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DR.MAHMUDUL HSASN FORHAD
FCPS PART-1(MEDICINE)
MD PHASE – A(GASTROENTEROLOGY)
Approach to proteinuria
Overview
 Normal or Physiological Urinary Protein Excretion.
 Definition.
 Pathological Proteinuria(Types & Causes).
 Evaluation.
 Detection & Measurement.
 Management.
 Prognosis.
 Take Home Messages.
Normal Urinary Protein Excretion
 Normally,Urinary Protein Excretion is less than 150 mg/day in adults.
 It is usually not detected by ordinary methods.
 It is composed of :
1.Tamm-Horsfall Glycoprotein-50%
2.Albumin- 20%
3.Immunoglobulin-5%
4.Others- Small Amounts of Hormones and Enzymes &
Blood Group related substances
Davidson 24th Edition+PubMed
Definition
 Proteinuria: Urinary protein excretion >150mg/24 hr.
 Albuminuria: Urinary albumin excretion >30mg/24 hr.
 Micro-Albuminuria: Persistent albumin excretion between 30 to 300 mg/24hr is
called moderately increased albuminuria(Formerly called microalbuminuria).
 Macro-Albuminuria : Albumin excretion above 300mg/24 hr is considered Overt
Proteinuria or Macroalbuminuria(Dipstick-positive).
Davidson 24th Edition
Benign or Transient Proteinuria
 Transient proteinuria is the temporary excretion of protein.
 Most common form of proteinuria.
 Usually resolves without treatment.
 Causes:
1.Fever
2.After vigorous Exercise.
3.Extreme cold.
4.Seizures
5.CCF.
6.Severe Acute illness.
7.UTI.
UP TO DATE
Postural(Orthostatic)Proteinuria
 When one loses protein in the urine while in upright position but not when
lying down.
 Excrete less than 1g/24hrs of protein.
 Benign disorder that does not require treatment.
UP TO DATE
Persistent Proteinuria
 In contrast to transient and orthostatic proteinuria,Persistent proteinuria occurs
in people with underlying Kidney diseases or other medical problems.Examples
incude:
1.Kidney Diseases.
2.Diseases that affect the kidney,such as DM and High Blood pressure.
3.Diseases that cause the body to overproduce certain types of protein.
UP TO DATE
Pathological
Proteinuria(Types& Causes)
Pathological
Proteinuria(Types& Causes)Continued…..
Evalution of the patient with Proteinuria
History
 Onset: Acute/Chronic,On basis of duration.
 Diabetic history if applicable(Specially H/O retinopathy/neuropathy)
 Renal symptoms: Oedema,HTN,Haematuria,Foamy Urine.
 Constitutional symptoms: Fever,nausea,appetite,wt change.
 Symptoms of coagulopathy: DVT,Pulmonary Embolism.
 Rheumatological history.
 Malignancy.
 Family history of renal disease.
 Exposure to toxins.
Cont…..
Physical Examination
 General Examination: BP and weight,Oedema,rashes.
 Systemic Examinations including Cardiopulmonary and musculoskeletal system.
 Fundoscopic examination.
Continued
Lab Investigations
 Required: Urine R/E, 24 hr Urinary total protein or spot urine for Protein/creatinine ratio(PCR),
Albumin/Creatinine ratio(ACR), Urine Dipstick Test.
 As Clinically indicated: Fasting lipid profile, HbA1c, ANA, C3,C4, HBsAg, AntiHCV.
 Opthalmological examination,Renal Ultra sound.
 Renal Biopsy as Indicated.
Detection & Measurement of Total Urinary Protein Excretion
Semiquantitative Measurement
 Standard Urine Dipstick: The standard urine dipstick primarily detects albumin but is relatively insensitive to non-albumin
proteins.Thus,a positive dipstick usually reflects glomerular proteinuria.
 Sulfosalicylc Acid Test: In contrast to the urine dipstick, which primarily detects all proteins in the urine at a sensitivity of 5 to 10
mg/dl.Use of SSA is primarily indicated in patients who present with-
1. Acute kidney Injury.
2. A Benign Urinalysis.
3. A negative or trace dipstick
4. A setting in which myeloma kidney should be excluded.
Sulfosalicylic Acid Test
Negative : No cloudiness
Trace: Faint turbidity.
1+ : definite turbidity
2+ : Heavy turbidity but no flocculation
3+ : Heavy turbidity with light flocculation.
4+ : Heavy turbidity with heavy flocculation.
