Proteinuria and Haematuria an update Alex Heaton 11

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 Urine protein/creatinine ratio Urine albumin/creatinine ratio

Why bother testing urine? • Detection of renal disease • Cardiovascular risk factor

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? • establish persistent proteinuria • clinical assessment • interpreting test results

Step 1. Establish persistent proteinuria (1+ or more) ↓ exclude urinary infection ↓ repeat urinalysis after at least one week ↓ ↓ 1+ or more continue trace or negative – no action

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 • <5 • 5 -30 • 31 -70 • >70 within reference range does not indicate renal disease but consider cardiovascular risk factors check 6 monthly blood pressure and ACR. No need to refer to nephrology unless patient also has haematuria, severe hypertension, e. GFR <60 or a systemic disease refer to Nephrology

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

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

Urology Referral • male • >40 years • smoker • industrial exposure to hydrocarbons • chemotherapy = cystoscopy

Renal referral • e. GFR < 60 • proteinuria (ACR >30) • hypertension • family history = nephrology

What tests? • • e. GFR plain urinary tract X-ray ultrasound ? urine microscopy ? cytology

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