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Rapid Responses: Rapid Responses published:
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Do not use urine microscopy to 'confirm' microscopic haematuria
- Peter A Andrews (16 June 2009)
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Is there no role for an MSU?
- Peter G Watson (16 June 2009)
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muda
- muir gray (16 June 2009)
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should BMJ papers fit UK guidelines?
- Jonathan P Richards (18 June 2009)
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Peter A Andrews, Consultant Nephrologist KT10 0NA
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Baaker and Boon (BMJ 2009;338:b1324) correctly state that the presence of urinary myoglobin will generate occasional false positive results when using dipstick urinalysis for the diagnosis of microscopic haematuria. However, it is poor practice to attempt to 'confirm' the presence of red cells by urine microscopy. Urinary red cells are lysed in acidic urine or following prolonged storage, and laboratory error is common in urine microscopy; the result of adopting such a policy is to convert a small false positive rate into a large false negative rate. If investigation or follow-up is contemplated, far better to follow the advice of the UK Renal Association and the NICE CKD Guideline and to omit this step. Of course, it is debatable whether there is any value in the investigation of a patient aged <40 presenting with microscopic haematuria, in the absence of hypertension, alert symptoms, proteinuria or abnormal renal function. The fact that such patients are inappropriately (and often invasively) investigated ignores the high frequency of the condition, the very low pick up rate of significant pathology, the possible complications, and the opportunity cost of such resource allocation. Many nephrologists now routinely return such referrals back to primary care. (References available on request). Competing interests: None declared |
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Peter G Watson, consultant, genitourinary medicine Bronglais General Hospital, Aberystwyth, SY23 1ER
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When a 40 year old woman presents with urinary frequency and the urine dipstick analysis shows haematuria 3+, shouldn't the list of what should be done include a midstream specimen of urine for bacterial culture and sensitivity? Competing interests: None declared |
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muir gray, public health director , campaign for greener healthcare oxford ox2 8jq
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The woman with microscopic haematuria could have been told that frequency without dysuria is not a symptom of serious disease and that she should not worry explore any anxieties she might have , fear of cancer for example, and discharged. The urinary dipstick that detects microscopic haematuria is an intervention of , at best very low value and it can have a negative value, doing more harm than good. It should be used with very great care. The resources consumed by the consequences of ‘positive’ test are huge, as your 10 minute consultation demonstrates – referrals to urology, more tests, and ‘monitoring’. At least the woman escaped the option which a friend who is an epidemiologist when he found himself facing a renal biopsy needle as the result of a ‘positive’ dipstick until he walked out of the doctor’s office but she has become a patient. In the 21st century we need to increase the value we get from the resources for healthcare, one step would be to remove the haematuria test for the dipstick. The total cost of the consequences of the automatic and unthinking use dipsticks is unknown but it is not the money that is of concern it is the waste, using the word waste with the Toyota meaning of an activity that does not add value; muda is the japanese word. The activities waste clinical time which could be used on other higher value activities, preventing venous thrombo-embolism or identifying people with familial hypercholesterolaemia for example and it is a waste of carbon. Surely external peer review, particularly for the BMJ, should appraise the sustainability of the measures proposed in articles submitted for publication. Competing interests: None declared |
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Jonathan P Richards, general practitioner Morlais Medical Practice CF48 3 AL
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Our general practice changed its policy for the management of haematuria following the publication of the NICE guidance on Chronic Kidney disease in 2008 (1). This 10 minute consultation review, written by authors who do not need to apply NICE guidance in their clinical settings, would suggest that we should revert to our previous policy. Our patients expect us to be up to date and evidence based. Is the BMJ doing us a disservice by publishing recommendations that go against recent UK national guidance? I know that British is not always best or right. I often quote the low blood pressure papers from 1989 and 1990(2)to students and patients as a reminder that as English speaking scientists we must be humble about insights from other cultures and settings. How should the editorial team at the BMJ handle these issues? Should a "not suitable for clinicians in the NHS" health warning be attached to recommendations that contradict the pronouncements of NICE? 1.CG 73 Chronic Kidney Disease http://www.nice.org.uk/guidance/CG73 2.S Wessely, J Nickson and B Cox Symptoms of low blood pressure: a population study doi:10.1136/bmj.301.6748.362 BMJ 1990;301;362-365 Competing interests: None declared |
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