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10/2/2015 AQEEL ALGHAMDI 1. PROTEINURIA DR AQEEL ALGHAMDI MBBS,DCH,JBCP,ABP,FBN consultant pediatric...
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Transcript of 10/2/2015 AQEEL ALGHAMDI 1. PROTEINURIA DR AQEEL ALGHAMDI MBBS,DCH,JBCP,ABP,FBN consultant pediatric...
04/19/23AQEEL ALGHAMDI1
PROTEINURIA
DR AQEEL ALGHAMDIMBBS,DCH,JBCP,ABP,FBNconsultant pediatric nephrology
04/19/232
Contents:
Introduction
Pathophysiology
Causes
History
Examination
Investigations
Management
IntroductionIntroduction
proteinuria on a routine screening urinalysis is proteinuria on a routine screening urinalysis is commoncommon
ProteinProtein can be found in the urine of healthy can be found in the urine of healthy children , LESS THAN children , LESS THAN 150mg/24hr (4150mg/24hr (4
mg/m2/hrmg/m2/hr) )
up to up to 10% 10% of children aged 8-15 yr test of children aged 8-15 yr test positivepositive for proteinuria by for proteinuria by urinary dipstick urinary dipstick at at
some timesome time
In a 24-hour urine collection: In a 24-hour urine collection:
Normal values : <4 mg of Normal values : <4 mg of protein/m2/hr protein/m2/hr
Significant values 4–40 mg/m2/hr Significant values 4–40 mg/m2/hr
Nephrotic range >40 mg/m2/hr Nephrotic range >40 mg/m2/hr ""
The challenge is to differentiate The challenge is to differentiate the child with the child with proteinuria related to renal disease from the proteinuria related to renal disease from the
otherwise healthy child with transient orotherwise healthy child with transient or
other benign forms of proteinuria other benign forms of proteinuria
Causes of proteinuriaCauses of proteinuria
Isolated Orthostatic Persistant
Glomerular tubulointerstitial
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11..Transient ProteinuriaTransient Proteinuria
The majority of children found to have The majority of children found to have positive urinary dipstick values for protein positive urinary dipstick values for protein
have have normal dipstick values on repeated normal dipstick values on repeated measurementsmeasurements
The proteinuria usually does not exceed 1-2+ on The proteinuria usually does not exceed 1-2+ on the dipstickthe dipstick
No evaluation or therapy No evaluation or therapy is neededis needed
22..Orthostatic (Postural) ProteinuriaOrthostatic (Postural) Proteinuria
Orthostatic proteinuria is the Orthostatic proteinuria is the most common most common cause of persistent proteinuria in school-cause of persistent proteinuria in school-
aged children and adolescentsaged children and adolescents
Occurring in up to Occurring in up to 60% 60% of children with of children with persistent proteinuriapersistent proteinuria
Patients Patients with orthostatic proteinuria excrete with orthostatic proteinuria excrete normal or minimally increased amounts of normal or minimally increased amounts of
protein in the supine positionprotein in the supine position..
Children with this condition are usually Children with this condition are usually asymptomatic, and the condition is discovered asymptomatic, and the condition is discovered
on routine urinalysison routine urinalysis..
In the In the upright position, urinary protein upright position, urinary protein excretion may be increased 10-foldexcretion may be increased 10-fold, up , up
to 1,000 mg/24 hr (1 g/24 hr)to 1,000 mg/24 hr (1 g/24 hr)..
33..Persistant ProteinuriaPersistant Proteinuria
proteinuria proteinuria indicates renal diseaseindicates renal disease and may be caused by either :and may be caused by either : glomerular or tubular disordersglomerular or tubular disorders
Significant proteinuria on a first morning Significant proteinuria on a first morning urine sample on 3 consecutive days urine sample on 3 consecutive days (>1+ (>1+ on dipstick ,urine specific gravity >1.015 on dipstick ,urine specific gravity >1.015
or protein : creatinine ratio >0.2) or protein : creatinine ratio >0.2)
Initial evaluation of a child with persistantInitial evaluation of a child with persistant proteinuria should include :proteinuria should include :
- Measurement of serum creatinine- Measurement of serum creatinine and electrolyte and electrolyte
- First morning urine - First morning urine protein :creatinineprotein :creatinine
ratio ratio - Serum albumin level - Serum albumin level - Complement - Complement levels.levels.
