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 continuetrace 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 & Es, 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 >70refer 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.