Albuminuria, Proteinuria, and Renal Disease Progression in Children with CKD

Total Page:16

File Type:pdf, Size:1020Kb

Albuminuria, Proteinuria, and Renal Disease Progression in Children with CKD Article Albuminuria, Proteinuria, and Renal Disease Progression in Children with CKD Dana Y. Fuhrman, Michael F. Schneider, Katherine M. Dell, Tom D. Blydt-Hansen, Robert Mak, Jeffrey M. Saland, Susan L. Furth, Bradley A. Warady, Marva M. Moxey-Mims, and George J. Schwartz Abstract Background and objectives The role of albuminuria as an indicator of progression has not been investigated in Due to the number of children with CKD in the absence of diabetes. contributing authors, the affiliations are Design, setting, participants, &measurementsChildren wereenrolledfrom 49 centersof the CKD in Children study provided in the between January of 2005 and March of 2014. Cross-sectional multivariable linear regression (n=647) was used Supplemental to examine the relationship between urine protein-to-creatinine (UP/C [milligrams per milligram]) and Material. albumin-to-creatinine (ACR [milligrams per gram]) with eGFR (milliliters per minute per 1.73 m2). Parametric Correspondence: time-to-event analysis (n=751) was used to assess the association of UP/C, ACR, and urine nonalbumin-to- Dr.GeorgeJ.Schwartz, creatinine (Unon-alb/cr [milligrams per gram]) on the time to the composite endpoint of initiation of RRT or Department of Pediatrics, Division of 50% decline in eGFR. Pediatric Nephrology, University of Rochester Results The median follow-up time was 3.4 years and 202 individuals experienced the event. Participants with a Medical Center 601 UP/C$0.2 mg/mg and ACR$30 mg/g had a mean eGFR that was 16 ml/min per 1.73 m2 lower than those Elmwood Avenue, Box with a UP/C,0.2 mg/mg and ACR,30 mg/g. Individuals with ACR,30 mg/g, but a UP/C$0.2 mg/mg, had a 777, Rochester, NY 14642. Email: 2 , , mean eGFR that was 9.3 ml/min per 1.73 m lower than those with a UP/C 0.2 mg/mg and ACR 30 mg/g. george_schwartz@ When categories of ACR and Unon-alb/cr were created on the basis of clinically meaningful cutoff values of UP/C urmc.rochester.edu with the same sample sizes for comparison, the relative times (RTs) to the composite end-point were almost identical when comparing the middle (RT=0.31 for UP/C [0.2–2.0 mg/mg], RT=0.38 for ACR [56–1333 mg/g], RT=0.31 for Unon-alb/cr [118–715 mg/g]) and the highest (RT=0.08 for UP/C [.2.0 mg/mg], RT=0.09 for ACR [.1333 mg/g], RT=0.07 for Unon-alb/cr [.715 mg/g]) levels to the lowest levels. A similar trend was seen when categories were created on the basis of clinically meaningful cutoff values of ACR (,30, 30–300, .300 mg/g). Conclusions In children with CKD without diabetes, the utility of an initial UP/C, ACR, and Unon-alb/cr for characterizing progression is similar. Clin J Am Soc Nephrol 12: 912–920, 2017. doi: https://doi.org/10.2215/CJN.11971116 Introduction The 2012 Kidney Disease Improving Global Outcomes Proteinuria is a major prognostic indicator of renal guidelines for staging and predicting the progression of progressioninbothchildrenandadultswithCKD CKD designate a urine albumin-to-creatinine ratio (ACR) (1–4). The Chronic Kidney Disease in Children (CKiD) of ,30 mg/g as “normal-to-mildly increased,” 30– study reported that total urine protein-to-creatinine ratios 300 mg/g as “moderately increased,” and .300 mg/g (UP/C) .2.0 mg/mg in children with glomerular CKD as “severely increased.” (5) Traditionally, in studies of were associated with a 94% reduction in the time to adults with CKD, albuminuria, rather than overall either a 50% decline in eGFR or the initiation of RRT (1). proteinuria, has been utilized in studies of progres- Children with nonglomerular CKD and a UP/C.2.0 sion (2, 6–10). Although the association of normal or mg/mg had a 79% reduction in the time to this same