting with microscopic hematuria, proteinuria, and hypertension requires a comprehensive evaluation and management, starting with a complete urologic workup with cystoscopy and upper tract imaging (CT urography) to rule out urologic malignancy, given his age and history of gross hematuria, as recommended by the ACR Appropriateness Criteria for hematuria 1.

Initial Evaluation

Initial steps should include:

• A thorough history, physical examination, urinalysis, and serologic testing prior to any initial imaging, as suggested by the ACR Appropriateness Criteria for hematuria 1
• Cystoscopy and upper tract imaging (CT urography) to rule out urologic malignancy
• Nephrology consultation to evaluate for glomerular disease

Management of Hypertension and Proteinuria

Blood pressure control is essential, preferably with an ACE inhibitor like lisinopril (starting at 10mg daily) or an ARB such as losartan (50mg daily), as these medications provide both antihypertensive effects and reduce proteinuria, as recommended by the KDIGO 2021 guideline for the management of glomerular diseases 1.

• Target systolic blood pressure in most adult patients is <120 mm Hg using standardized office BP measurement
• Proteinuria goal is variable depending on the GN-type, but reduction of proteinuria to <1 g/day is associated with a more favorable prognosis, as suggested by the KDIGO practice guideline on glomerulonephritis 1

Laboratory Testing and Monitoring

Laboratory testing should include:

• Serum creatinine, estimated GFR, complete blood count, urinalysis with microscopy, urine protein-to-creatinine ratio, and serum complement levels
• Regular monitoring of kidney function, proteinuria, and blood pressure every 3-6 months is important to assess response to therapy and disease progression

Kidney Biopsy

If proteinuria exceeds 1g/day or if there are other concerning features (declining kidney function, active urinary sediment), a kidney biopsy may be necessary to determine the underlying cause, as suggested by the KDIGO practice guideline on glomerulonephritis 1.

This approach addresses both potential urologic and nephrologic causes while providing appropriate treatment for hypertension and proteinuria to prevent further kidney damage, prioritizing morbidity, mortality, and quality of life as the outcome, based on the most recent and highest quality study available 1.

From the Research

Management Approach

To manage a 72-year-old male with resolved gross hematuria, now presenting with microscopic hematuria, proteinuria, and hypertension, the following approach can be considered:

• The patient's hypertension should be managed to achieve a blood pressure goal of less than 130/80 mm Hg to maximize renal and cardiovascular protection 2.
• Drugs interfering with the renin-angiotensin system, such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), should be used as first-line antihypertensive therapy due to their blood pressure-independent antiproteinuric effect 2, 3, 4.
• If blood pressure levels are still not at goal, a diuretic can be added to the regimen 2.
• Combination therapy with an ACE inhibitor and an ARB, or other classes of medications that decrease protein excretion, such as non-dihydropyridine calcium antagonists or aldosterone receptor blockers, can be considered to further decrease proteinuria 2, 4.

Considerations for Specific Medications

• ACE inhibitors have been shown to reduce proteinuria effectively and are considered a widely used class of agents in nephrology 5, 3.
• ARBs also reduce proteinuria and have a similar effect to ACE inhibitors 4.
• The combination of ACE inhibitors and ARBs has been shown to further reduce proteinuria compared to either agent alone 4.
• Calcium channel blockers, particularly dihydropyridine CCBs, may not be the best choice as first-line therapy in patients with proteinuric renal diseases due to their potential to not lower proteinuria despite reducing blood pressure 6.

Monitoring and Titration

• Patients at the greatest risk for renal adverse effects, such as those with heart failure, diabetes mellitus, and/or chronic renal failure, should have their dosages carefully titrated, with monitoring of renal function and serum potassium levels 5.
• The initial proteinuria-lowering response to ACE inhibition can predict long-term renal function outcome, with greater proteinuria reduction associated with better preservation of renal function 3.