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Three Part Question

In [adults under the age of 50 with haematuria] is [referral to a nephrologists better than referral to a urologist] at [detecting significant underlying pathology in a timely and cost effective manner]?

Clinical Scenario

A 44 year old man presents to the Emergency Department with a week long history of blood in his urine. You wonder if this patient would be more appropriately referred to a nephrologist or a urologist since you are aware that there are many causes of haematuria and that in a younger person a lot of them are not surgically defined urological problems.

Search Strategy

Medline using the OVID interface - 1966 to June Week 1 2005
Embase - 1980 to 2005 Week 24
CINAHL - 1982 to June Week 1 2005
Cochrane Library - Issue 2 2005
(exp. HEMATURIA OR haematuria.mp) AND ((REFERRAL.mp. or exp. "Referral and Consulation"/) OR (urolog$.mp. OR exp. Urology/ or UROLOGIST.mp.) OR (NEPHROLOG$.mp. OR exp. Nephrology/ or NEPHROLOGIST.mp.))
Limit to (Humans, English Language, Adults (19 and over))

Search Outcome

Medline - 562 papers found of which 3 were relevant
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Topham et al 1994 UK	All patients (165) referred with isolated microscopic haematuria between Jan 1984 and Dec 1991. 94 male and 71 female. All undergoing renal biopsy and cystourethroscopy. Mean age was 37.5 (range 10-71). 135/165 (81.2%) of subjects under 50 years of age.	Prospective cohort study	Renal pathology detected	77/165 (46.6%)	Referral bias. 17% had already had urological investigation including cystoscopy which might result in a low perceived incidence of urological abnormalities. No clear indication of what proportion of which pathologies were in which age group. Subjects under 18 years of age included. Gross haematuria not included.
			% of patients under 45 years of age with normal cystoscopy	100%
			Urological pathology detected	5/165 (3%) of which 2 also had IgA nephropathy
			% of renal biopsy abnormalities in subjects older than 50 years	41%
			% of renal biopsy abnormalities in subjects younger than 50 years	53.5%
Sparwasser et al 1994 Germany	157 men (mean age 24.8 years, age range 19-35) presenting with asymptomatic haematuria between Jan 1989 and Dec 1991	Prospective study	Patients discovered to have urological disease	23 (14.6%)	Gross haematuria not included. Only men included. 24 patients withdrew before IVU, 10 rejected cystourethroscopy, 18 did not consent to renal biopsy therefore 57/157 (33.1%) not evaluated properly. Sample not comparable to the general population as all were military personnel.
			Patients discovered to have glomerulopathy	26 (16.5%)
Froom et al 1984 Israel	1000 asymptomatic male air force personnel examined for the results of 15 yearly examinations of urinary sediment. Period covered 1968-82 beginning with subjects aged 18-33 years	Retrospective cohort study	Incidence of urological pathology at 15 years	0.1% TCC	Sample not representative of general population - all male, all military personnel.
				0.6% Urolithiasis
				0.1% Vesical calculi
			Incidence of nephrological pathology at 15 years	0.1%

Comment(s)

Lack of good quality specific evidence makes a definitive clinical bottom line difficult to reach. However, the evidence shows a similar incidence of nephrological and urological pathology in this group of patients.

Clinical Bottom Line

Patients under 40 years of age presenting to the Emergency Department with haematuria are equally appropriately referred to a urologist or a nephrologist for further investigation.

References

1. Topham PS, Harper SJ, Furness PN, Harris kpg, Walls J, Feehally J Glomerular disease as a cause of isolated microscopic haematuria Quarterly Journal of Medicine 1994; 87:329-335
2. Sparwasser C, Cimniak HU, Treiber U, Pust RA Significance of the evaluation of asymptomatic microscopic haematuria in young men British Journal of Urology 1994; 74:723-729
3. Froom P, Ribak J, Benbassat J Significance of microhaematuria in young adults British Medical Journal Clinical Research Ed. 288(6410):20-2, 1984 Jan 7