Approach to Proteinuria KIV Urine phase contrast & U/S kidneys as indicated Diagnostic pathwayMain concern is glomerular disease. Signs: Proteinuria heavy proteinuria >3g/day (Cut off 0.5g/day) lipiduria edema UFEME red cell cast or dysmorphic RBCs Exclude orthostatic proteinuria (esp in adolescents) Do early morning UPCR or split collection of 24hr3 questions to answer urine into supine and upright specimens No proteinuria expected in early morning UPCR1) Amount of protein excreted <2g/day = likely benign isolated proteinuria amt correlates to prognosis in primary glomerular disease2) Condition under which protein is being excreted Orthostatic proteinuria Non- Orthostatic proteinuria Transient: common, usually secondary to stresses eg fever/exercise. Resolves subsequently Repeat urine dipstick in 1 wk Orthostatic: increased proteinuria in upright position, usually in adolescents. Persistent: more likely to have underlying renal or systemic disorder. Common causes: CCF, IgA nephropathy, membranous nephropathy, focal glomerulosclerosis3) Type of protein excreted Persistent proteinuria Transient proteinuria Glomerular: mostly albumin, detected on urine dipstick Dipstick positive x2 Dipstick positive x1 Tubular: LMW proteins eg β2-microglobulin, Ig light chains, retinol-binding protein, amino acids, not detectable on urine dipstick.Normally filtered across GBM and reabsorbed completely by prox tubule. Tubulointerstitial dz & some pri glomerular dz 24hr UTP or UPCR F/u 6mths then yrly: decrease tubular reabsorption leading to increased excretion. Check BP Urine dipstick Overflow: overproduction of LMW proteinuria exceeds prox tubule reabsorptive capacity. Renal function Check BP Usually secondary to monoclonal Ig light chain over production in multiple myeloma – Renal function excreted light chains also toxic to tubules, leading to further decrease in reabsorption UFEMEUrine dipstick: UTP <1g/day UTP ≥1g/day Detects mostly albumin, therefore mainly detects glomerular proteinuria. Cr & BP Cr & BP Tubular & overlow proteinuria not well dx by urine dipstick, and usually require 24hr UTP normal abnormal Persists or Resolution convert to ofHistory persistent proteinuria Urinary symptoms Renal biopsy proteinuria PMHX: DM /CCF /renal disease (APCKD) /hx of post strep GN Drug hx: Membranous nephropathy (gold, penicillamine, captopril), allergic interstitial Discharge nephritis (NSAIDS, penicillins) from f/u * UACR used in DM. Does not take into account non-albumin proteins – cut off:Physical examination Macroalbuminuria >300 Microalbuminuria >30 BP Signs of HPT end organ damage Signs of renal failure EdemaInvestigations U/E/Cr, fasting glucose if glycosuria + UFEME – hematuria, glycosuria Urine C/S UPCR / 24hr UTP – for proteinuria
Mx 1) BP control ACEI in DM type1 ARB in DM type 2 Monitor for RAS: check Cr 2 wks after starting ACEI/ARB. Stop if Cr increase >20% 2nd line Rx: CCB (verapamil, diltiazem). Avoid beta-blockers w CCB – risk of heartblock 2) RAS Suspect if HPT + IHD/LVH + PVD Invx: MRA / doppler 3) Hyperlipidaemia statin 4) Decrease smoking Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT- Campus, Terengganu, ou=Internal Medicine Group, email@example.com Reason: This document is for UCSI year 4 students. Date: 2009.02.24 10:20:51 +0800
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