mildly increased levels of albuminuria on worsening endpoint. Indeed, compared with hypoalbuminemia, renal function has been explored in the adult CKD elevated BP, dyslipidemia, and anemia, nephrotic range population, the association of smaller amounts of proteinuria was the strongest risk factor for renal pro- albuminuria (alternatively termed “microalbuminuria”) gression in children with CKD, regardless of glomerular and kidney disease progression in pediatric patients or nonglomerular cause (1). In 2009, the randomized, has largely been confined to studies of patients prospective The Effect of Strict Blood Pressure Control with diabetes mellitus (8, 11). Because of this and ACE Inhibition on the Progression of Chronic Renal difference in urine protein quantification methods Failure in Pediatric Patients (ESCAPE) trial in children in adult versus pediatric studies, we wanted to with CKD demonstrated that higher levels of proteinuria determine whether albuminuria, specifically, has partic- were associated with a more rapid decline in GFR (3). ular importance compared with general proteinuria as 912 Copyright © 2017 by the American Society of Nephrology www.cjasn.org Vol 12 June, 2017 Clin J Am Soc Nephrol 12: 912–920, June, 2017 Albuminuria in Children with CKD, Fuhrman et al. 913 Table 1. Characteristics at the index visit of the 751 CKiD participants Characteristics Median (Interquartile Range) or % (n) Age, yr 12.4 (8.6–15.7) Men 61 (457) White race 65 (491) Systolic or diastolic BP $95th percentilea 15 (108) Current ACE or ARB use 56 (417) eGFRb, ml/min per 1.73 m2 54.6 (39.5–71.8) Glomerular CKD cause 30 (228) Age-sex–specific body mass index $95th percentilec 17 (129) Urine protein-to-creatinine, mg/mg 0.32 (0.12–1.04) Urine albumin-to-creatinine, mg/g 112.0 (20.9–615.0) Urine nonalbumin-to-creatinine, mg/g 167.6 (75.0–400.7) Urine albumin-to-protein, mg/mg 0.44 (0.15–0.65) n, number of participants. aBP percentiles were determined using age/sex/height–specific values; missing for 33 participants. beGFR=0.4133(height [centimeters]/serum creatinine [milligrams per deciliter]). cBody mass index percentiles were determined using age/sex–specific values; missing for 12 participants. an indicator of renal progression in children without diabetes 49 nephrology centers across North America. The study mellitus. design and conduct were approved by an observational Evaluation for albuminuria is currently not part of the study-monitoring board appointed by the National In- routine care of children with CKD without diabetes. stitute of Diabetes and Digestive and Kidney Diseases and Likewise, investigating the amount of nonalbumin proteins by the internal review boards of each participating center. in the urine, whose increased presence indicates tubular Each participating family provided informed consent. The dysfunction, is not routinely done in the evaluation of demographic and clinical characteristics of the cohort as a pediatric patients with CKD (12–14). This study sought to: whole have been published elsewhere (15). Study partic- (1) quantify the cross-sectional relationship between both ipants were seen at annual follow-up visits after their initial UP/C and ACR with eGFR, (2) determine the cross- baseline visit which occurred between January of 2005 and sectional relationships between UP/C, ACR, and urine March of 2014. Beginning in June of 2008, urine albumin nonalbumin-to-creatinine (Unon-alb/cr), and (3)compare was added to the urine panel of tests as part of each annual the association of each of UP/C, ACR, and Unon-alb/cr visit. Of the 891 participants enrolled, 757 had at least one visit with time to RRT or .50% decline in eGFR. with ACR measured; the visit with the first ACR measure- ment was defined as the index visit. Our time-to-event analyses were restricted to the 751 participants who