Letters to the Editor
In Reply
The guideline on chronic kidney disease (CKD) addresses disease management in general practice (1). Testing for hematuria is discussed in connection with newly diagnosed impaired renal function. In this constellation, nephritic syndrome, which requires specialized nephrological care, should not be overlooked.
Macrohematuria—which is not the subject of the guideline—should be assessed promptly and is, like microhematuria, notably more often caused by a urological disease. In this scenario, referral to a urology department is almost always indicated, especially in the absence of albuminuria. Microscopic urinalysis can usually be performed in this setting, and the further diagnostic evaluation can be decided on an case-by-case basis.
Only one out-of-date S1 clinical practice guideline exists for the management of non-visible hematuria in general practice (2), which is currently being updated (3). Since microhematuria is extremely common and mostly caused by neither severe urological nor nephrological disease, further testing using urine dipstick test is recommended if no other explanation has been found.
Microscopy of the urine sediment requires equipment (microscope, centrifuge), expertise, and regular practice, which most general practices cannot—and are not obliged to—offer. Sending a specimen to the laboratory is rarely feasible due to cell breakdown.
It is unrealistic to recommend a testing modality that has not been widely available for a long time. The guideline from the UK National Institute for Health and Care Excellence (NICE) recommends explicitly to refrain from microscopic urinalysis in CKD. The guideline from the Kidney Disease: Improving Global Outcome (KDIGO) organization does not provide specific guidance on how to evaluate hematuria. Examination under the microscope (billing codes 32031) is reimbursed at €0.25. Given this reimbursement its availability in the outpatient setting is likely to decrease further.
DOI: 10.3238/arztebl.m2025.0060
On behalf of the authors
Prof. Dr. med. Jean-François Chenot, MPH
Abteilung Allgemeinmedizin
Institut für Community Medicine
Universitätsmedizin Greifswald
jchenot@uni-greifswald.de
Conflict of interest statement
JFC has received seminar fees from IHF and medical associations and fees for expert opinions provided to courts, medical associations, and the medical service of health insurers. He is Vice President of DEGAM, a member of the Guidelines and Quality Management Section of DEGAM, and a member of the General Practitioners’ Association of Mecklenburg-Western Pomerania.
| 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 CrossRef MEDLINE VOLLTEXT |
| 2. | www.register.awmf.org/assets/guidelines/053-028k_S1_Nicht_sichtbare_Haematurie_2020-11-abgelaufen.pdf. |
| 3. | www.innovationsfonds.g-ba.de/projekte/versorgungsforschung/haem-up.644. |
