Macter’s Clinical Excellence & Leadership Program (CELP)
Diabetes is the single most common cause of End-Stage Renal Disease (ESRD): Experts discussed in the tenth session of CELP’s National CME Series 2008
KARACHI – Macroscopic haematuria always needs investigation to rule out a urinary tract infection where it is usually associated with symptoms and to rule out malignancy or other causes when it may be painless, said Dr Aziz Abdullah, Consultant Urologist, Liaquat National Hospital (LNH) while speaking at the 10th session of the National CME Series being conduced under the aegis of Clinical Excellence and Leadership Program (CELP) of Macter International (Pvt) Ltd.
Dr Aziz Abdullah informed that 20 per cent of the cases of macroscopic hematuria are due to malignancy. Discussing about microscopic hematuria, he stated that loss of red cells in the urine is physiologically normal in small amounts of less than 20 RBC per micro liter. He informed that positive dipstick with one or more positive MSU (Mid-Stream Urine) results confirm microscopic haematuria. He stated that it is highly unlikely that the patient has haematuria, if the dipstick test is negative, and unless there is other demonstrable urological pathology no further investigation is required. Where the dipstick is positive, he said, a history should exclude menstruation or trauma (which includes vigorous exercise or sexual activity within 24 hours) and examination should exclude genital or urethral lesions. In people over 40 years, he informed, the lower urinary tract is a more common cause of haematuria and as bladder lesions are a significant cause of haematuria in this age group, cystoscopy is advised.
Conditions associated with microscopic haematuria, he informed, include thin glomerular basement membrane nephropathy, IgA nephropathy, urethritis, cystitis, prostatitis (bacterial and non bacterial), benign prostatic hypertrophy, calculi, malignancies of the bladder, prostate or kidney, tuberculosis of the urinary tract, etc.
Dr Aziz Abdullah stated that carcinoma of urinary bladder is the second most common genitourinary malignancy; its peak incidence is 50-70 years of age; and male-female ratio is 3:1. Risk factors for carcinoma of bladder, he informed, are industrial toxins, cigarette smoking, radiation exposure, chemotherapy (Thiotepa, cyclophosphamide), and chronic bladder irritation (stone, catheter, infection); while the signs and symptoms of the disease include painless gross haematuria (in 80% of the patients), microscopic haematuria (20%), dysuria & irritative symptoms especially with Ca in situ (30%), urinary tract infection (30%), symptoms of metastasis (10%), while upper tract obstruction is rare on initial presentation but if present, is a sign of advanced disease.
Consultant Urologist, Dr Ishrat Saleem, in his presentation on benign prostatic hyperplasia (BPH), stated that the prevalence of symptomatic BPH increases with age and almost half the men over 60 years of age are affected by this disease. He said that the three points that may help detect any prostatic disease are; need to get up at night to pass urine, slow urine flow and botheration by bladder function. Elaborating upon interpretation of prostate-specific antigen (PSA) values, he stated that value of 0.4-5 ng/ml is considered as normal while levels of 4-10 ng/ml indicate chances of cancer up to 20%, and 50% or more chances of cancer are associated with a level of more than 10 ng/ml. He advised that the patient should be referred immediately for biopsy if there is more than 20 per cent increase in the level of PSA per year.
Treatment options for BPH, he said, include watchful waiting; medical therapy including phyto-therapy, alpha-blockers and finasteride; minimally invasive therapy including High Intensity Focused Ultrasound (HIFU), interstitial lasers, thermo therapy (RF, microwave); surgical therapy including BNI (TUIP), TURP; while recent advances in the treatment modalities include holmium laser and plasmakinetic energy.
Dr Farzana Adnan, Assistant Professor, Department of Nephrology & Transplantation LNH, in her presentation on diabetic nephropathy stated that diabetes is the single most common cause of End-Stage Renal Disease (ESRD). Prevalence of diabetic nephropathy, she informed, is 15-40% in Type I diabetes and 5-20% in Type II. There is a linear increase in prevalence of nephropathy with the duration of disease in Type II diabetes, she said. More than 80 per cent of diabetics on dialysis are those having type II, she added. Risk factors for diabetic nephropathy, she informed, include genetics, poor diabetic control, elevated blood pressure, albuminuria or proteinurea, hyperlipidemia, smoking and high dietary protein intake. Counseling is the most neglected aspect, she said, though it is equally important as that of pharmacological treatment.
Discussing about the measures to prevent progression of diabetic nephropathy, she advised for tight glucose control (HbA1c < 7.0), blood pressure control, smoking cessation, lipid lowering and dietary protein restriction to 0.6 gram per kilogram body weight per day. She stated that diabetic nephropathy is a common disorder with a great financial burden and its progress is preventable by early detection and timely intervention. She advised that screening for diabetic nephropathy should be performed at an early stage and doctors should spend at least 5-10 minutes for patient’s counseling.