had Materials and Methods follow-up data after the index visit to determine time to first of Study Population .50% decline in eGFR or RRT. eGFR (milliliters per minute The CKiD study is a multicenter, prospective cohort per 1.73 m2) was calculated at each visit using: 0.4133(height study of children with mild-to-moderate CKD conducted at [centimeters]/serum creatinine [milligrams per deciliter]) (16). Table 2. Multivariablea linear regression analysis of index visit values of eGFR on urine protein-to-creatinine (milligrams per milligram) and urine albumin-to-creatinine (milligrams per gram), n=647 Mean eGFR (millilitre per minute per 1.73 m2) 95% Confidence Exposureb No. Relative to Interval Reference Urine protein-to-creatinine 170 0 (reference) ,0.2 and urine albumin-to-creatinine ,30 Urine protein-to-creatinine 86 23.1 28.1 to 1.9 ,0.2 and urine albumin-to-creatinine $30 Urine protein-to-creatinine 21 29.3 217.8 to 20.7 $0.2 and urine albumin-to-creatinine ,30 Urine protein-to-creatinine 370 216.0 219.7 to 212.4 $0.2 and urine albumin-to-creatinine $30 aAdjusted for age, sex, race, CKD cause, hypertension status, body mass index, and uric acid. bFor urine protein-to-creatinine the units are mg/mg; for urine albumin-to-creatinine the units are mg/g. 914 Clinical Journal of the American Society of Nephrology Figure 1. | Collinearity between the three methods to quantify proteinuria at the index study visit, n=751. Thedashedlineshownineachof the panels in Figure 1 is the line on which all of the data would fall if there were perfect agreement between the two variables. Protein Measures and also among those not reporting an angiotensin converting Participants provided a random urine collection on the enzyme (ACE) inhibitor or angiotensin receptor blocker morning of the study. Urine albumin was measured using an (ARB)attheindexvisit.Onthebasisofpreviousstudies immunoturbidimetric assay whereby anti-albumin antibodies showing significant associations with eGFR, the linear re- react with the urine sample to form antigen-antibody com- gression model was adjusted for: age, sex, race (white versus plexes.
Recommended publications
  • Surgeons, Columbia University, New York City) (Received for Publication August 9, 1932)
    THE ADDIS SEDIMENT COUNT IN NORMAL CHILDREN By JOHN D. LYTTLE (From the Babies Hospit and the Department of Pediatrics, Colege of Physicians and Surgeons, Columbia University, New York City) (Received for publication August 9, 1932) THE METHOD In 1925 Addis (1) described a method by which, in a concentrated acid urine, the rate of excretion of protein, casts and red and white cells could be determined. His method, with certain modifications, has been followed here. All of the counts were made on the 12 hour night specimen from 7 or 8 P.M. to 7 or 8 A.M. Addis recommended that fluids be restricted during, and for 12 hours preceding the collection, since in dilute and alkaline urine hyaline casts dissolve and red cells may be completely lysed. With children this rigid restriction of fluid proved impossible. Withholding fluid during the afternoon and night except for 200 cc. at the evening meal, gave urines of such concentration and acidity that they were suitable for a count. Most children had an early supper and col- lections were started at 7 or 8 P.M. Under these conditions, the urinary pH was between 5.0 and 6.0 and the specific gravity usually well above 1.020. The specimens were treated as described by Addis: "the con- centrated night urine is thoroughly mixed by repeated inversion of the rubber-stoppered bottle and a 10 cc. sample is transferred to a special graduated tube, and centrifugalized for five minutes at 1,800 revolutions per minute. The supernatant urine is decanted and pipetted down to a known volume which varies with the amount of sediment as judged by direct observation.
