Imaging Recommendations for Microscopic Hematuria Workup in Patients with Impaired Renal Function

Risk Assessment and Imaging Selection Algorithm

A 68-year-old male with microscopic hematuria (RBC 11-30) is considered intermediate-to-high risk for urologic malignancy, according to the American Urological Association 3
The American College of Radiology recommends MR urography when there are contraindications to multiphasic CT urography, such as impaired renal function (eGFR <45 ml/min) 1
History of elevated PSA and BPH increases risk for urologic pathology, as stated by the American Urological Association 4

MR urography without and with IV contrast is the most appropriate imaging modality for patients with impaired renal function (eGFR of 36) and microscopic hematuria, as recommended by the American College of Radiology and the American Urological Association 1, 2
The MR urography protocol should include heavily T2-weighted sequences, pre-contrast T1-weighted imaging, post-contrast sequences, and thin-slice acquisition with multiplanar imaging, according to the American College of Radiology 7

MR urography has comparable accuracy to CT in detection and characterization of renal masses, and can adequately evaluate the upper urinary tract for malignancy, as stated by the American College of Radiology 6, 2
MR urography is superior to ultrasound for detection of small urothelial lesions and better characterization of complex renal lesions, according to the American College of Radiology 8, 2
MR urography provides more comprehensive evaluation of the collecting system compared to non-contrast CT, as recommended by the American College of Radiology 7

If imaging reveals no significant findings, continued monitoring is recommended with repeat urinalysis at 6, 12, 24, and 36 months, as stated by the American Urological Association 5, 4
Additional evaluation should be considered if there is development of gross hematuria, significant increase in degree of microscopic hematuria, or new urologic symptoms, according to the American Urological Association 3