What treatment should be given to a patient with hematuria and a history of sepsis and Acute Kidney Injury (AKI)?

Treatment for Hematuria in a Patient with Resolved Sepsis and AKI

The primary treatment is to complete a comprehensive urologic evaluation to exclude malignancy while avoiding nephrotoxic agents, particularly NSAIDs, and monitoring for residual renal dysfunction. 1

Immediate Management Priorities

Exclude Active Infection First

• Perform urine culture immediately to rule out urinary tract infection as the cause of hematuria 1
• If infection is present, treat with appropriate antibiotics and repeat urinalysis in 6 weeks; if hematuria resolves after treatment, no further evaluation is needed 1
• Ensure the prior sepsis has fully resolved before attributing hematuria to other causes 2, 3

Strict Avoidance of Nephrotoxins

• Do not prescribe NSAIDs under any circumstances - these are absolutely contraindicated in patients with recent AKI 4, 1
• Each additional nephrotoxic exposure increases AKI odds by 53% 1
• Review and discontinue all potentially nephrotoxic medications when possible 4
• Avoid aminoglycosides unless no suitable alternatives exist 4

Complete Urologic Evaluation Protocol

Detailed Urinalysis with Microscopy

• Examine urine sediment for dysmorphic red blood cells and red cell casts, which indicate glomerular disease rather than urologic pathology 1
• Quantify RBCs per high-power field to confirm significant hematuria 1
• Assess for proteinuria degree, as significant proteinuria suggests renal parenchymal disease 1
• Check for white blood cells to exclude concurrent infection 1

Upper Tract Imaging

• Obtain imaging using CT urography, intravenous urography, or ultrasonography to detect renal cell carcinoma, transitional cell carcinoma, urolithiasis, or renal infection 1
• This imaging is mandatory to exclude malignancy in the upper urinary tract 1

Cystoscopic Examination

• Perform cystoscopy to evaluate for bladder pathology, as urothelial malignancies are the most commonly detected cancers in patients with microscopic hematuria 1
• This is essential even if upper tract imaging is negative 1

Additional Testing When Indicated

• Consider voided urinary cytology if risk factors for transitional cell carcinoma are present: age >40 years, smoking history, occupational chemical exposures, prior pelvic radiation, or chronic cyclophosphamide use 1
• If cytology shows malignant or atypical cells, cystoscopy is mandatory 1
• In women, ensure proper specimen collection to avoid vaginal contamination; consider catheterized specimen if clean-catch is unreliable 1

Ongoing Monitoring for Post-AKI Complications

Surveillance Requirements

• Monitor for development of hypertension, as patients with prior AKI are at increased risk 1
• Assess for progressive renal disease and proteinuria development 1
• Screen for cardiovascular complications, as even a single episode of septic AKI increases risk of chronic kidney disease 5
• If isolated hematuria persists after negative urologic evaluation, continue follow-up for hypertension, renal insufficiency, or proteinuria 1

Fluid Management Considerations

Volume Status Assessment

• Use isotonic crystalloids rather than colloids for any volume expansion needs 4
• Avoid starch-containing fluids entirely - these are nephrotoxic and decrease renal function 4, 5
• Monitor fluid status closely to avoid pulmonary edema, especially if cardiac comorbidity exists 6
• Consider that patients with recent sepsis may have residual cardiac dysfunction requiring careful fluid management 6

Critical Pitfalls to Avoid

• Never assume hematuria is simply residual from AKI without proper evaluation - this could miss treatable malignancies 1
• Do not delay evaluation if hematuria persists, as urothelial cancers require early detection 1
• Do not perform renal biopsy for isolated hematuria without additional risk factors for primary renal disease, as the role of biopsy in this setting is not well-defined 1
• Do not use protocol-based eGFR equations (MDRD, CKD-EPI) immediately post-AKI, as these require steady-state creatinine and are unreliable in the acute setting 4

When Urologic Evaluation is Negative

• If complete urologic evaluation is negative and no glomerular disease is identified, establish regular follow-up 1
• Monitor for development of hypertension, renal insufficiency, or proteinuria over time 1
• Recognize that persistent AKI after sepsis requires extended evaluation and management protocols to avoid further kidney damage 4