    [Show full text]
  • A Dipstick Test Combined with Urine Specific Gravity Improved the Accuracy of Proteinuria Determination in Pregnancy Screening
    Kobe J. Med. Sci., Vol. 56, No. 4, pp. E165-E172, 2010 A Dipstick Test Combined with Urine Specific Gravity Improved the Accuracy of Proteinuria Determination in Pregnancy Screening NATSUKO MAKIHARA1, MINEO YAMASAKI1,2, HIROKI MORITA1, and HIDETO YAMADA1* 1Division of Obstetrics and Gynecology, Department of Surgery-related, and 2Division of Integrated Medical Education, Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan. Received 12 July 2010/ Accepted 20 August 2010 Key Words: dipstick test, pregnancy proteinuria, protein/creatinine ratio, urine specific gravity Proteinuria screening using a semi-quantitative dipstick test of the spot urine in antenatal clinic is known to have high false-positive rates. The aim of this study was to assess availability of a dipstick test combined with the urine specific gravity for the determination of pathological proteinuria. A dipstick test was performed on 582 urine samples obtained from 283 pregnant women comprising 260 with normal blood pressure and 23 with pregnancy-induced hypertension. The urine protein (P) and creatinine (C) concentrations, specific gravity (SG), P/C ratio were determined, and compared with dipstick test results. The P concentration increased along the stepwise augmentations in dipstick test result. Frequencies of the urine samples with 0.265 or more P/C ratio were 0.7% with − dipstick test result, 0.7% with the ± result, 3.3% with the 1+ result, and 88.9% with the ≥2+ result. However, if the urine specific gravity was low, frequencies of the high P/C ratio were 5.0% with ± dipstick test result and 9.3% with the 1+ result.
    [Show full text]
  • Albuminuria Versus Egfr
    Albuminuria versus GFR as markers of diabetic CKD progression KDIGO Controversies Conference: “Diabetic Kidney Disease” New Delhi, March 2012 Richard J MacIsaac PhD FRACP Director of Endocrinology & Diabetes, St Vincent's Hospital Professorial Fellow, University of Melbourne Evolution of Diabetic CKD Incipient Overt Nephropathy Nephropathy GFR 100 Log AER (ml/min) GFR 10 15 20 yrs Normoalbuminuria Microalbuminuria Macroalbuminuria (AER < 20 µµµg/min) (AER 20-200 µµµg/min) (AER > 200 µµµg/min) Stages of CKD Stage eGFR Description Predominant (ml/min/1.73 m2) AER status 1 > 90 Kidney damage with normal/high GFR Normo- Micro- 2 60-89 Kidney damage with mild reduction in GFR Micro- 3 30-59 Kidney damage with moderate reduction in Micro/Macro- GFR 4 15-29 Kidney damage with severe reduction in Macro- GFR 5 < 15 Kidney failure Albuminuria versus GFR as markers of diabetic CKD progression 1. Albuminuria as a predictor of diabetic CKD 2. GFR as a predictor of diabetic CKD 3. Albuminuria & GFR uncoupling/coupling 4. Summary Albuminuria as a marker of diabetic CKD progression • High Variability M N • Low Specificity • Spontaneous Regression µ • Δ AER ≠ Δ GFR Higher levels of urinary albumin excretion within the normal range predict faster decline in glomerular filtration rate in diabetic patients Babazono T et al. Diabetes Care 2009;32:1518-1520 Albuminuria versus GFR as markers of diabetic CKD progression 1. Albuminuria as a predictor of diabetic CKD 2. GFR as a predictor of diabetic CKD 3. ALbuminuria & GFR uncoupling/coupling 4. Summary GFR as
    [Show full text]
  • Proteinuria and Albuminuria: What’S the Difference? Cynthia A
    EXPERTQ&A Proteinuria and Albuminuria: What’s the Difference? Cynthia A. Smith, DNP, CNN-NP, FNP-BC, APRN, FNKF What exactly is the difference between TABLE Q the protein-to-creatinine ratio and the Persistent Albuminuria Categories microalbumin in the lab report? How do they compare? Category Description UACR For the non-nephrology provider, the options for A1 Normal to mildly < 30 mg/g evaluating urine protein or albumin can seem con- increased (< 3 mg/mmol) fusing. The first thing to understand is the impor- tance of assessing for proteinuria, an established A2 Moderately 30-300 mg/g marker for chronic kidney disease (CKD). Higher increased (3-30 mg/mmol) protein levels are associated with more rapid pro- A3 Severely > 300 mg/g gression of CKD to end-stage renal disease and in- increased (> 30 mg/mmol) creased risk for cardiovascular events and mortality in both the nondiabetic and diabetic populations. Abbreviation: UACR, urine albumin-to-creatinine ratio. Monitoring proteinuria levels can also aid in evaluat- Source: KDIGO. Kidney Int. 2012.1 ing response to treatment.1 Proteinuria and albuminuria are not the same low-up testing. While the UACR is typically reported thing. Proteinuria indicates an elevated presence as mg/g, it can also be reported in mg/mmol.1 Other of protein in the urine (normal excretion should be options include the spot urine protein-to-creatinine < 150 mg/d), while albuminuria is defined as an “ab- ratio (UPCR) and a manual reading of a reagent strip normal loss of albumin in the urine.”1 Albumin is a (urine dipstick test) for total protein.