I. Glomerular ProteinuriaI. Glomerular Proteinuria
Glomerular proteinuria can range from <1 g toGlomerular proteinuria can range from <1 g to >30 g/24 hr.>30 g/24 hr.
Glomerular proteinuria results from alterations in the Glomerular proteinuria results from alterations in the permeability permeability of any of the layers of the glomerular of any of the layers of the glomerular
capillary wall to normally filtered proteins and capillary wall to normally filtered proteins and occurs in a variety of renal diseases. occurs in a variety of renal diseases. ""
Glomerular proteinuria should be suspectedGlomerular proteinuria should be suspected in any patient with:in any patient with:
- First morning urine protein : creatinine- First morning urine protein : creatinine ratio >1.0, or ratio >1.0, or
- Proteinuria accompanied by:- Proteinuria accompanied by: . Hypertension. Hypertension
. Hematuria. Hematuria . Edema . Edema
. Renal dysfunction. Renal dysfunction
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ii. Tubular Proteinuriaii. Tubular Proteinuria
A variety of renal disorders that primarily A variety of renal disorders that primarily involve the tubulointerstitial compartment of the involve the tubulointerstitial compartment of the
kidney can cause kidney can cause low-grade fixed proteinuria low-grade fixed proteinuria (protein : creatinine ratio <1.0(protein : creatinine ratio <1.0
Injury to the proximal tubules Injury to the proximal tubules can result in:can result in:• Diminished reabsorptive capacity Diminished reabsorptive capacity
• Loss of these low molecular weight proteinsLoss of these low molecular weight proteins in the urinein the urine
Tubular Tubular proteinuria may be seen in acquiredproteinuria may be seen in acquiredand inherited disorders and may be associated with and inherited disorders and may be associated with other defects of proximal tubular functionother defects of proximal tubular function, such as, such as
the Fanconi syndrome. the Fanconi syndrome. (glycosuria, phosphaturia, bicarbonate (glycosuria, phosphaturia, bicarbonate
wasting, and aminoaciduria).wasting, and aminoaciduria).
Asymptomatic Asymptomatic patients having persistent persistent proteinuria proteinuria generally have glomerular rather than glomerular rather than
tubular proteinuriatubular proteinuria
Tubular proteinuria is a consistent finding among patients with the X-linked tubular syndromeX-linked tubular syndrome, Dent Dent diseasedisease, caused by mutations of the renal chloride
channel
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In occult cases , glomerular and tubular In occult cases , glomerular and tubular proteinuria can be distinguished by proteinuria can be distinguished by electrophoresis electrophoresis of the urine.of the urine.
In In tubular proteinuria, little or no albumin is tubular proteinuria, little or no albumin is detected, whereas in glomerular proteinuria detected, whereas in glomerular proteinuria
the major protein is albuminthe major protein is albumin.
Clinical Approach
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Asymptomatic proteinuria 11
Hematuria or other signs of
kidney disease
Nonrenal diseases Recheck when resolves
Isolated proteinuriaCollected 12 –hrRecumbent urine
<50 mg/m2/12hr
Isolated intermittent Proteinuria
or orthostatic proteinuria
Reassure
90%
No
No
Yes
Asymptomatic proteinuria
22
Hematuria or other signs of
kidney disease
Nonrenal diseases
Isolated proteinuriaCollected 12 –hrRecumbent urine
50 - 200mg/m2/12hr
Limited evaluationBUN ,Creatinine ,S.electrolyte
sSpot UPr: UCr ratio , S .Total
proteinC3 ,C4 ,ASOT, Lupus
serology (selected cases)Renal imaging ,index of
tubular proteinuria
Follow -up
5%
No
No
Normal
Asymptomatic proteinuria
33
Hematuria or other signs of
kidney disease
Nonrenal diseases
Isolated proteinuriaCollected 12 –hrRecumbent urine
>200mg/m2/12hr
50 - 200mg/m2/12hr
Limited evaluationBUN ,Creatinine ,S.electrolytes
Spot UPr: UCr ratio , S .Total proteinC3 ,C4 ,ASOT, Lupus serology
(selected cases)Renal imaging ,index of tubular
proteinuria
•Evaluation•Consider referral•S .Total protein•HIV status•Fractionated 24-hr urine collection•S. Albumin•S. Cholesterol•ASOT•C3,C4•ANA , anti-DNA•GFR•Renal imaging•Renal biopsy
Abnormal
Yes
5%
No
No