Continue
Quantitative measurement
 Determination of degree of protein excretion is a central part of the evaluation of patients with acute and chronic kidney diseases and in
patients incidentally noted to have persistent proteinuria by semiquantitative method.
 24 hr Urine Protein.
 Protein Creatinine ratio.
 Albumin Creatinine ratio.
Quantifying Proteinuria in Random urine samples
Continued
Urine Microscopic Analysis
 When proteinuria is found on Dipstick analysis, the urinary sediment should be examined microscopically
for:
 Fatty casts , Free fat or Oval fat bodies Nephrotic range proteinuria(>3.5g/24hrs)
 Leukocytes , leukocyte casts with bacteria UTI
 Leukocytes, leukocyte casts without bacteria Renal Interstitial Diseases
 Red Cell Casts , Dysmorphic Erythrocytes Glomerular Disease
 Waxy , Granular or Cellular casts Advanced chronic renal disease
 Eosinophiluria Drug-induced AIN
 Hyaline casts No renal Diseases, present with Dehydration.
Davidson 24th Edition + UP TO DATE
Management
Blood Pressure Control
 Diabetics: Control of BP shown to slow progression of nephropathy in several studies.
 Non-Diabetics: BP control to MAP < 92 vs 107 with less progression of diseases .
Benefit greatest in nephrotic patients.
 ACEI and ARB are the first line drugs.
 Some meta analysis shows that non-dihydropiridine Ca channel blockers have anti
proteinuric effect.
Management(Cont…..)
Non-Specific Treatment
 BP Control:<130/80 for both nondiabetics & Diabetics.
 Lipid Control:Tchol <200,LDL <100 with HMG Co-A reductase inhabitors.
 Glycemic control for diabetics: HbA1c <6.5%
 Moderate dietary protein restriction: 0.8mg/kg/day +urine protein loses,careful
monitoring of nutritional status.
 Edema:Diuretics,Sodium restriction.
 Specific immunosuppressive therapies for primary glomerular diseases as indicated.
Prognosis
 Diabetic nephropathy : Progression to ESRD over 10-20 yrs
after onset of proteinuria.
 Nephrotic Syndrome: Variable but poorer overall prognosis.
Take Home Message
 Proteinuria is not a specific diseases.
 A systemic approach to the patient with proteinuria will
allow the clinician to efficiently distinguish between
benign and pathological causes.
THANK YOU ALL

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DR.FORHAD(PROTEINURIA).pptx

  • 1. DR.MAHMUDUL HSASN FORHAD FCPS PART-1(MEDICINE) MD PHASE – A(GASTROENTEROLOGY)
  • 3. Overview  Normal or Physiological Urinary Protein Excretion.  Definition.  Pathological Proteinuria(Types & Causes).  Evaluation.  Detection & Measurement.  Management.  Prognosis.  Take Home Messages.
  • 4. Normal Urinary Protein Excretion  Normally,Urinary Protein Excretion is less than 150 mg/day in adults.  It is usually not detected by ordinary methods.  It is composed of : 1.Tamm-Horsfall Glycoprotein-50% 2.Albumin- 20% 3.Immunoglobulin-5% 4.Others- Small Amounts of Hormones and Enzymes & Blood Group related substances Davidson 24th Edition+PubMed
  • 5. Definition  Proteinuria: Urinary protein excretion >150mg/24 hr.  Albuminuria: Urinary albumin excretion >30mg/24 hr.  Micro-Albuminuria: Persistent albumin excretion between 30 to 300 mg/24hr is called moderately increased albuminuria(Formerly called microalbuminuria).  Macro-Albuminuria : Albumin excretion above 300mg/24 hr is considered Overt Proteinuria or Macroalbuminuria(Dipstick-positive). Davidson 24th Edition
  • 6. Benign or Transient Proteinuria  Transient proteinuria is the temporary excretion of protein.  Most common form of proteinuria.  Usually resolves without treatment.  Causes: 1.Fever 2.After vigorous Exercise. 3.Extreme cold. 4.Seizures 5.CCF. 6.Severe Acute illness. 7.UTI. UP TO DATE
  • 7. Postural(Orthostatic)Proteinuria  When one loses protein in the urine while in upright position but not when lying down.  Excrete less than 1g/24hrs of protein.  Benign disorder that does not require treatment. UP TO DATE
  • 8. Persistent Proteinuria  In contrast to transient and orthostatic proteinuria,Persistent proteinuria occurs in people with underlying Kidney diseases or other medical problems.Examples incude: 1.Kidney Diseases. 2.Diseases that affect the kidney,such as DM and High Blood pressure. 3.Diseases that cause the body to overproduce certain types of protein. UP TO DATE
  • 11. Evalution of the patient with Proteinuria History  Onset: Acute/Chronic,On basis of duration.  Diabetic history if applicable(Specially H/O retinopathy/neuropathy)  Renal symptoms: Oedema,HTN,Haematuria,Foamy Urine.  Constitutional symptoms: Fever,nausea,appetite,wt change.  Symptoms of coagulopathy: DVT,Pulmonary Embolism.  Rheumatological history.  Malignancy.  Family history of renal disease.  Exposure to toxins.