    [Show full text]
  • Understanding What It Means to Have Protein in Your Urine Understanding What It Means to Have Protein in Your Urine
    UNDERSTANDINGUnderstanding WHAT ITYour MEANS TO HAVE Hemodialysis PROTEINAccess Options IN YOUR URINE 2 AAKP: Understanding What It Means to Have Protein in Your Urine Understanding What It Means to Have Protein in Your Urine The kidneys are best known for making urine. This rather simple description does not tell the whole story. This brochure describes other important functions of the kidneys; including keeping protein in the blood and not letting any of the protein in the liquid (plasma) part of blood escape into the urine. Proteinuria is when “Proteinuria” is when kidneys allow proteins to kidneys appear in the urine and be lost from the body. allow Proteinuria is almost never normal, but it can proteins to be normal - rarely - in some healthy, active appear in the urine children or young adults. and be The kidneys are paired organs located on either lost from the body. side of the backbone. They are located at the Proteinuria level of the lowest part of the rib cage. They are is almost the size of an adult fist (4.5 – 5 inches in length). never Together the two kidneys receive a quarter of normal, but it can the blood that is pumped from the heart every be normal minute. This large blood flow is needed in order - rarely - for the kidneys to do one of the kidneys’ main in some jobs: healthy, active • remove waste products in the blood every children day or young adults. • keep the body in balance by eliminating the extra fluids and salts we consume on a regular basis.
    [Show full text]
  • Obesity, Albuminuria, and Urinalysis Findings in US Young Adults from the Add Health Wave III Study
    CJASN ePress. Published on October 17, 2007 as doi: 10.2215/CJN.00540107 Obesity, Albuminuria, and Urinalysis Findings in US Young Adults from the Add Health Wave III Study Maria Ferris,* Susan L. Hogan,* Hyunsook Chin,* David A. Shoham,† Debbie S. Gipson,* Keisha Gibson,* Sema Yilmaz,‡ Ronald J. Falk,* and J. Charles Jennette§ *University of North Carolina Kidney Center and Division of Nephrology and Hypertension and §Department of Pathology and Laboratory Animal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; †Department of Preventive Medicine and Epidemiology, Loyola University Chicago, Stritch School of Medicine, Maywood, Illinois; and ‡Department of Pediatrics, Hospital of Dumlupinar University, Kutahya, Turkey Background and objectives: Obesity has been associated with kidney disease in adults. This study was designed to evaluate the association of obesity with an early marker of kidney disease, albuminuria, among young adults. and body mass ,(4463 ؍ albumin-to-creatinine ratio (n ,(9371 ؍ Design, setting, participants, & measurements: Urinalysis (n index (kg/m2) were measured in the Add Health Wave III cohort (2001 to 2002), a multiethnic sample of young adults followed for approximately 6 yr. Multivariate logistic regression modeled the association of sex-specific albuminuria with body mass index, adjusted for sample weights, sex, race, ethnicity, and glycosuria. Results: Urinalysis revealed that 0.8% had proteinuria, 4.6% had hematuria, 0.2% had combined hematuria and proteinuria, and 1.5% had glycosuria. Albuminuria prevalence was 4.4%. Mean body mass index was higher among those with albuminuria compared with those without. There were no associations between body mass index categories of 25 to <30 or 30 to <35 kg/m2 with albuminuria compared with the lowest body mass index (<25 kg/m2); however, the highest category (>35 kg/m2) was %95 ;4.0 ؍ CI: 1.02 to 3.04).
