Med I - Proteinuria

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Proteinuria
-definition

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-excessive/abnormal urine protein excretion

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Proteinuria
-typical protein

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-albumin

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normal amount of albumin in normal urine

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< 1mg/dL

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Amt. of albumin in plasma

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4 g/dL

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Amt. of albumin filtered by the glomerulus

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2-3 mg/dL

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Most albumin reabsorption occurs where?

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-proximal tubule

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Proteinuria
-methods of diagnosis

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-Conventional urinalysis (dipstick, SSA)
-urine protein/creatinine ration
-albumin specific assay

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Proteinuria
-diagnosis needs to be made in light of

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-USG
-Urine sediment exam

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Effect of USG on proteinuria

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-lower USG suggests a greater proteinuria than a proteinuria with a higher USG

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Proteinuria
-dipstick test

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-most sensitive to albumin but will pick up other proteins as well

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Proteinuria
-SSA test

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-precipitates protein found in urine
-very sensitive, don't need much albumin to get reaction

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Dipstick and SSA tests
-problem with cats

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Create false positives
-produce cauxin which gets detected as albumin

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Proteinuria
-benefit of albumin specific assay

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-can tell you how much is present

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Proteinuria
-physiologic causes

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**Transient proteinuria**

-exercise
-seizures
-fever
-stress
-heat/cold
-activity level

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Physiologic causes of proteinuria
-reason why proteinuria may occur

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-relative renal vasoconstriction
-ischemia
-congestion

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Proteinuria
-pathologic nonurinary causes

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-Bence jones proteinuria
-hemoglobinuria
-myoglobinuria
-CHF
-genital tract inflammation

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Proteinuria
-pathologic urinary causes

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Nonrenal
-lower urinary tract inflammation
-hemorrhage

Renal
-glomerular lesions
-abnormal tubular reabsorption
-parenchymal inflammation/hemorrhage

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Occurrence of persistent proteinuria with a normal urine sediment or accompanied by hyaline cast formation is suggestive of:

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-glomerular disease

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Assessments that can be made from a persistent proteinuria with a normal protein sediment

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-quantitative assessment
-qualitative assessment

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Assessments that can be made from a renal biopsy

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-histological assessment

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Renal biopsy
-ways to examine for histological assessment

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-light microscopy
-immunofluorescent (rule in/out immune mediated disease)
-electron microscopy (look at tubular wall)

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Proteinuria
-reason to spread urinalysis out across 2-3 weeks

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-rule out transient

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Hyaline casts
-indicative of

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-high amounts of protein in the tubular fluid

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Normal urine protein/creatinine ratio

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0.1

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Importance of urine protein/creatinine ratio for detecting proteinuria

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-negates the effects of urine volume/concentration

-helps assess severity of disease
-helps assess response to treatment or progression of disease

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Normal UP/C ratio

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<0.2

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Borderline UP/C
-cats
-dogs

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Cats = 0.2-0.4

Dogs = 0.2-0.5

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Renal proteinuria UP/C

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>0.4/0.5
-if persistent with inactive urine sediment

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UP/C >0.4/0.5 is indicative of:

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-either glomerular or tubular renal proteinuria

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Glomerular Proteinuria
-UP/C

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> 2.0
-if persistent with inactive sediment

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A 2 year-old, SF, Cocker Spaniel is presented because of decreased appetite and weight loss. Physical exam is unremarkable. The only abnormality on CBC and serum biochemistry profile is mild hypoalbuminemia. Proteinuria is detected on urinalysis and there is an inactive urine sediment. The urine protein/creatinine ratio is 4.32 and most likely represents:
-pre-glomerular proteinuria
-glomerular proteinuria
-post-glomerular proteinuria
-benign or physiologic proteinuria
-none of the above are correct

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-glomerular proteinuria

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Which of the following statements about the urine protein/creatinine ratio is true?
-the ratio from a single urine sample correlates well with 24 hr urine protein loss
-a ratio of less than 0.5 in dogs is normal
-the ratio does not allow differentiation of renal proteinuria from proteinuria assoc with lower tract inflammation
-the ratio is unaffected by urine concentration and volume
-all of the above statements are true

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-all of the above are true

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Which of the following is not part of the nephrotic syndrome definition?
-proteinuria
-hypoalbuminemia
-azotemia
-edema and/or ascites
-hypercholesterolemia
-all are part of the nephrotic syndrome

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-azotemia

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Reasons for a non-responsive, non-healing wound

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-fungal
-foreign body
-neoplasia

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Glomerular amyloidosis
-significant finding

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-extremely high protein loss

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Amyloid
-production due to

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-long standing inflammatory process

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Renal proteinuria
-defining characteristics

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-persistent
-urine protein excretion > 5-10 mg/kg/24hrs
-no evidence of urinary tract inflammation

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Suspect renal proteinuria
-quantified by:

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-collecting all urine produced over a 24 hr period

-UP/C ratio

-Species specific quantitative albuminuria assay measured in urine diluted to USG = 1.010

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Reasons to quantitate renal proteinuria

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-rough assessment of the severity of renal lesions
-noninvasive way to follow response to treatment or progression of disease
-prognostic information in the face of azotemia

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UP/Cs associated with decreased survival time in:
-dogs
-cats

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-Dogs > 1.0

-Cats > 0.2

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Glomerular disease
-causes

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-immune complexes in glomerular capillary walls
-intraglomerular hypertension
-structural abnormalities
-amyloid deposition

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Glomerular disease
-definitive diagnosis

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-renal biopsy

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Nephrotic syndrome
-characterized by

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-proteinuria
-hypoalbuminemia
-hypercholesterolemia
-edema and/or ascites
-hypertension
-hypercoagulability