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PROTEINURIA

PROTEINURIA. DR HEDAYATI. INTRODUCTION. URINARY PROTEIN > 150mg/day More than 1 time ↑ capillary permeability. ISOLATED PROTEINURIA. PROTEINURIA WITHOUT HEMATURIA WITHOUT ↑ IN CREATININE. ISOLATED PROTEINURIA. MAY BE ASYMPTOMATIC

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PROTEINURIA

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  1. PROTEINURIA DR HEDAYATI

  2. INTRODUCTION

  3. URINARY PROTEIN > 150mg/day • More than 1 time • ↑ capillary permeability

  4. ISOLATED PROTEINURIA • PROTEINURIA WITHOUT HEMATURIA WITHOUT ↑ IN CREATININE

  5. ISOLATED PROTEINURIA • MAY BE ASYMPTOMATIC • HEAVY PROTEIONURIA , LIPIDURIA ,EDEMA , +/- ACTIVE URINE SEDIMENT

  6. SCREENING • NO COST- EFFECTIVE FOR GENERAL POPULATION, < 60y/o • HIGH RISK PATIENTS : DM HTN → ACEI or ARB SLOWING THE PROGRESSION OF PROTEINURIA

  7. TYPES OF PROTEINURIA • Glomerular proteinuria • Tubular proteinuria • overflow proteinuria

  8. Glomerular proteinuria • ↑ filteration of macromolecules Diabetic nephropathy ,glomerulopathy , exercise-induced, orthostatic proteinuria • Most : 1-2g/day

  9. Tubular proteinuria • Low molecular wt proteins • Interference with PCT reabsorption • No detection by dipstick

  10. overflow proteinuria • ↑ excretion of LMW • Almost always : MM • Others : AML ( Lysozyme ) Rhabdomyolysis ( Myoglobin) Hemolysis ( Hb) • Filtered load > reabsorption by PCT

  11. MIXED FORMS OF PROTEINURIA • MM • FSGS

  12. MEASUREMENT

  13. STANDARD URINE DIPSTICK • ALBUMIN • COLORIMETRIC REACTION • TETRABROMOPHENOL • GREEN SHADES • GLOMERULAR PROTEINURIA • HIGH SPECIFIC • NOT VERY SENSITIVE ( + ONLY : > 300-500 mg/d )

  14. STANDARD URINE DIPSTICK • INSENSITIVE METHOD TO DETECT INITIAL INCREASE IN PROTEIN EXCRETION • MICROALBUMINURIA (DIABETIC NEPHROPATHY ) • FALSE POSITIVE : CONTRAST ( 24 h ).

  15. STANDARD URINE DIPSTICK • GRADING : • NEGATIVE • 1 + : 15-30 mg /dL • 2 + : 30-100 mg/dL • 3 + : 100-300 mg/dL • 4 + : > 1000 mg/dL • ROUGH GUIDE : URINE VOLUME

  16. SULFOSALICYLIC ACID • ALL PROTEINS • AKI + BENIGN U/A +NEGATIVE DIPSTICK :MM • SULFOSALICYLIC ACID : + URINE DIPSTICK : - → NONALBUMIN PROTEINS MOST : LIGHT Ig

  17. SULFOSALICYLIC ACID • 1 part urine urine + 3 part SSA3% • TURBIDITY • GRADING: 0 TRACE : 1-10 mg/dL 1+ : 15-30 mg/dL 2+ : 40-100 mg/dL 3+ : 150-300 mg/dL 4+ : > 500 mg/Dl • FALSE POPSITIVE : CONTRAST (24h )

  18. LYSOZYME • AML • URINE DIPSTICK : + • SSA : + • NO OTHER SIGNS OF NEPHROTIC SYNDROME • DIRECT MEASUREMENT

  19. QUANTITATIVE MEASUREMENT • BENIGN FORMS : < 1-2 g/d • PROGNOSTIC IMPORTANCE • MONITOR THE RESPONSE TO THERAPY

  20. QUANTITATIVE MEASUREMENT • 24 HOUR URINE • RANDOM URINE : PROTEIN /Cr ratio (mg/ g) • ~ daily protein excretion (g/m2 ) • SERIAL MONITORING

  21. MICROALBUMINURIA • NL ALBUMIN EXCRETION : < 20mg/d • MICROALBUMINURIA : 30-300 mg/d • SPECIFIC DIPSTICKS • ALBUMIN/Cr RATIO

  22. APPROACH TO PROTEINURIA

  23. HISTORY • PHYSICAL EXAMINATION If systemic disease : MANAGEMENT OF PROTEINURIA : MANAGEMENT OF DISEASE

  24. URINE EXAMINATION • ALL PATIENTS • URINE SEDIMENT • REPEATED

  25. R/O TRANSIENT PROTEINURIA • COMMON • FEVER, EXERCISE (Ag – NEP) • NO FURTHER EVALUATION

  26. R/O ORTHOSTATIC PROTEINURIA • < 30y/o • ↑ proteinuria in UPRIGHT POSITION BUT NL in SUPINE • < 1g/d • Benign / No further evaluation

  27. R/O ORTHOSTATIC PROTEINURIA • First morning : - • 16 hour : 7 am- 11 pm NL activity . • Recumbent position : 2 hours before daytime collection finished • Overnight collection : 11 pm- 7 am

  28. R/O ORTHOSTATIC PROTEINURIA • Protein /Cr ratio: • First morning • Before bed • Must be normal excretion in SUPINE

  29. Persistent proteinuria • Underlyiong disease • BUN ,Cr • Quantitative measurement • Kidney sonography • Refer to nephrologist • Renal biopsy

  30. PROGNOSIS

  31. GLOMERULAR PROTEINURIA : QUANTITY OF PROTEINURIA NON-NEPHROTIC > NEPHROTIC • PERSISTENT MONITORING

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