Proteinuria and haematuria an update
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Proteinuria and Haematuria – an update. Alex Heaton 11.02.2009. What is normal?. Normal 80 +/- 25 mg/day (<150 mg is quoted as upper normal limit). Adolescents up to 300 mg/day ( ♀ 10-16 years, ♂ 12-18 years). Measurements of proteinuria. Dipstick tests 24 hour urinary protein

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Proteinuria and Haematuria – an update

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Proteinuria and haematuria an update

Proteinuria and Haematuria – an update

Alex Heaton

11.02.2009


What is normal

What is normal?

  • Normal 80 +/- 25 mg/day (<150 mg is quoted as upper normal limit).

  • Adolescents up to 300 mg/day (♀ 10-16 years, ♂ 12-18 years)


Measurements of proteinuria

Measurements of proteinuria

  • Dipstick tests

  • 24 hour urinary protein

  • Urine protein/creatinine ratio

  • Urine albumin/creatinine ratio


Why bother testing urine

Why bother testing urine?

  • Detection of renal disease

  • Cardiovascular risk factor


Clinical significance of proteinuria

Clinical significance of proteinuria

Proteinuria on dipstick in healthy patient

? Any systemic disease, e.g hypertension, diabetes mellitus  likely renal disease

>1 gram a day  likely renal disease

>3.5 g/day  likely glomerular disease


Protein in urine what next

Protein in urine – what next?

  • establish persistent proteinuria

  • clinical assessment

  • interpreting test results


Step 1 establish persistent proteinuria

Step 1. Establish persistent proteinuria

proteinuria (1+ or more)

exclude urinary infection

repeat urinalysis after at least one week

↓ ↓

1+ or more continuetrace or negative –

no action


Step 2 initial assessment if persistent proteinuria 1 or more

Step 2. Initial assessment if persistent proteinuria 1+ or more

  • send early morning urine for albumin/creatinine ratio

  • blood tests: U & E’s, fasting glucose, cholesterol and albumin

  • Check blood pressure


Step 3 what to do with an albumin creatinine mg mmol result

Step 3: What to do with an albumin/creatinine(mg/mmol) result

  • <5 within reference range

  • 5-30 does not indicate renal disease but consider cardiovascular risk factors

  • 31-70 check 6 monthly blood pressure and ACR. No need to refer to nephrology unless patient also has haematuria, severe hypertension, eGFR <60 or a systemic disease

  • >70refer to Nephrology


Proteinuria summary

Proteinuria - summary

  • urine protein testing is worthwhile (vs blood)

  • use dipstix to decide when to test further

  • albumin : creatinine ratio instead of 24 hour collection.

  • use ACR to decide who to refer


Haematuria

Haematuria

  • frank haematuria – high yield on investigation

  • microscopic haematuria

    + symptoms – high yield

    - symptoms – low or very low yield


Microscopic haematuria

Microscopic haematuria

  • trace blood + no symptoms – no investigation

  • 1+ or more, confirmed on repeat testing – investigate/refer?


Urology referral

Urology Referral

  • male

  • >40 years

  • smoker

  • industrial exposure to hydrocarbons

  • chemotherapy

    = cystoscopy


Renal referral

Renal referral

  • eGFR < 60

  • proteinuria (ACR >30)

  • hypertension

  • family history

    = nephrology


What tests

What tests?

  • eGFR

  • plain urinary tract X-ray

  • ultrasound

  • ? urine microscopy ? cytology


Summary haematuria

Summary - haematuria

  • try to avoid testing asymptomatic patients

  • most asymptomatic patients do not need referral?

  • limited benefit from renal referral unless specific indication.


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