    [Show full text]
  • Storm in a Pee Cup: Hematuria and Proteinuria
    Storm in a Pee Cup: Hematuria and Proteinuria Sudha Garimella MD Pediatric Nephrology, Children's Hospital-Upstate Greenville SC Conflict of Interest • I have no financial conflict of interest to disclose concerning this presentation. Objectives • Interpret the current guidelines for screening urinalysis, and when to obtain a urinalysis in the pediatric office. • Interpret the evaluation of asymptomatic/isolated proteinuria and definitions of abnormal ranges. • Explain the evaluation and differential diagnosis of microscopic hematuria. • Explain the evaluation and differential diagnosis of gross hematuria. • Explain and discuss appropriate referral patterns for hematuria. • Racial disparities in nephrology care 1. APOL-1 gene preponderance in African Americans and risk of proteinuria /progression(FSGS) 2. Race based GFR calculations which have caused harm 3. ACEI/ARB usage in AA populations: myths and reality Nephrology Problems in the Office • Hypertension • Proteinuria • Microscopic Hematuria • Abnormal Renal function The Screening Urinalysis • Choosing Wisely: • Don’t order routine screening urine analyses (UA) in healthy, asymptomatic pediatric patients as part of routine well child care. • One study showed that the calculated false positive/transient abnormality rate approaches 84%. • Population that deserves screening UA: • patients who are at high risk for chronic kidney disease (CKD), including but not necessarily limited to patients with a personal history of CKD, acute kidney injury (AKI), congenital anomalies of the urinary tract, acute nephritis, hypertension (HTN), active systemic disease, prematurity, intrauterine growth retardation, or a family history of genetic renal disease. • https://www.choosingwisely.org/societies/american-academy-of-pediatrics-section-on- nephrology-and-the-american-society-of-pediatric-nephrology/ Screening Urinalysis: Components A positive test for leukocyte esterase may be seen in genitourinary inflammation, irritation from instrumentation or catheterization, glomerulonephritis, UTIs and sexually transmitted infections.
    [Show full text]
  • Hematuria in the Child
    Hematuria and Proteinuria in the Pediatric Patient Laurie Fouser, MD Pediatric Nephrology Swedish Pediatric Specialty Care Hematuria in the Child • Definition • ³ 1+ on dipstick on three urines over three weeks • 5 RBCs/hpf on three fresh urines over three weeks • Prevalence • 4-6% for microscopic hematuria on a single specimen in school age children • 0.3-0.5% on repeated specimens Sources of Hematuria • Glomerular or “Upper Tract” – Dysmorphic RBCs and RBC casts – Tea or cola colored urine – Proteinuria, WBC casts, renal tubular cells • Non-Glomerular or “Lower Tract” – RBCs have normal morphology – Clots/ Bright red or pink urine The Glomerular Capillary Wall The Glomerular Capillary Wall Glomerular Causes of Hematuria • Benign or self-limiting – Benign Familial Hematuria – Exercise-Induced Hematuria – Fever-Induced Hematuria Glomerular Causes of Hematuria • Acute Glomerular Disease – Poststreptococcal/ Postinfectious – Henoch-Schönlein Purpura – Sickle Cell Disease – Hemolytic Uremic Syndrome Glomerular Causes of Hematuria • Chronic Glomerular Disease – IgA Nephropathy – Henoch-Schönlein Purpura or other Vasculitis – Alport Syndrome – SLE or other Collagen Vascular Disease – Proliferative Glomerulonephritis Non-Glomerular Hematuria • Extra-Renal • UTI • Benign urethralgia +/- meatal stenosis • Calculus • Vesicoureteral Reflux, Hydronephrosis • Foreign body • Rhabdomyosarcoma • AV M • Coagulation disorder Non-Glomerular Hematuria • Intra-Renal • Hypercalciuria • Polycystic Kidney Disease • Reflux Nephropathy with Renal Dysplasia •
    [Show full text]
  • Screening for Microalbuminuria in Patients with Diabetes
