Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Tutorial )4( عدد االوراق باطنية ضياء الحمداني.د 2012-11-12 Proteinuria Introduction 180 liters /24hr. 11 -15 gm of protein. 600 -1200 ml fluid as urine,(8O mg) less than 150 mg of protein. 40% albumin,light chain IG 9%,tam-horsfull protein. Normally not more than 150 mg/24hr. increase on standing ambulation fever with use of presser drug norepinephrine,and angiotensin. proteinuria more than 200mg/24 hr is regarded as abnormal the amount of proteinuria . The clinical importance of proteinuria Early diagnosis prevent progression of disease. Proteinuria is a marker of renal disease. The importance of urine examination. Patients at risk: who required urine examination as screening test for proteinuria.: Hypertension. DM. Systemic dis. Pregnancy. Nephrotoxic drug. 1 Source of proteinuria plasma protein normal or abnormal filtered at glomerulqr capillaries escape reabsorptionby pct.(glomerular proteinuria. Protein secreted by renal tubules . lower urinary tract. Amount of proteinuria: Normally proteinuria less than 150 mg/24hr the physiological range of albuminnuria is 6 - 20 mg/24hr and greater than 30 mg/24hr are abnormal. microalbuminuria refer to albuminuria in arrange of 30 – 300 mg/24hr.this equates to urinary albumin to creatinine ratio 17- 250 mg/g for men and 25 – 355mg/g for women . its escape the detection by conventional method dipstick it need albumin specific strip test . 300 – 500 mg/24hr termed overt proteinuria detected by dipstick. More than 3.5 gm/24h nephrotic range and give frothy appearance of the urine. Pathophysiology of proteinuria Glomerular (selective and nonselective. Albumin. Glomerular lesion Primary GD include :Minimalchanges glomerulopathy,IgA nephropathy,focal and segmental glomerulosclerosis, membranous, membranoproliferative, andcrescentic glomerulonephritis. Secondary causes:multisystemic disease, SLE, SSC, metabolic (DM,) neoplasm mylomamlymphoma solid tumors. infection, drug (pencillin, gold, lithium, NSAID,). 2 Tubular proteinuria: B2 microglobulins more than albumin . Causes : Heavy metal poisoning . tubulintrestitial disease. acute hypersensitivity interstitial nephritis. obstructive uropahy . acute bacterial pyelonephritis. light chain nephropathy. it compromised alpha and B globins which can be detected by urine electrophoresis appearing in the alopha and Beta fraction.it is in a range of 200 to 2000 mg/24hr. Overflow proteinuria. Overflow proteinuria occurs when the capacity of renal tubules. In hemolytic anemia free Hb will appear in the urine rhabdomyolysis there will be myoglobinuria.these proteins discolor the urine and are detected by specific reagent . Monoclonal gamopathies can result in monoclonal light chains or immuonglobulins in the urine.their identity is confirmed by monoclonal band in urine immuonoelectrophoresis. hemoglobinuria,myoglobinuria,myloma,light chain disease.and amyloidosis. quantity rang from minor to nephrotic range. Tissue proteinuria Tissue proteinuria occur secondary to: UTD ,inflammation,tumors. Its relatively low concentration up to 0.5 gm/gm mg/24hr . 3 500 associated with non glomeruler hematuria,and can be detected by urine electrophoresis. Evaluation (Detection and quantification of proteinuria. dipstick (Strip test) a paper impregnated with indicator dye (tetrabromophenole) which change its color change color green to blue with albumin In concentration range of (20 – 300 mg/dl). it is insensitive to other protein(glibuline,BJ protein). a false positive result with strong alkaline urine,tobutamide,cephalosporine use and radiocontrast agent. and false negative result with diluted urine. the dipstick test is available for detection of microalbuminuria as a screening test in DM,raised BP,SLE. false positive result : strong alkaline urine. tobutamide,cephalosporine use. radiocontrast agent. Fever. Vigorous exercise. Postural proteinuria. 4 false negative result with diluted urine. Microalbuminuria. Turbidmetry test utilizing acetic acid or sulfosalicylic acid used to detect lower level proteinuria (5mg/dl) and react equally to albumin and globulins. borderline or negative test with dipstick test positive result with Turbidmetry indicate presence of globulin like light chain . orthostatic proteinuria confirmation by comparison with recumbent sample . timed 24 hr collection. Its important to differentiate between u protinuria/ u creatinine and urinary albumin/ creatinine . to measure the selectivity urinary protein content one can do electrophoresis of the urinary protein. Selective proteinuria mean mainly excretion of albumin. Urinary Protein to creatinine ratio. The inaccuracies in urine collection . inconvenience of transporting a large volume of urine. Have made the estimation of protein content in a sample of urine more attractive . urinary protein in mg/d / urinary creatinine mg / day. The unit of measuring urinary protein to creatinine ratio is mg/mg or gm/gm. Abnormal ratio will be greater than 0.2mg/dl protein on 1mg creatinine or 0.2 mg/mg or gm/gm. 5 The most consistent results are obtained from 1st voided sample in the morning but the test can be applied to random sample obtain in the clinic. If the level exceed 200 mg/24hr, then the evaluation should consider the identification of the cause. The initial step is urine microscopic examination for freshly voided sample. To assess the presence of erythrocytes leucocytes and erythrocytes cast. presence of proteinuria and glomerular hematuria suggest glomerular pathology. History is important for symptoms of renal disorder or extra renal disease in autoimmune disease,family history of renal disease,drug history or exposure to toxic substance. CBP,serum albumin,globulins, cholesterol,calcium,phosphate,uric acid. liver function test. serological test for HBV,HCV,HIV. US of kidney. immunological studies including ANA,ANCA,complement levels rheumatoid factor,cryoglobulins . serum protein electrophoresis. Proteinuria less than 2000 mg/24 not accompanied by hematuria,no symptoms of renal disease,the kidney size normal and symmetrical immunological studies are normal observation for several months . orthostatic proteinuria without other features of renal disease should in frequently and does not required further evaluation. Renal biopsy indicated in Nephrotic range proteinuria. Proteinuria in SLE. 6 Glomerular protiuria, investigation protein – creatinine ratio or 24hr protein excretion. Serumalbumin. Cholesterol. plasma and urine protein electrophorsis. GUE.for RBC cast. Tubular proteinuria. plasma and urine electrophoresis. U protein electrophoresis: alpha, beta microglobulins. heavy metal screen. Bence Jones protein LDH. haptoglobins. 7