How would you treat a patient who has hepatitis C, cirrhosis, and gross hematuria? A platelet count is 50,000/µL. Cystoscopy and abdominal CT are negative.
—Filadelfo V. Oandasan Jr, MD, Palo Alto, Calif.

The differential diagnosis for gross hematuria includes urinary tract malignancy, nephrolithiasis, and renal disease (glomerular). In this patient, the cystoscopy and CT have ruled out urinary tract malignancy and nephrolithiasis. To work up your patient for renal disease, I would suggest 24-hour urine assays to check for protein and monitoring creatinine clearance. If either finding is abnormal, referral to a nephrologist for renal biopsy is indicated. This particular patient’s low platelet count is likely due to splenic sequestration associated with portal hypertension and splenic enlargement. However, idiopathic thrombocytopenic purpura can be seen in association with hepatitis C. It would be unusual to have bleeding complications at a platelet count >15,000 in the absence of a concomitant prolonged prothrombin time.
—Karen E. Brown, MD (99-11)

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