To the Editor In their cost-effectiveness evaluation of diagnostic approaches to asymptomatic microscopic hematuria in a recent issue of JAMA Internal Medicine, Halpern et al1 point out the superiority of using ultrasonography over the alternative of computed tomography together with cystoscopy for detection of urinary tract cancer. However, I believe that their advice needed to be more nuanced to properly inform the reader. While occult cancer may be of greatest concern, glomerular disease with its attendant risks for chronic kidney disease and premature death is a serious condition in those with microscopic hematuria, particularly when affected patients present in the primary care setting and are not referred to specialty clinics or urologists. First, a careful urinary sediment examination looking for either erythrocyte casts or greater than 5% acanthocytes,2 which has almost 100% specificity for glomerular disease, is a noninvasive way to spare patients from unnecessary imaging or cystoscopy.
Brown RS. Search Images and Extrapolation Risk. JAMA Intern Med. 2017;177(12):1870. doi:10.1001/jamainternmed.2017.6310
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