How to approach a case of proteinuria and differential diagnosis of proteinuria, how to assess protein loss in the kidney Dr. Abdel Rahman Mansy, Beni-Suef University, internal medicine department, nephrology unit

1. by

2. Case 1

3. Male patient 49 y old , DM 5 years ago controlled
on insulin , not HTN,
labs of routine follow up
24 hour urinary protein 120 mg /d.
what`s the best choice ?
1. Add ACEI
2. Protein restriction
3. Follow up after 3 months
4. Assess proteinuria e different method

13. GN presentation
GN PRESENTING WITH NEPHROTIC SYNDROME
Minimal change GN
Membranous GN
Focal segmental GN (FSGN)
Amyloidosis
Diabetic nephropathy
GN PRESENTING WITH NEPHRITIC SYNDROME
Diffuse proliferative GN
Rapidly progressive GN (RPGN)
GN WITH NEPHROTIC SYNDROME or NEPHRITIC SYNDROME or MIXED NEPHROTIC/NEPHRITIC
Membranoproliferative GN
Mesangioproliferative GN

15. Nephritic syndrome
A disease characterized by acute onset of :
Proteinuria (sub nephrotic)
Hematuria… dysmorphic RBCs,RBCs cast
Oliguria
Hypertension
Odema

16. GN presentation
GN PRESENTING WITH NEPHROTIC SYNDROME
Minimal change GN
Membranous GN
Focal segmental GN (FSGN)
Amyloidosis
Diabetic nephropathy
GN PRESENTING WITH NEPHRITIC SYNDROME
Diffuse proliferative GN
Rapidly progressive GN (RPGN)
GN WITH NEPHROTIC SYNDROME or NEPHRITIC SYNDROME or MIXED NEPHROTIC/NEPHRITIC
Membranoproliferative GN
Mesangioproliferative GN

28. Proteinuria and
KDIGO
guidelines

29. Proteinuria and CKD

32. Proteinuria and
Supportive TTT

35. ACEi and/or ARBs lower GFR, and a 10%–20% increase in
SCr is often observed.
Unless creatinine continues to rise,
this moderate increase reflects their effect on kidney
hemodynamics
and not worsening intrinsic kidney disease, and should not
prompt withdrawal of the medication

36. If the patient is unable to tolerate an
ACEi or ARB
a direct renin inhibitor (DRI) or
mineralocorticoid receptor antagonist
(MRA) can be used

37. unable to tolerate even low-dose
ACEi, ARB, MRA, or DRI.
antihypertensive agents are recommended for both
control of BP and improvement in urine protein excretion.
&Non dihydropyridine (CCB), such as diltiazem and verapamil,
modestly reduce proteinuria.
&Beta blockers, diuretics, and a-1 blockers also reduce
proteinuria, but to a lesser degree.
&Dihydropyridine CCB and methyldopa have little impact on
proteinuria and may even increase proteinuria.

39. Proteinuria and anticoagulation

40. Bleeding Risk

43. Can use NOAC or not in NS?

44. Case 2

45. Female patient 48 y old, HTN on bisoprolol 5mg
,presented e lower limb edema and poly
arthropathy
labs :
24 h urinary protein 1.8 g/d
serum albumin 3.6
ANA 1/80
C3,C4 :normal
virology : -ve
Renal biopsy done

47. NB: F/u ANA in diff lab ANA less than 1/40
What`s the next step?
1- start steroid
2- start steroid and cyclosporine
3- supportive TTT { ACEI,…}e f/u ptnuria.albumin
4- follow up after 3 months

48. Proteinuria in FSGS

49. NB: F/u ANA in diff lab ANA less than 1/40
What`s the next step?
1- start steroid
2- start steroid and cyclosporine
3- supportive TTT { ACEI,…}e f/u ptnuria.albumin
4- follow up after 3 months

51. Proteinuria in IgA N

53. Proteinuria in Membranous
Nephropathy

56. Proteinuria in ICGN(MPGN)

57. Proteinuria in SLE