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Proteinuria and Haematuria – an update

Proteinuria and Haematuria – an update. Alex Heaton 11.02.2009. What is normal?. Normal 80 +/- 25 mg/day (<150 mg is quoted as upper normal limit). Adolescents up to 300 mg/day ( ♀ 10-16 years, ♂ 12-18 years). Measurements of proteinuria. Dipstick tests 24 hour urinary protein

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Proteinuria and Haematuria – an update

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  1. Proteinuria and Haematuria – an update Alex Heaton 11.02.2009

  2. What is normal? • Normal 80 +/- 25 mg/day (<150 mg is quoted as upper normal limit). • Adolescents up to 300 mg/day (♀ 10-16 years, ♂ 12-18 years)

  3. Measurements of proteinuria • Dipstick tests • 24 hour urinary protein • Urine protein/creatinine ratio • Urine albumin/creatinine ratio

  4. Why bother testing urine? • Detection of renal disease • Cardiovascular risk factor

  5. Clinical significance of proteinuria Proteinuria on dipstick in healthy patient  ? Any systemic disease, e.g hypertension, diabetes mellitus  likely renal disease  >1 gram a day  likely renal disease  >3.5 g/day  likely glomerular disease

  6. Protein in urine – what next? • establish persistent proteinuria • clinical assessment • interpreting test results

  7. Step 1. Establish persistent proteinuria proteinuria (1+ or more) ↓ exclude urinary infection ↓ repeat urinalysis after at least one week ↓ ↓ 1+ or more continue trace or negative – no action

  8. Step 2. Initial assessment if persistent proteinuria 1+ or more • send early morning urine for albumin/creatinine ratio • blood tests: U & E’s, fasting glucose, cholesterol and albumin • Check blood pressure

  9. Step 3: What to do with an albumin/creatinine(mg/mmol) result • <5 within reference range • 5-30 does not indicate renal disease but consider cardiovascular risk factors • 31-70 check 6 monthly blood pressure and ACR. No need to refer to nephrology unless patient also has haematuria, severe hypertension, eGFR <60 or a systemic disease • >70 refer to Nephrology

  10. Proteinuria - summary • urine protein testing is worthwhile (vs blood) • use dipstix to decide when to test further • albumin : creatinine ratio instead of 24 hour collection. • use ACR to decide who to refer

  11. Haematuria • frank haematuria – high yield on investigation • microscopic haematuria + symptoms – high yield - symptoms – low or very low yield

  12. Microscopic haematuria • trace blood + no symptoms – no investigation • 1+ or more, confirmed on repeat testing – investigate/refer?

  13. Urology Referral • male • >40 years • smoker • industrial exposure to hydrocarbons • chemotherapy = cystoscopy

  14. Renal referral • eGFR < 60 • proteinuria (ACR >30) • hypertension • family history = nephrology

  15. What tests? • eGFR • plain urinary tract X-ray • ultrasound • ? urine microscopy ? cytology

  16. Summary - haematuria • try to avoid testing asymptomatic patients • most asymptomatic patients do not need referral? • limited benefit from renal referral unless specific indication.

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