Urinary Protein Loss Research Articles

Proteinuria is Associated with Urinary Loss of Cubilin and Vitamin D-Binding Protein in Patients with Preeclampsia

Women with preeclampsia (PE) form a vulnerable group for vitamin D3 deficiency. Reabsorption of vitamin D3 occurs in the proximal tubule after being endocytosed in combination with DBP (vitamin D binding protein) by the megalin/cubilin receptor. Because proteinuria promotes tubule injury and dysfunction, we hypothesized that the proteinuria present in PE could promote the loss of these components into the urine. Twenty preeclamptic patients and ten normal pregnant women with a gestational age greater than 20 weeks composed three groups: NC, normotensive control pregnant patients; PE, non-proteinuric preeclamptic patients; and PPE, preeclamptic patients with proteinuria. When proteinuria was absent, preeclampsia was diagnosed accordingly to the American College of Obstetricians and Gynecologists’ (ACOG) guideline. The presence of 24-hour proteinuria equal to or greater than 300 mg was considered to form the PPE group. Urinary cubilin, megalin, and DBP were measured by ELISA and normalized by urinary creatinine. Regarding gestational age, there was no difference between the groups. NC group had arterial pressure within normal values, whereas PE and PPE groups had a significant increase (p < 0.01). As expected, PPE group presented elevated ACR (p < 0.05), accompanied by large amounts of cubilin and DBP in the urine (p < 0.05 vs. NC and PE). No difference was found in urinary megalin. PPE patients showed more chance of shedding cubilin into the urine compared to non-proteinuric patients (odds ratio 12.7 (1.2–136.3). In conclusion, this study further tightens the relationship between PE and vitamin D3 deficiency, since proteinuria present in PE induces the loss of molecules responsible for renal tubular vitamin D3 reabsorption for subsequent activation. Combined with other factors, the proteinuria may intensify vitamin D3 deficiency in PE.

Proteinuria

Measurement of urinary protein is an essential part of the evaluation of chronic kidney disease; it has both diagnostic and prognostic significance. Proteinuria is an independent risk factor for progression of renal disease, but is also independently associated with increased cardiovascular mortality. Despite its far-reaching implications, the definition, diagnosis and treatment of proteinuria can cause confusion in primary care. Early detection of proteinuria in the context of diabetes or otherwise is vital given the potential for intervention to reduce urinary protein losses and improve renal and cardiovascular outcomes. This article will focus on the definition, potential causes and management of proteinuria, including which individuals should be referred to secondary care.

Longitudinal follow-up of kidney function in patients with a history of preeclampsia: From 11 to 18years postpartum.

Formerly preeclamptic (fPE) women are reported to have an increased risk to develop end stage kidney disease. To gain more insight in the course of kidney function after preeclampsia we assessed blood pressure, eGFR and urinary protein loss in 75 fPE women at 11 and 18years postpartum. We found that during follow-up blood pressure did not increase and no cases of CKD were identified. Only a small decrease in eGFR (6-7mL/min) and a small increase in urinary protein loss were observed, which fall within the expected range of normal aging. In conclusion, our data suggests that progression to kidney disease might not be a major concern in women after preeclampsia within 18years postpartum.

Preeclampsia with Intrauterine Growth Restriction Generates Morphological Changes in Endothelial Cells Associated with Mitochondrial Swelling-An In Vitro Study.

Pregnancy complicated by preeclampsia (PE) and intrauterine growth restriction (IUGR) promotes endothelial cell (EC) dysfunction. Our in vitro study aimed to evaluate the endothelial cell morphology after acute and chronic exposition to medium supplemented with serum taken from healthy pregnant women and women with IUGR and IUGR with PE. In the same condition, ECs viability, proliferation, reactive oxygen species (ROS) production, and serum concentration of vascular endothelial growth factor (VEGF) were also measured. Pregnant women with IUGR and IUGR with PE-delivered babies with reduced body mass and were characterized in elevated blood pressure, urine protein loss, and reduced level of VEGF. The 24 hours of exposition did not exert any morphological changes in ECs, except the reduction in cell viability, but prolonged exposition resulted in significant morphological changes concerning mostly the swelling of mitochondria with accompanying ROS production, cell autophagy, reduced cell viability, and proliferation only in complicated pregnancies. In conclusion, the sera taken from women with IUGR and IUGR with PE show a detrimental effect on ECs, reducing their viability, proliferation, and generating oxidative stress due to dysfunctional mitochondria. This multidirectional effect might have an adverse impact on the cardiovascular system in women with IUGR and PE.

Correlation between spot and 24h proteinuria: Derivation and validation of equation to estimate daily proteinuria.

Daily urine protein (UP) loss is a cumbersome but important measurement to guide diagnosis and treatment of renal disease. Spot urine protein-creatinine ratio (UPCR) can been applied to estimate daily proteinuria. However, the correlations between spot and 24h proteinuria remain controversial. In this cross-sectional study, simultaneous collection of 24h and spot urines were performed from 1,039 (derivation cohort) and 204 CKD patients (validation cohort) of Chang Gung Memorial Hospital, from 2007 to 2017. The correlations between spot UPCR and 24h proteinuria were compared. The mean age of patients of derivation and validation cohort was 63 and 55 years and the mean estimated glomerular filtration rate was 62 ± 35 and 59 ± 36 mL/min/m2, respectively. The correlation coefficient was 0.819 between UPCR and 24hUP. Prediction equation was derived as: Log1024hUP (g) = 0.814 x Log10UPCR (mg/mg) + 0.110 x Gender– 0.004 x Age + 0.004 x Body weight (kg) + 0.002 x CKD stage coefficient– 0.018, where CKD stage coefficient: CKD stage G1 = 1, G2 = 2, G3a = 3.1, G3b = 3.2, G4 = 4, G5 = 5. Correlation coefficient between measured and predicted 24hUP among derivation group and validation group is 0.866 and 0.915, respectively. However, the agreement of spot and daily estimates was less pronounced with proteinuria > 3g than lower values in Bland-Altman analysis. Spot UPCR can accurately predict 24hUP in patients with daily proteinuria below 3g. The development of this equation may facilitate estimation of 24hUP in the clinical practice.

