What is the management approach for hematuria caused by viral illness?

Management of Hematuria Caused by Viral Illness

For hematuria caused by viral illness, the management approach should focus on supportive care, monitoring for complications, and treating the underlying viral infection, as hematuria typically resolves with resolution of the viral illness.

Diagnostic Approach

• Confirm hematuria with microscopic examination of urine, as dipstick testing alone is insufficient for clinical decision-making. A threshold of ≥3 erythrocytes per high-power field (HPF) is considered abnormal 1, 2.
• If menstruation, vigorous exercise, or other benign causes are suspected, repeat the evaluation after the cause is excluded 1.
• If infection is suspected based on urinalysis or symptoms, obtain a urine culture; if infection is confirmed, repeat evaluation after treatment to document resolution of hematuria 1.
• Assess for risk factors for genitourinary malignancy, medical renal disease, and non-malignant genitourinary causes through history and physical examination 2.

Management of Viral-Associated Hematuria

Supportive Care

• Provide adequate hydration to maintain good urine output 1.
• Monitor vital signs, water-electrolyte balance, and acid-base balance 1.
• Ensure nutritional support with high-protein, high-vitamin diets 1.

Monitoring

• Perform urinalysis to detect worsening or new onset of proteinuria or hematuria 1.
• Monitor for development of acute kidney injury (AKI), as hematuria during viral illness can be associated with increased risk of AKI 3.
• Pay particular attention to patients with pre-existing kidney disease, as they may be at higher risk for complications 1.

Specific Viral Infections

COVID-19

• Patients with COVID-19 who develop hematuria should be closely monitored for AKI, as hematuria at admission is associated with increased risk of ICU admission, mechanical ventilation, and mortality 3.
• De novo proteinuria during hospitalization for COVID-19 is significantly associated with increased risk of death (OR 8.94) 3.

HIV-Associated Hematuria

• For HIV-infected patients with hematuria, perform urinalysis at least yearly during follow-up if clinically stable and virologically suppressed 1.
• Initiate antiretroviral therapy in all patients with biopsy-proven HIV-associated nephropathy, regardless of CD4 count 1.
• Monitor more frequently in persons who are clinically unstable, severely immunocompromised, or viremic 1.

Hepatitis B and C

• Test patients with proteinuric glomerular disease for HBV infection 1.
• For patients with replicative HBV infection (HBV DNA levels >2000 IU/ml) and glomerulonephritis, provide treatment with nucleos(t)ide analogues 1.
• For HCV-infected patients with kidney disease, consider antiviral treatment based on kidney function 1.

Special Considerations

IgA Nephropathy

• Gross hematuria may occur following viral upper respiratory tract infections in patients with IgA nephropathy 4.
• Monitor these patients carefully as repeated gross hematuria and persistent microhematuria may lead to irreversible kidney injury 4.
• Consider ACE inhibitor treatment if proteinuria is between 0.5 and 1 g/day 1.

When to Refer to Specialist

• Refer to a nephrologist when:
  • Hematuria does not resolve within 2 weeks of onset of suspected glomerulonephritis 5.
  • There is persistent microscopic hematuria 5.
  • Hematuria is accompanied by significant proteinuria, hypertension, or worsening kidney function 6.
  • There is a need for specific urine biochemistry testing or imaging studies 5.

Common Pitfalls to Avoid

• Relying solely on dipstick results without microscopic confirmation 2.
• Attributing hematuria solely to antiplatelet or anticoagulant therapy without further investigation 2.
• Neglecting to evaluate women with hematuria as thoroughly as men 2.
• Failing to repeat urinalysis after treatment of presumed benign causes 2.
• Overlooking the possibility of drug-induced hematuria, especially from analgesics 5.