  • 12. Cont….. Physical Examination  General Examination: BP and weight,Oedema,rashes.  Systemic Examinations including Cardiopulmonary and musculoskeletal system.  Fundoscopic examination.
  • 13. Continued Lab Investigations  Required: Urine R/E, 24 hr Urinary total protein or spot urine for Protein/creatinine ratio(PCR), Albumin/Creatinine ratio(ACR), Urine Dipstick Test.  As Clinically indicated: Fasting lipid profile, HbA1c, ANA, C3,C4, HBsAg, AntiHCV.  Opthalmological examination,Renal Ultra sound.  Renal Biopsy as Indicated.
  • 14. Detection & Measurement of Total Urinary Protein Excretion Semiquantitative Measurement  Standard Urine Dipstick: The standard urine dipstick primarily detects albumin but is relatively insensitive to non-albumin proteins.Thus,a positive dipstick usually reflects glomerular proteinuria.  Sulfosalicylc Acid Test: In contrast to the urine dipstick, which primarily detects all proteins in the urine at a sensitivity of 5 to 10 mg/dl.Use of SSA is primarily indicated in patients who present with- 1. Acute kidney Injury. 2. A Benign Urinalysis. 3. A negative or trace dipstick 4. A setting in which myeloma kidney should be excluded.
  • 15. Sulfosalicylic Acid Test Negative : No cloudiness Trace: Faint turbidity. 1+ : definite turbidity 2+ : Heavy turbidity but no flocculation 3+ : Heavy turbidity with light flocculation. 4+ : Heavy turbidity with heavy flocculation.
  • 16. Continue Quantitative measurement  Determination of degree of protein excretion is a central part of the evaluation of patients with acute and chronic kidney diseases and in patients incidentally noted to have persistent proteinuria by semiquantitative method.  24 hr Urine Protein.  Protein Creatinine ratio.  Albumin Creatinine ratio.
  • 17. Quantifying Proteinuria in Random urine samples
  • 19. Urine Microscopic Analysis  When proteinuria is found on Dipstick analysis, the urinary sediment should be examined microscopically for:  Fatty casts , Free fat or Oval fat bodies Nephrotic range proteinuria(>3.5g/24hrs)  Leukocytes , leukocyte casts with bacteria UTI  Leukocytes, leukocyte casts without bacteria Renal Interstitial Diseases  Red Cell Casts , Dysmorphic Erythrocytes Glomerular Disease  Waxy , Granular or Cellular casts Advanced chronic renal disease  Eosinophiluria Drug-induced AIN  Hyaline casts No renal Diseases, present with Dehydration. Davidson 24th Edition + UP TO DATE
  • 20. Management Blood Pressure Control  Diabetics: Control of BP shown to slow progression of nephropathy in several studies.  Non-Diabetics: BP control to MAP < 92 vs 107 with less progression of diseases . Benefit greatest in nephrotic patients.  ACEI and ARB are the first line drugs.  Some meta analysis shows that non-dihydropiridine Ca channel blockers have anti proteinuric effect.
  • 21. Management(Cont…..) Non-Specific Treatment  BP Control:<130/80 for both nondiabetics & Diabetics.  Lipid Control:Tchol <200,LDL <100 with HMG Co-A reductase inhabitors.  Glycemic control for diabetics: HbA1c <6.5%  Moderate dietary protein restriction: 0.8mg/kg/day +urine protein loses,careful monitoring of nutritional status.  Edema:Diuretics,Sodium restriction.  Specific immunosuppressive therapies for primary glomerular diseases as indicated.
  • 22. Prognosis  Diabetic nephropathy : Progression to ESRD over 10-20 yrs after onset of proteinuria.  Nephrotic Syndrome: Variable but poorer overall prognosis.
  • 23. Take Home Message  Proteinuria is not a specific diseases.  A systemic approach to the patient with proteinuria will allow the clinician to efficiently distinguish between benign and pathological causes.