    Screening for Microalbuminuria in Patients with Diabetes Why? How? To identify patients with diabetic kidney disease (DKD). Test for microalbuminuria To distinguish DKD patients from diabetic patients with chronic kidney disease (CKD) from other causes. The latter require further investigation and possibly different No clinical management. + for albumin Because markers of kidney damage are required to detect early stages of CKD. Yes Estimated glomerular filtration rate (eGFR) alone can only detect CKD stage 3 or worse. Condition that may invalidate* urine albumin excretion When? Yes Begin screening: No Treat and/or wait until No resolved. Repeat test. In type 1 diabetes – 5 years after diagnosis, then annually + for protein? In type 2 diabetes – at diagnosis, then annually Yes Repeat microalbuminuria test twice within 3-6 month period. Is it Microalbuminuria? Measure urinary albumin-creatinine ratio (ACR) Yes Rescreen No in a spot urine sample. 2 of 3 tests positive? in one year Category Spot (mg/g creatinine) Yes Normoalbuminuria <30 Microalbuminuria, begin treatment Microalbuminuria 30-300 Macroalbuminuria >300 * Exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, pregnancy, marked hypertension, urinary tract infection, and hematuria. Screening for Microalbuminuria in Patients with Diabetes Is it DKD? CKD should be attributable to diabetes if: Macroalbuminuria is present; or Microalbuminuria is present: • in the presence of diabetic retinopathy • in type 1 diabetes of at least 10 years’ duration Albuminuria GFR (mL/min) CKD Stage* Normoalbuminuria Microalbuminuria Macroalbuminuria >60 1 + 2 At risk† Possible DKD DKD 30-60 3 Unlikely DKD‡ Possible DKD DKD <30 4 + 5 Unlikely DKD‡ Unlikely DKD DKD * Staging may be confounded by treatment because RAS blockade could render microalbuminuric patients normoalbuminuric and macroalbuminuric patients microalbuminuric.
    [Show full text]
  • Prevalence of Micro Albuminuria and Diagnostic Accuracy of Urine Dipstick for the Screening of Diabetic Nephropathy in Type 2 Diabetes Patients
    Biocatalysis and Agricultural Biotechnology 21 (2019) 101316 Contents lists available at ScienceDirect Biocatalysis and Agricultural Biotechnology journal homepage: http://www.elsevier.com/locate/bab Prevalence of micro albuminuria and diagnostic accuracy of urine dipstick for the screening of diabetic nephropathy in type 2 diabetes patients Sindhu Varghese, S. Gowtham Kumar * Faculty of Allied Health Sciences, Chettinad Academy of Research and Education Kelambakkam, Tamil Nadu, 603103, India ARTICLE INFO ABSTRACT Keywords: Diabetic nephropathy can be early diagnosed by the detection of micro albuminuria in spot urine sample. Diabetic nephropathy Microalbuminuria can strongly predict the progression of renal diseases such as diabetic nephropathy among Microalbuminuria high risk population. Hypertension is a major factor which doubles the risk of renal failures. Urine dipstick Hypertension method is a frequently used way for screening and evaluation of microalbuminuria so as to detect the early Type 2 diabetes mellitus symptoms of diabetic nephropathy. Urine albumin /creatinine ratio In this background, a case control study of total 200 subjects were studied. The patient reports were diagnosed with HbA1c levels, systolic and diastolic BP, blood sugar level and other renal parameters were recorded and compared with micro albuminuria levels. Diagnostic performance of the dip stick was expressed in terms of sensitivity, specificity, PPV (positive predictive value) and NPV (negative predictive value). The statistical analysis was carried out using logistic regression analysis. The prevalence rate of microalbuminuria was higher in females when compared with males. There is no association of sex, HbA1c, diastolic bp, FBS with micro­ albuminuria in type 2 diabetes mellitus male subjects. The area under ROC curve for UACR (urine albumin/ creatinine ratio) was 0.92 in mcroalbuminuria (p < 0.001).
