Gender, race, and variation in the evaluation of microscopic hematuria among Medicare beneficiaries

BACKGROUND

Female gender and black race are associated with delayed diagnosis and inferior survival in patients with bladder cancer.

OBJECTIVE

We aimed to determine the association between gender, race, and evaluation of microscopic hematuria (an early sign of bladder cancer).

DESIGN AND PARTICIPANTS

This was a cohort study using a 5 % random sample of fee-for-service Medicare beneficiaries diagnosed with incident hematuria (International Classification of Diseases, Ninth Revision [ICD-9] code 599.7x) between January 2009 and June 2010 in a primary care setting. Beneficiaries with pre-existing explanatory diagnoses or genitourinary procedures were excluded.

MAIN MEASURES

The main endpoint was completeness of the hematuria evaluation in the 180 days after diagnosis. Evaluations were categorized as complete, incomplete, or absent based on receipt of relevant diagnostic procedures and imaging studies.

KEY RESULTS

In all, 9,211 beneficiaries met the study criteria. Hematuria evaluations were complete in 14 %, incomplete in 21 %, and absent in 65 % of subjects. Compared to males, females were less likely to have a procedure (26 vs. 12 %), imaging (41 vs. 30 %), and a complete evaluation (22 vs. 10 %) (p < 0.001 for each comparison). Receipt of a complete evaluation did not differ by race. Controlling for baseline characteristics, a complete evaluation was less likely in white women (OR, 0.40 [95 % CI, 0.35-0.46]) and black women (OR, 0.46 [95 % CI, 0.29-0.70]) compared to white men; no difference was found between black and white men.

CONCLUSIONS

Women are less likely than men to undergo a complete and timely hematuria evaluation, a finding likely relevant to women's more advanced stage at bladder cancer diagnosis. System-level process improvement between providers of urologic and primary care in the evaluation of hematuria may benefit women harboring malignancy.

Patterns of autosomal dominant polycystic kidney diseases in black Africans

Autosomal dominant polycystic kidney disease (ADPKD) is not well described in black Africans while some data suggesting the disease is exceptional in this race. A retrospective study of patients with ADPKD followed in nephrology department of a teaching hospital in Dakar (January 1, 1995 to December 31, 2005) was therefore undertaken. Prevalence of ADPKD was one in 250. Mean age was 47 + or - 5 years with a predominance of male (57%). High blood pressure (HBP) was present in 68% of patients. Other renal manifestations were flank pain, hematuria and proteinuria. Majority of patients had impaired renal function at time of diagnosis. Extra-renal cysts were essentially found in liver (45.5%), pancreas and seminal vesicles. Main complications: ESRD (51%) occurred within a 6 year mean period, urinary tract infection (13%) and cerebral haemorrhage (2%). HBP control, in general needed 2 or more antihypertensive drugs. Fourteen patients died, ten patients had been on haemodialysis and four others died from uremic complications. In conclusion, ADPKD in black African adults is not rare and probably underdiagnosed. Early HBP and ESRD are likely more frequent than in other races. Earlier ultrasound detection and strategies to preserve renal function should be offered to at-risk individuals to improve outcomes.

Post-streptococcal glomerulonephritis in Sydney: a 16-year retrospective review

AIM

Post-streptococcal glomerulonephritis (PSGN) is a frequent cause of acute nephritis in children. Numerous studies have described PSGN in high-risk populations yet few data describing PSGN in a low-incidence population exist. This study aimed to describe the epidemiology, clinical manifestations, diagnosis, complications and outcomes of PSGN in an urban Australian population.

METHODS

A 16-year retrospective review of case notes and laboratory data was conducted at a tertiary Sydney paediatric hospital.

RESULTS

Thirty-seven children were treated for PSGN with a mean age of 8.1 years (range 2.6-14.1 years). Twenty-eight subjects (75.7%) had a history of a recent upper respiratory tract or skin infection. Hypertension and/or oedema was present in 29 subjects (78.4%). Streptococcal pharyngitis was identified as the likely source in 17 subjects (45.9%). Skin infections occurred less frequently. Antibodies against streptolysin O, streptokinase or deoxyribonuclease B were elevated when a single titre was measured in 35 subjects (94.6%). Thirty subjects (81.1%) developed renal impairment (median peak creatinine, 95 micromol/L, range 39-880 micromol/L). No correlation was demonstrated between peak creatinine, age, ethnicity, streptococcal titres and serum complement levels. The mean length of admission was 8.2 days. Seven subjects (18.9%) had a complicated course with three subjects requiring dialysis. Only one subject has ongoing renal dysfunction.

CONCLUSION

Significant differences are seen in a low-incidence urban Australian population with PSGN when compared with endemic or epidemic disease in high-risk populations. The higher rates of complications that were seen compared with previously studied populations need further clarification.

