Hematuria Following Resolved Sepsis and AKI: Evaluation and Management
In a patient with resolved sepsis and AKI who now presents with hematuria, perform a comprehensive urologic evaluation including urinalysis with microscopy, urine culture, upper tract imaging, and cystoscopy to exclude malignancy and other urologic pathology, while simultaneously assessing for residual renal parenchymal disease. 1
Initial Diagnostic Approach
Urinalysis and Microscopy
- Examine the urine sediment carefully for dysmorphic red blood cells, red cell casts, and degree of proteinuria, as these findings suggest glomerular or renal parenchymal disease rather than urologic causes 1
- Quantify the number of RBCs per high-power field to confirm significant hematuria 1
- Check for white blood cells and perform urine culture to exclude urinary tract infection as the cause 1
- If infection is present, treat appropriately and repeat urinalysis in 6 weeks; if hematuria resolves, no further evaluation is needed 1
Assess for Renal Parenchymal Disease
- The presence of significant proteinuria, red cell casts, renal insufficiency, or predominantly dysmorphic RBCs should prompt evaluation for renal parenchymal disease rather than proceeding directly to urologic workup 1
- Measure serum creatinine to assess current renal function, as your patient had recent AKI 1
- Consider that sepsis-associated AKI can cause residual renal damage and chronic kidney disease, increasing risk for ongoing hematuria from parenchymal injury 2
Complete Urologic Evaluation (If No Glomerular Disease)
Upper Tract Imaging
- Obtain imaging of the upper urinary tract using intravenous urography, ultrasonography, or computed tomography to detect renal cell carcinoma, transitional cell carcinoma, urolithiasis, or renal infection 1
- Intravenous urography has traditionally been the standard modality, though it has limited sensitivity for small renal masses 1
Cystoscopy
- Perform cystoscopic examination of the urinary bladder to evaluate for bladder pathology, particularly urothelial malignancies which are the most commonly detected cancers in patients with microscopic hematuria 1
Urine Cytology
- Consider voided urinary cytology, especially if risk factors for transitional cell carcinoma are present (age >40, smoking history, occupational exposures, prior pelvic radiation, chronic cyclophosphamide use) 1
- If cytology shows malignant or atypical cells, cystoscopy is mandatory 1
Critical Considerations in Post-Sepsis/AKI Context
Rule Out Medication-Related Causes
- Review all medications, as certain antibiotics used during sepsis treatment can cause crystalluria, cylindruria, and hematuria 3
- Fluoroquinolones specifically list hematuria as a reported adverse event 3
Avoid Nephrotoxic Agents
- Do not use NSAIDs for any concurrent symptoms, as these are nephrotoxic and contraindicated in patients with recent AKI 1
- Minimize exposure to additional nephrotoxins, as each additional nephrotoxin increases AKI odds by 53% 4
Long-Term Monitoring Plan
- Patients with prior AKI require ongoing surveillance for hypertension, progressive renal disease, proteinuria, and cardiovascular complications, as even one episode of AKI increases risk of chronic kidney disease and death 2
- If isolated hematuria persists after negative urologic evaluation and no glomerular disease is identified, follow for development of hypertension, renal insufficiency, or proteinuria 1
Common Pitfalls to Avoid
- Do not assume hematuria is simply residual from the AKI without proper evaluation, as this could miss treatable malignancies or other serious pathology 1
- Do not delay evaluation if hematuria persists, as urothelial cancers require early detection 1
- Do not perform renal biopsy in isolated hematuria without risk factors for primary renal disease, as the role of biopsy in this setting is not well-defined 1
- In women, ensure proper specimen collection to avoid vaginal contamination; consider catheterized specimen if clean-catch is unreliable 1