Complication-Free Examination Method

Letters to the editor regarding the article The Management of Chronic Kidney Disease Not Requiring Renal Replacement Therapy in General Practice by Simone Kiel, Martha Negnal, Sylvia Stracke, Susanne Fleig, Martin K. Kuhlmann, and Jean-François Chenot, in issue 2/2025

In my experience, the routine presentation of patients with chronic kidney disease in a specialist nephrology practice is often associated with substantial fears. For this reason I am strongly in favor of managing such patients in general practice. The article by Kiel et al. (1) does, however, not deal with sick persons but with diseases—as a quasi-independent entity—and thus also with the initial diagnosis, as indicated in the article title. But this guideline rather leaves primary care physicians in the lurch.

I regret that the guideline authors obviously did not read a recently published guideline in Deutsches Ärzteblatt (2) that focuses more on patient care. In 2024 (2) attention was drawn to the importance of urine cytology in hematuria. This method is, however, barely known outside nephrology, in spite of excellent scientific publications (3).

Acanthocytes or dysmorphic erythrocytes and fragmentocytes in urine are unfamiliar terms for doctors outside the small group of nephrologists and urologists (4).

It is undoubtedly correct that macrohematuria mostly originates from a disease falling under the urology specialty (1). But why should the simple, painless, and risk-free examination for erythrocyte anomalies not be done before anything else? I remember some cases of young men in whom cystoscopy and computed tomography of kidneys and urinary tract were carried out because of macrohematuria, and who were referred in a rather traumatized condition to nephrology with rising creatinine concentrations and suspected contrast-medium induced renal failure. The renal biopsy specimens of these patients showed rapidly progressive glomerulonephritis. The patients then asked themselves, and later us, why the fruitless invasive tests had been deemed to be necessary.

Admittedly, these were rare individual cases. But we—and that includes authors of guidelines—are obliged to avert harm from the patients entrusted to our care where possible. First, do no harm! Which brings me to the microscopic urinalysis. This truly is a complication-free examination.

DOI: 10.3238/arztebl.m2025.0059

Prof. Dr. med. Friedrich Lübbecke

Uelzen

Conflict of interest statement

The author declares that no conflict of interest exists.

References

1. Kiel S, Negnal M, Stracke S, Fleig S, Kuhlmann MK, Chenot JF: The management of chronic kidney disease not requiring renal replacement therapy in general practice. Dtsch Arztebl Int 2025; 122: 49–54

2. Latta K, Boeckhaus J, Weinreich I, Borisch A, Müller D, Gross O: Clinical practice guideline: Microhematuria in children and young adults—evaluation for the early detection of kidney disease. Dtsch Arztebl Int 2024; 121: 461–6

3. Köhler H, Wandel E, Brunck B: Acanthocyturia—a charccteristic marker of glomerular bleeding. Kidney Int 1991; 40: 115–20

4. Wirnsberger G, Schröttner B, Worm H: Die renale Hämaturie. Journal für Urologie und Urogynäkology 2023; 10: 36–8.