PROTEINURIA DR HEDAYATI

INTRODUCTION

URINARY PROTEIN > 150mg/day More than 1 time ↑ capillary permeability

ISOLATED PROTEINURIA PROTEINURIA WITHOUT HEMATURIA WITHOUT ↑ IN CREATININE

ISOLATED PROTEINURIA 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

TYPES OF PROTEINURIA Glomerular proteinuria Tubular proteinuria overflow proteinuria

Glomerular proteinuria

↑ filteration of macromolecules Diabetic nephropathy ,glomerulopathy , exercise-induced, orthostatic proteinuria Most : 1-2g/day

Tubular proteinuria

Low molecular wt proteins Interference with PCT reabsorption No detection by dipstick

overflow proteinuria

↑ excretion of LMW Almost always : MM Others : AML ( Lysozyme ) Rhabdomyolysis ( Myoglobin) Hemolysis ( Hb) Filtered load > reabsorption by PCT

MIXED FORMS OF PROTEINURIA MM FSGS

MEASUREMENT

STANDARD URINE DIPSTICK ALBUMIN COLORIMETRIC REACTION TETRABROMOPHENOL GREEN SHADES GLOMERULAR PROTEINURIA HIGH SPECIFIC NOT VERY SENSITIVE ( + ONLY : > 300-

500 mg/d )

STANDARD URINE DIPSTICK INSENSITIVE METHOD TO DETECT INITIAL

INCREASE IN PROTEIN EXCRETION MICROALBUMINURIA (DIABETIC

NEPHROPATHY ) FALSE POSITIVE : CONTRAST ( 24 h ).

STANDARD URINE DIPSTICK 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

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 )

LYSOZYME AML URINE DIPSTICK : + SSA : + NO OTHER SIGNS OF NEPHROTIC

SYNDROME DIRECT MEASUREMENT

QUANTITATIVE MEASUREMENT BENIGN FORMS : < 1-2 g/d PROGNOSTIC IMPORTANCE MONITOR THE RESPONSE TO THERAPY

QUANTITATIVE MEASUREMENT 24 HOUR URINE RANDOM URINE : PROTEIN /Cr ratio (mg/

g) ~ daily protein excretion (g/m2 ) SERIAL MONITORING

MICROALBUMINURIA 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

URINE EXAMINATION ALL PATIENTS URINE SEDIMENT REPEATED

R/O TRANSIENT PROTEINURIA COMMON FEVER, EXERCISE (Ag – NEP) NO FURTHER EVALUATION

R/O ORTHOSTATIC PROTEINURIA < 30y/o ↑ proteinuria in UPRIGHT POSITION BUT NL in SUPINE < 1g/d Benign / No further evaluation

R/O ORTHOSTATIC PROTEINURIA 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 Protein /Cr ratio: First morning Before bed

Must be normal excretion in SUPINE

Persistent proteinuria Underlyiong disease BUN ,Cr Quantitative measurement Kidney sonography Refer to nephrologist Renal biopsy

PROGNOSIS

GLOMERULAR PROTEINURIA : QUANTITY OF PROTEINURIA NON-NEPHROTIC > NEPHROTIC PERSISTENT MONITORING