Early chronic kidney disease in Aboriginal and non-Aboriginal Australian children: remoteness, socioeconomic disadvantage or race?

Indigenous people suffer substantially more end-stage kidney disease (ESKD), especially Australian Aboriginals. Previous work suggests causal pathways beginning early in life. No studies have shown the prevalence of early markers of chronic kidney disease (CKD) in both Indigenous and non-Indigenous children or the association with environmental health determinants--geographic remoteness and socioeconomic disadvantage. Height, weight, blood pressure, and urinary abnormalities were measured in age- and gender-matched Aboriginal and non-Aboriginal children from elementary schools across diverse areas of New South Wales, Australia. Hematuria was defined as>or=25 red blood cells/microl (>or=1+), proteinuria>or=0.30 g/l (>or=1+), and albuminuria (by albumin:creatinine)>or=3.4 mg/mmol. Remoteness and socioeconomic status were assigned using the Accessibility and Remoteness Index of Australia and Socio-Economic Indexes For Areas. From 2002 to 2004, 2266 children (55% Aboriginal, mean age 8.9 years) were enrolled from 37 elementary schools. Overall prevalence of hematuria was 5.5%, proteinuria 7.3%, and albuminuria 7.3%. Only baseline hematuria was more common in Aboriginal children (7.1 versus 3.6%; P=0.002). At 2-year follow-up, 1.2% of Aboriginal children had persistent hematuria that was no different from non-Aboriginal children (P=0.60). Socioeconomic disadvantage and geographical isolation were neither significant nor consistent risk factors for any marker of CKD. Aboriginal children have no increase in albuminuria, proteinuria, or persistent hematuria, which are more important markers for CKD. This suggests ESKD in Aboriginal people may be preventable during early adult life.

Kidney volume, blood pressure, and albuminuria: findings in an Australian aboriginal community

BACKGROUND

Australian Aborigines are experiencing epidemic proportions of renal disease, marked by albuminuria and, variably, hematuria. They also have high rates of low birth weight, which have been associated with lower kidney volumes and higher blood pressures. The authors evaluated relationships between kidney volume, blood pressure, albuminuria, and hematuria in 1 homogeneous group.

METHODS

Forty-three percent (672 of 1,560) of the population in a remote coastal Australian Aboriginal community aged 4.4 to 72.1 years participated in the study.

RESULTS

Kidney size correlated closely with body size. Systolic blood pressure (SBP) was correlated inversely with kidney length and kidney volume, after adjusting for age, sex, and body surface area (BSA); a 1-cm increase in mean kidney length was associated with a 2.2-mm Hg decrease in SBP, and a 10-mL increase in mean kidney volume was associated with a 0.6-mm Hg decrease in SBP (P = 0.001). Mean kidney volume explained 10% of the variance in SBP in a multivariate model containing age, sex, and BSA. In addition to higher SBP, adults who had the lowest quartiles of kidney volume also had the highest levels of overt albuminuria (P = 0.044).

CONCLUSION

Smaller kidneys predispose to higher blood pressures and albuminuria in this population. The lower volumes possibly represent kidneys with reduced nephron numbers, which might be related to an adverse intrauterine environment. Susceptibility to renal disease could be a direct consequence of reduced nephron numbers; the higher blood pressures with which they are associated could also contribute to, as well as derive from, this association.

Prevalence of hematuria among Zuni Indians with and without diabetes: The Zuni kidney Project

BACKGROUND

There is an epidemic of kidney disease among the Zuni Indians. In contrast to other American Indian tribes, the epidemic among the Zuni Indians is attributable to diabetic and nondiabetic renal disease.

METHODS

The Zuni Kidney Project, established to reduce the burden of renal disease, conducted a population-based cross-sectional survey of Zuni Indians aged 5 years or older to precisely estimate the prevalence of hematuria. The survey used neighborhood household clusters as the sampling frame to maximize ascertainment and minimize bias. During the survey, we administered a questionnaire; collected blood and urine samples; and measured blood pressure, height, and weight.

RESULTS

Age and sex distributions in our sample (n = 1,469) were similar to those of the eligible Zuni population (n = 9,228). Prevalences of hematuria, defined as dipstick of trace or greater and 50 red blood cells/microL or greater, age- and sex-adjusted to the Zuni population aged 5 years or older, were 33.2% (95% confidence interval [CI], 30.7 to 35.6) and 17.8% (95% CI, 15.8 to 19.8), respectively. Hematuria of trace or greater was more common among females (40.6%; 95% CI, 37.0 to 44.1) than males (25.1%; 95% CI, 21.8 to 28.4). Hematuria of trace or greater was common among Zuni Indians without diabetes (females, 39.7%; 95% CI, 35.7 to 43.8; males, 22.7%; 95% CI, 19.4 to 26.1) and with diabetes (females, 47.5%; 95% CI, 39.8 to 55.2; males, 45.8%; 95% CI, 34.3 to 57.3). Diabetes and alcohol use for greater than 10 years were associated with hematuria among males, but not females.

