Proteinuria and Haematuria an update

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Proteinuria and Haematuria an update

• Alex Heaton
• 11.02.2009

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What is normal?

• Normal 80 /- 25 mg/day (lt150 mg is quoted as
  upper normal limit).
• Adolescents up to 300 mg/day (? 10-16 years, ?
  12-18 years)

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Measurements of proteinuria

• Dipstick tests
• 24 hour urinary protein
• Urine protein/creatinine ratio
• Urine albumin/creatinine ratio

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Why bother testing urine?

• Detection of renal disease
• Cardiovascular risk factor

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Clinical significance of proteinuria

• Proteinuria on dipstick in healthy patient
• ?
• ? Any systemic disease, e.g hypertension,
  diabetes mellitus ? likely renal disease
• ?
• gt1 gram a day ? likely renal disease
• ?
• gt3.5 g/day ? likely glomerular disease

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Protein in urine what next?

• establish persistent proteinuria
• clinical assessment
• interpreting test results

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Step 1. Establish persistent proteinuria

• proteinuria (1 or more)
• ?
• exclude urinary infection
• ?
• repeat urinalysis after at least one week
• ?
  ?
• 1 or more continue trace or negative
• no action

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Step 2. Initial assessment if persistent
proteinuria 1 or more

• send early morning urine for albumin/creatinine
  ratio
• blood tests U Es, fasting glucose,
  cholesterol and albumin
• Check blood pressure

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Step 3 What to do with an albumin/creatinine(mg/m
mol) result

• lt5 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 lt60 or a systemic disease
• gt70 refer to Nephrology

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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

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Haematuria

• frank haematuria high yield on
  investigation
• microscopic haematuria
• symptoms high yield
• - symptoms low or very low yield

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Microscopic haematuria

• trace blood no symptoms no investigation
• 1 or more, confirmed on repeat testing
  investigate/refer?

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Urology Referral

• male
• gt40 years
• smoker
• industrial exposure to hydrocarbons
• chemotherapy
• cystoscopy

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Renal referral

• eGFR lt 60
• proteinuria (ACR gt30)
• hypertension
• family history
• nephrology

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What tests?

• eGFR
• plain urinary tract X-ray
• ultrasound
• ? urine microscopy ? cytology

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Summary - haematuria

• try to avoid testing asymptomatic patients
• most asymptomatic patients do not need referral?
• limited benefit from renal referral unless
  specific indication.