ANSWER 59
Microscopic haematuria has many renal and urological causes, e.g. prostatic disease,
stones, but the presence of significant proteinuria, hypertension and renal impairment sug-
gest this man has some form of chronic glomerulonephritis. The high gamma-glutamyl
transpeptidase level is compatible with liver disease related to a high alcohol intake. The
recommended upper limit for men is 28 units per week.
- Immunoglobulin A (IgA) nephropathy
- Thin basement membrane disease
- Alport’s syndrome (predominantly affects males)
! Commonest glomerular causes of microscopic haematuria
IgA nephropathy is the commonest glomerulonephritis in developed countries, and is char-
acterized by diffuse mesangial deposits of IgA. Patients often have episodes of macroscopic
haematuria concurrent with upper respiratory tract infection. Most cases of IgA nephrop-
athy are idiopathic, but this it is also commonly associated with Henoch–Schönlein purpura
and alcoholic cirrhosis. This man has IgA nephropathyin association with alcoholic liver
disease. About 20 per cent of patients with IgA nephropathy will develop end-stage renal
failure after 20 years of follow-up.
Thin basement membrane disease is a familial disorder which presents with isolated micro-
scopichaematuria, minimal proteinuria and normal renal function that does not deteri-
orate. Electron microscopy shows diffuse thinning of the glomerular basement membranes
(the width is usually between 150 and 225 nm versus 300–400 nm in normal subjects).
Alport’s syndrome is a progressive form of glomerular disease, associated with deafness
and ocular abnormalities and is usually inherited as an X-linked dominant condition so
that males are more seriously affected.
This patient should have a renal biopsy to reach a histological diagnosis. As the patient is
over 50 years old he should have urine cytology/prostate-specific antigen/cystoscopy per-
formed to exclude concurrent bladder and prostatic lesions. He needs a liver ultrasound,
and liver biopsy should be considered.
The patient should be advised to abstain from alcohol, and needs his blood pressure con-
trolling. He needs regular follow-up as he is at risk of progressing to dialysis and/or renal
transplantation. The raised creatinine appears modest in terms of the actual figures, but as
plasma/serum creatinine does not begin to rise until the glomerular filtration rate is reduced
to 50 per cent of normal (irrespective of the patient’s age), the raised creatinine in this case
indicates a serious loss of renal function to approximately 40 per cent of normal. There is
no convincing evidence for immunosuppression retarding the progression into renal fail-
ure in most patients with IgA nephropathy.
- Patients with isolated haematuria aged!50 years should be initially referred to a
nephrologist. - Patients with isolated haematuria aged#50 years should be initially referred to a urolo-
gist for investigation, to exclude bladder or prostatic disease. - Small elevations in serum/plasma creatinine indicate large loss in renal function.
- Liver damage from a high alcohol intake may occur with no obvious signs and symptoms.