What is the management approach for a 78-year-old patient with hematuria (presence of blood in urine) and proteinuria (presence of protein in urine)?

Management of Hematuria and Proteinuria in a 78-Year-Old Patient

This 78-year-old patient with concurrent hematuria and proteinuria requires urgent evaluation to exclude rapidly progressive glomerulonephritis (RPGN) and malignancy, with immediate urine microscopy to assess for glomerular disease, followed by risk-stratified urologic and nephrologic workup based on findings. 1, 2

Immediate Diagnostic Steps

Confirm and Characterize the Findings

• Obtain microscopic urinalysis immediately to confirm ≥3 RBCs per high-power field and quantify proteinuria, as dipstick testing has limited specificity (65-99%) and requires microscopic confirmation 2, 3
• Examine urine sediment for critical findings that determine the urgency and direction of workup 1:
  • RBC casts (virtually pathognomonic for glomerular bleeding) 3
  • Dysmorphic RBCs (>80% suggests glomerular origin) 2, 3
  • Cellular crescents or pyuria without infection 1
• Assess renal function with serum creatinine, eGFR, and BUN to identify acute kidney injury 1, 3
• Quantify proteinuria with spot urine protein-to-creatinine ratio or 24-hour collection (significant if >1 g/day) 1, 3

Assess for Rapidly Progressive Glomerulonephritis

If the patient presents with rapid decline in kidney function alongside positive urine dipstick for protein and blood, consider RPGN as a medical emergency 1. The 2024 KDIGO guidelines provide a clear diagnostic algorithm:

• Evaluate for extrarenal signs/symptoms of systemic vasculitis (pulmonary hemorrhage, skin lesions, neuropathy, constitutional symptoms) 1
• Obtain urgent autoimmune serologies: ANCA, ANA, anti-GBM antibodies, complement levels 1
• Exclude infection as a mimicker of vasculitis 1
• Obtain kidney biopsy if feasible - though in older adults with high clinical suspicion for AAV, treatment should not be delayed for biopsy 1

Critical point: Immunosuppressive treatment improves survival even in adults >75 years of age with AAV, making early diagnosis crucial 1

Risk Stratification for Malignancy

Given this patient's age (78 years), they fall into the high-risk category for urologic malignancy requiring complete evaluation 2, 3:

High-Risk Features Present

• Age ≥60 years (men ≥60 are high-risk; women ≥60 are intermediate-risk) 2
• Gross hematuria has 30-40% association with malignancy and requires urgent urologic referral even if self-limited 2
• Additional risk factors to assess: smoking history (>30 pack-years = high risk), occupational chemical exposure, history of pelvic irradiation 2, 3

Algorithmic Approach Based on Urine Microscopy Findings

Pathway A: Evidence of Glomerular Disease

If dysmorphic RBCs, RBC casts, significant proteinuria (>1 g/day), or elevated creatinine are present, initiate concurrent nephrologic evaluation 3:

• Immediate nephrology referral for potential glomerulonephritis 1, 3
• Obtain serologic workup: ANCA, ANA, anti-GBM, complement (C3, C4), serum protein electrophoresis 1
• Consider renal biopsy when systemic causes are not identified or to guide immunosuppressive therapy 1, 3
• Initiate blood pressure control with target <130/80 mmHg (or <125/75 mmHg if proteinuria >1 g/day) 1
• Start ACE inhibitor or ARB for antiproteinuric effect, uptitrating as tolerated 1

Important caveat: While hematuria and proteinuria are present during active glomerular disease, their persistence does not necessarily imply ongoing active disease after treatment 1

Pathway B: Non-Glomerular Hematuria (Normal RBCs, Minimal Proteinuria)

If RBCs are normal-appearing (doughnut-shaped) without casts and proteinuria is minimal, proceed with urologic evaluation 2, 3:

• Multi-phasic CT urography as the imaging procedure of choice for upper tract evaluation 3
• Cystoscopy is mandatory given age >35 years and high-risk status 3
• Urine cytology in select cases, particularly with irritative voiding symptoms 2

Pathway C: Mixed Picture (Both Glomerular and Non-Glomerular Features)

Concurrent nephrologic AND urologic evaluation is warranted when both glomerular markers and risk factors for malignancy coexist 3:

• This is particularly important in elderly patients where both glomerulonephritis and malignancy can coexist
• Do not defer urologic workup assuming glomerular disease explains all findings 3

Special Considerations for This 78-Year-Old Patient

Age-Related Factors

• Older adults (>75 years) with AAV benefit from immunosuppressive treatment with improved survival, so age alone should not preclude aggressive evaluation and treatment 1
• Malignancy risk is substantially elevated in this age group, making urologic evaluation essential 2

Anticoagulation Status

• If patient is on anticoagulation or antiplatelet therapy, do NOT attribute hematuria solely to these medications - they may unmask underlying pathology but do not cause hematuria 2, 3
• Full evaluation is required regardless of anticoagulation status 3

Exclude Benign Causes

Before extensive workup, briefly assess for and exclude:

• Recent vigorous exercise (causes transient hematuria) 2
• Active urinary tract infection - if present, treat and repeat urinalysis 6 weeks post-treatment 3
• Recent urologic instrumentation or trauma 2

Follow-Up Protocol

If Initial Workup is Negative

• Repeat urinalysis, blood pressure, and urine cytology at 6,12,24, and 36 months 2, 3
• Consider nephrology referral if hematuria persists with development of:
  • Hypertension 2
  • Increasing proteinuria 2
  • Declining renal function 2
  • Evidence of glomerular bleeding 2

If Glomerular Disease is Confirmed

• Monitor proteinuria levels, blood pressure, and renal function regularly 3
• Optimize renin-angiotensin system blockade to reduce proteinuria and slow progression 1, 4
• Consider combination therapy (ACE inhibitor + ARB, or addition of aldosterone antagonist) if proteinuria remains >1 g/day despite monotherapy 4

Critical Pitfalls to Avoid

• Never ignore gross hematuria even if self-limited - it requires urologic referral 2
• Do not delay treatment for biopsy in older adults with high clinical suspicion for RPGN/AAV 1
• Do not assume anticoagulation explains hematuria - complete evaluation is mandatory 2, 3
• Do not rely on dipstick alone - always confirm with microscopic examination 2, 3
• Do not defer urologic evaluation in patients with glomerular disease who also have risk factors for malignancy 3
• Tea-colored urine suggests glomerular source and should prompt immediate nephrologic evaluation 2