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  HEAVY PROTEIONURIA, LIPIDURIA,EDEMA, +/- ACTIVE URINE SEDIMENT

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

TYPES OF PROTEINURIA  Glomerular proteinuria  Tubular proteinuria  overflow proteinuria

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

Tubular proteinuria  Low molecular wt proteins  Interference with PCT reabsorption  No detection by dipstick

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

 MIXED FORMS OF PROTEINURIA  MM  FSGS

MEASUREMENT

STANDARD URINE DIPSTICK  ALBUMIN  COLORIMETRIC REACTION  TETRABROMOPHENOL  GREEN SHADES  GLOMERULAR PROTEINURIA  HIGH SPECIFIC  NOT VERY SENSITIVE ( + ONLY : > mg/d )

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

STANDARD URINE DIPSTICK  GRADING :  NEGATIVE  1 + : mg /dL  2 + : mg/dL  3 + : mg/dL  4 + : > 1000 mg/dL  ROUGH GUIDE : URINE VOLUME

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

SULFOSALICYLIC ACID  1 part urine urine + 3 part SSA3%  TURBIDITY  GRADING: 0 TRACE : 1-10 mg/dL 1+ : mg/dL 2+ : mg/dL 3+ : mg/dL 4+ : > 500 mg/Dl  FALSE POPSITIVE : CONTRAST (24h )

LYSOZYME  AML  URINE DIPSTICK : +  SSA : +  NO OTHER SIGNS OF NEPHROTIC SYNDROME  DIRECT MEASUREMENT

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

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

MICROALBUMINURIA  NL ALBUMIN EXCRETION : < 20mg/d  MICROALBUMINURIA : mg/d  SPECIFIC DIPSTICKS  ALBUMIN/Cr RATIO

APPROACH TO PROTEINURIA

 HISTORY  PHYSICAL EXAMINATION If systemic disease : MANAGEMENT OF PROTEINURIA : MANAGEMENT OF DISEASE

URINE EXAMINATION  ALL PATIENTS  URINE SEDIMENT  REPEATED

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

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

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

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

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

PROGNOSIS

 GLOMERULAR PROTEINURIA : QUANTITY OF PROTEINURIA NON-NEPHROTIC > NEPHROTIC  PERSISTENT MONITORING