How is hematuria managed?
• Conservative measures, including bedrest and oral hydration, remain the cornerstone in the management gross hematuria.
• In more severe cases, hydration with alkaline fluids may be used to correct volume depletion, acidemia, or both, to reduce sickling and minimize HbS precipitation. Other considerations include the use of loop diuretic to prevent microtubular obstruction, and blood transfusions to reduce HbS and sickling.
• Alternative therapeutic options may be considered in refractory cases and include high-dose urea, vasopressin, or epsilon-aminocaproic acid (EACA). High doses of oral or intravenous urea (up to 160 g/day) to achieve blood urea nitrogen greater than 100 mg/dL has been shown to inhibit the polymerization of deoxygenated sickle hemoglobin and are reported to be effective in some refractory cases. Vasopressin is thought to improve clotting via the increase in plasma factor VIII and von Willebrand factor. Vasopressin may be given intravenously over 30 minutes at 0.3 mcg of DDAVP/kg body weight. EACA inhibits fibrinolysis by inhibiting plasmin activity. However, blood clot formation within the collecting system from the use of EACA may lead to tubular obstruction, leading to kidney injury. Note that these alternative therapeutic options lack data and are not without adverse effects. Their use should only be considered for refractory cases. Optimal EACA dosing is not known, but has been suggested to be 2 to 3 g daily (5 to 50 mg/kg every 8 to 12 hours) over several days, not to exceed 12 g daily due to risk of thrombosis.
• Angiographic embolization of the involved kidney vessel or balloon tamponade for bleeding from papillary necrosis may be considered in cases of failed conservative medical therapies.
• Unilateral nephrectomy is not recommended, because bleeding can recur in the contralateral kidney.