CONCLUSION

The prevalence of hematuria is high among Zuni Indians with and without diabetes. These findings are consistent with the hypothesis that nondiabetic kidney disease is common among Zuni Indians with and without diabetes.

Childhood post-streptococcal glomerulonephritis as a risk factor for chronic renal disease in later life

OBJECTIVE

To test the hypothesis that post-streptococcal glomerulonephritis (PSGN) in childhood is a risk factor for chronic renal disease in later life.

DESIGN

Retrospective cohort study.

SETTING

A remote Aboriginal community in the "Top End" of the Northern Territory that experienced two epidemics of PSGN in 1980 and 1987, respectively.

PARTICIPANTS

472 people who were aged 2-15 years during either epidemic. They were categorised by clinical features recorded during the epidemics as having clinically defined PSGN (63), "abnormal urine" (haematuria or proteinuria; 86) or controls (323).

OUTCOME MEASURES

Urinary albumin to creatinine ratio (ACR), haematuria (by dipstick urinalysis), blood pressure, serum creatinine level, and calculated glomerular filtration rate (GFR) during community screening in 1992-1998.

RESULTS

Overt albuminuria (ACR > 34 mg/mmol) was present at follow-up in 13% of the PSGN group, 8% of the abnormal urine group, and 4% of the control group. The odds ratio (OR) for overt albuminuria in those with a history of PSGN compared with the control group, adjusted for age and sex, was 6.1 (95% CI, 2.2-16.9). Haematuria (>trace) was present in 21% of the PSGN group compared with 7% of the control group (adjusted OR, 3.7; 95% CI, 1.8-8.0). There were no significant differences between the groups in blood pressure, serum creatinine level or calculated GFR.

CONCLUSION

In this population, a history of PSGN in childhood is a risk factor for albuminuria and haematuria in later life.

[Bilharziasis and bladder cancer. A case report]

In our setting, the association between bilharziasis and bladder cancer is uncommon. However, the presence of recurrent haematuria in a patient from an endemic area of bilharziasis (east of Africa and Middle East), is highly suspicious of this disease. Lack of an adequate treatment by using anthelminthic drugs during the acute phase of disease, might lead to the onset of chronic bladder lesions and, on occasion, bladder cancer, of the epidermoid type in the majority of cases. Because of the high mortality and aggressivity of this type of cancer, an early diagnosis and appropriate treatment of acute lesions is mandatory. We report a 40-year-old black male from Senegal, presenting chronic bladder schistosomiasis and infiltrative epidermoid carcinoma of the bladder, diagnosed and treated in our department by palliative cystectomy.

Racial differences in the prevalence and presentation of glomerular disease in adults

In order to ascertain to prevalence of glomerulopathies in our patient population, all renal biopsies performed on patients older than 14 years of age presenting to a single military hospital from 1983 to 1992 were reviewed. Two hundred and eighty-five patients were included in the study. Indications for renal biopsy included evaluation for the nephrotic syndrome, asymptomatic proteinuria, hematuria/proteinuria, isolated hematuria or systemic disease. Fifty-one percent of the patients were white and 44 percent were black. The male/female ratio was 3.2:1. The most common etiology of the nephrotic syndrome or asymptomatic proteinuria was focal glomerular sclerosis, and was found predominantly in black males. IgA nephropathy was the most common cause of combined hematuria and proteinuria, and was not found in any black patients in 126 biopsies. Isolated hematuria was secondary to either IgA nephropathy or thin basement membrane disease in 70 percent of the biopsies. This is the first study to demonstrate such differences in glomerular disease in an American population on the basis of race and sex in a single center.

Hematuria in sickle cell anemia--not always benign: evidence for excess frequency of sickle cell anemia in African Americans with renal cell carcinoma

Between 1952 and 1992, we identified 117 African Americans with renal cell carcinoma (RCC) at the University of Chicago. Three of these had sickle cell disease (SS) and 11 had presumed sickle trait (AS). Based on genotype frequencies, these represented a 16.7-fold excess of SS patients (p < 0.0001), but the incidence of AS patients was as expected. In addition, the median age for the SS patients at presentation with RCC (36 years) was significantly less (p = 0.04) than for the AS patients (55 years). We have found no prior reports of SS in RCC patients and suggest that chronic renal injury from sickling and possible immunosuppressive effects of multiple red cell transfusions may be risk factors. We also suggest the need to be aware of the possibility of RCC in SS patients who may have hematuria solely related to sickling.