Download PROTEINURIA

PROTEINURIA
DR HEDAYATI
INTRODUCTION
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URINARY PROTEIN > 150mg/day
More than 1 time
↑ capillary permeability
ISOLATED PROTEINURIA
PROTEINURIA
WITHOUT HEMATURIA
WITHOUT ↑ IN CREATININE
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ISOLATED PROTEINURIA
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MAY BE ASYMPTOMATIC
HEAVY PROTEIONURIA , LIPIDURIA ,EDEMA , +/ACTIVE URINE SEDIMENT
SCREENING
NO COST- EFFECTIVE FOR GENERAL POPULATION,
< 60y/o
 HIGH RISK PATIENTS : DM
HTN
→ ACEI or ARB
SLOWING THE PROGRESSION OF PROTEINURIA
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TYPES OF PROTEINURIA
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Glomerular proteinuria
Tubular proteinuria
overflow proteinuria
Glomerular proteinuria
↑ filteration of macromolecules
Diabetic nephropathy ,glomerulopathy , exerciseinduced, orthostatic proteinuria
 Most : 1-2g/day
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Tubular proteinuria
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Low molecular wt proteins
Interference with PCT reabsorption
No detection by dipstick
overflow proteinuria
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↑ excretion of LMW
Almost always : MM
Others : AML ( Lysozyme )
Rhabdomyolysis ( Myoglobin)
Hemolysis ( Hb)
Filtered load > reabsorption by PCT
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MIXED FORMS OF PROTEINURIA
MM
FSGS
MEASUREMENT
STANDARD URINE DIPSTICK
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ALBUMIN
COLORIMETRIC REACTION
TETRABROMOPHENOL
GREEN SHADES
GLOMERULAR PROTEINURIA
HIGH SPECIFIC
NOT VERY SENSITIVE ( + ONLY : > 300-500 mg/d
)
STANDARD URINE DIPSTICK
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INSENSITIVE METHOD TO DETECT INITIAL
INCREASE IN PROTEIN EXCRETION
MICROALBUMINURIA (DIABETIC NEPHROPATHY )
FALSE POSITIVE : CONTRAST ( 24 h ).
STANDARD URINE DIPSTICK
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GRADING :
NEGATIVE
1 + : 15-30 mg /dL
2 + : 30-100 mg/dL
3 + : 100-300 mg/dL
4 + : > 1000 mg/dL
ROUGH GUIDE : URINE VOLUME
SULFOSALICYLIC ACID
ALL PROTEINS
 AKI + BENIGN U/A +NEGATIVE DIPSTICK :MM
 SULFOSALICYLIC ACID : +
URINE DIPSTICK : → NONALBUMIN PROTEINS
MOST : LIGHT Ig
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SULFOSALICYLIC ACID
1 part urine urine + 3 part SSA3%
 TURBIDITY
 GRADING:
0
TRACE : 1-10 mg/dL
1+ : 15-30 mg/dL
2+ : 40-100 mg/dL
3+ : 150-300 mg/dL
4+ : > 500 mg/Dl
 FALSE POPSITIVE : CONTRAST (24h )
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LYSOZYME
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AML
URINE DIPSTICK : +
SSA : +
NO OTHER SIGNS OF NEPHROTIC SYNDROME
DIRECT MEASUREMENT
QUANTITATIVE MEASUREMENT
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BENIGN FORMS : < 1-2 g/d
PROGNOSTIC IMPORTANCE
MONITOR THE RESPONSE TO THERAPY
QUANTITATIVE MEASUREMENT
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24 HOUR URINE
RANDOM URINE : PROTEIN /Cr ratio (mg/ g)
~ daily protein excretion (g/m2 )
SERIAL MONITORING
MICROALBUMINURIA
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NL ALBUMIN EXCRETION : < 20mg/d
MICROALBUMINURIA : 30-300 mg/d
SPECIFIC DIPSTICKS
ALBUMIN/Cr RATIO
APPROACH TO PROTEINURIA
HISTORY
 PHYSICAL EXAMINATION
If systemic disease :
MANAGEMENT OF PROTEINURIA :
MANAGEMENT OF DISEASE
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URINE EXAMINATION
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ALL PATIENTS
URINE SEDIMENT
REPEATED
R/O TRANSIENT PROTEINURIA
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COMMON
FEVER, EXERCISE (Ag – NEP)
NO FURTHER EVALUATION
R/O ORTHOSTATIC PROTEINURIA
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< 30y/o
↑ proteinuria in UPRIGHT POSITION
BUT NL in SUPINE
< 1g/d
Benign / No further evaluation
R/O ORTHOSTATIC PROTEINURIA
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First morning : 16 hour : 7 am- 11 pm
NL activity .
Recumbent position : 2 hours before daytime
collection finished
Overnight collection : 11 pm- 7 am
R/O ORTHOSTATIC PROTEINURIA
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Protein /Cr ratio:
First morning
Before bed
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Must be normal excretion in SUPINE
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Persistent proteinuria
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Underlyiong disease
BUN ,Cr
Quantitative measurement
Kidney sonography
Refer to nephrologist
Renal biopsy
PROGNOSIS
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GLOMERULAR PROTEINURIA :
QUANTITY OF PROTEINURIA
NON-NEPHROTIC > NEPHROTIC
PERSISTENT MONITORING