    [Show full text]
  • Blood Or Protein in the Urine: How Much of a Work up Is Needed?
    Blood or Protein in the Urine: How much of a work up is needed? Diego H. Aviles, M.D. Disclosure • In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturers of the products or providers of the services discussed in my presentation • This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA Screening Urinalysis • Since 2007, the AAP no longer recommends to perform screening urine dipstick • Testing based on risk factors might be a more effective strategy • Many practices continue to order screening urine dipsticks Outline • Hematuria – Definition – Causes – Evaluation • Proteinuria – Definition – Causes – Evaluation • Cases You are about to leave when… • 10 year old female seen for 3 day history URI symptoms and fever. Urine dipstick showed 2+ for blood and no protein. Questions? • What is the etiology for the hematuria? • What kind of evaluation should be pursued? • Is this an indication of a serious renal condition? • When to refer to a Pediatric Nephrologist? Hematuria: Definition • Dipstick > 1+ (large variability) – RBC vs. free Hgb – RBC lysis common • > 5 RBC/hpf in centrifuged urine • Can be – Microscopic – Macroscopic Hematuria: Epidemiology • Microscopic hematuria occurs 4-6% with single urine evaluation • 0.1-0.5% of school children with repeated testing • Gross hematuria occurs in 1/1300 Localization of Hematuria • Kidney – Brown or coke-colored urine – Cellular casts • Lower tract – Terminal gross hematuria – (Blood
    [Show full text]
  • Idiopathic Rhabdomyolysis D
    Arch Dis Child: first published as 10.1136/adc.46.249.594 on 1 October 1971. Downloaded from Archives of Disease in Childhood, 1971, 46, 594. Idiopathic Rhabdomyolysis D. C. L. SAVAGE, MEHROO FORBES*, and G. W. PEARCE From the Department of Child Health, Dundee University; and the Department of Pathology, Newcastle General Hospital, Newcastle upon Tyne Savage, D. C. L., Forbes, M., and Pearce, G. W. (1971). Archives of Disease in Childhood, 46, 594. Idiopathic rhabdomyolysis. The clinical, biochemical, and pathological findings in 2 children with idiopathic rhabdomyolysis are reported. Hypocalcaemic tetany, a previously unrecognized complication of severe muscle damage, was seen in one child and was associated with hyperphosphataemia and hyperphosphaturia consequent on the rhabdomyolysis. Respiratory distress and an acute tubular necrosis contributed to her eventual death. The second child recovered; an intracellular granular material of unknown nature was seen in his muscle biopsy on electron microscopy. The literature of idiopathic recurrent rhabdomyolysis occurring in childhood is reviewed. Idiopathic rhabdomyolysis, which may be re- with glucose 72 mg/100 ml. Urine contained a trace current, is a rare and potentially lethal disorder of of sugar and ketones. skeletal muscle, not previously recorded in the The child died shortly after admission to hospital, and copyright. British paediatric literature. Two forms of the death was recorded as being due to diabetic ketosis. At necropsy no abnormality was found; muscle tissue disease have been described: Type I usually pre- was not examined. In retrospect the CSF glucose ceded by physical exertion, and Type II often level makes this diagnosis untenable and it is probable associated with mild infections.
    [Show full text]