Anti-RNA polymerase III antibody in lupus patients with proteinuria

To investigate the relationship between serum anti-ribonucleic acid polymerase III (anti-RNAP3) autoantibodies (Abs) and proteinuria severity in lupus patients. Serum antibodies reacting with anti-RNAP3 were measured in 49 systemic lupus erythematosus (SLE) patients (29 cases of SLE with proteinuria and 20 cases of SLE without proteinuria) and 10 healthy controls (HCs). For the patients, we recorded demographic data, daily urinary protein loss, serum anti-double strand deoxyribonucleic acid (anti-ds-DNA) antibodies, serum creatinine (Cr), estimated glomerular filtrating rate (eGFR), complement 3 (C3), and C4. Fewer anti-RNAP3 antibodies were found in the SLE patients than in the HCs (p = 0.061). In the SLE with proteinuria group, positive correlations were observed among anti-RNAP3 antibodies and daily urinary protein loss, serum C3, C4, and eGFR, and negative correlations were observed between anti-RNAP3-Abs and anti-ds-DNA-Abs and serum Cr levels. However, these correlations were nonsignificant (p > 0.05). This study demonstrated the possible role of anti-RNAP3 antibodies in SLE patients with proteinuria, as evidenced by their positive and negative relationships with daily urinary protein loss, eGFR, C3, C4, serum Cr, and anti-ds-DNA-Abs. Although these correlations were nonsignificant, our study builds a foundation for future tailored studies, and more in-depth studies with larger samples are warranted to provide more information.

Influence of albumin leakage on glycated albumin in patients with type 2 diabetes undergoing hemodialysis.

Glycated albumin (GA) is recommended as a better glycemic indicator than HbA1c in patients undergoing hemodialysis, because the red blood cell lifespan is generally faster than that in normal subjects. However, GA can be also affected by protein loss in urine and hemodialysis fluid. Therefore, in this study, we investigated the effect of albumin leakage induced by hemodialysis on GA. Nine patients undergoing hemodialysis with a large or small amount of albumin leakage were observed for 9 months in a crossover manner. As a result, it was shown that albumin leakage could affect GA, but the effect was practically small considering the prescription of diabetic drugs. The correlations between HbA1c and blood glucose levels and between GA and blood glucose levels were similar in our study. In conclusion, GA was a reliable indicator, even with the change of hemodialysis modality. The influence of albumin leakage induced by hemodialysis on GA was negligible practically. We should recognize that the preferable glycemic indicator in patients undergoing hemodialysis depends on the hemoglobin and albumin metabolism of each patient.

Role of erythrocytes in short-term rewarming kidney perfusion after cold storage.

Short term normothermic reconditioning by machine perfusion after cold storage has shown beneficial effects in renal transplantation models. Systematic investigations concerning the inclusion of washed erythrocytes as oxygen carriers are lacking in this context. Porcine kidneys were subjected to 20h of static cold storage. Prior to reperfusion, grafts were put on a machine for 2h of oxygenated (95% O2 ; 5% CO2 ) rewarming perfusion. In one group (n=6) washed erythrocytes were added to the perfusate after temperature has reached 20°C; the other group (n=6) was run without additives. Control kidneys (n=6) were immediately reperfused without treatment. Upon reperfusion in vitro, a more than twofold improvement of renal clearance of creatinine, urinary protein loss, fractional excretion of sodium, efficiency of oxygen utilization (TNa/VO2 ) and a significant reduction of innate immune activation (HMGB1, tenascin C, expression of TLR4) was seen after machine perfusion, compared with the controls. However, no advantage could be obtained by the addition of erythrocytes and inner cortical tissue pO2 always remained above normal values during cell-free machine perfusion. Our data strongly argue in favor of a rewarming perfusion of cold stored donor kidneys but do not substantiate an indication for adding oxygen carriers in this particular setting.

Immature megalin expression in the preterm neonatal kidney is associated with urinary loss of vitamin carrier proteins.

Vitamin A and D deficiencies are common in preterm infants. Megalin is an endocytic receptor in the proximal tubule, which reabsorbs retinol-binding protein (RBP) and vitamin D-binding protein (VDBP). Although the proximal tubule is immature in preterm infants, little is known about megalin expression during kidney development. In this study, we establish the abundance of megalin in the developing human kidney and its relationship to the urinary excretion of vitamin carriers in preterm infants. We analyzed a postmortem group (20-40 weeks gestation), where we used morphometric means of measuring megalin and its ligands in kidney tissue and a living group of patients (28-40 weeks), where urinary RBP and VDBP were measured. The presence of megalin, RBP, and VDBP increased in the proximal tubule through gestation. At birth the urinary concentration of RBP and VDBP were higher in the 28-32 week group compared to the 38-40 week group and a significant inverse correlation of tissue megalin and urinary loss of RBP and VDBP existed. Preterm infants experience vitamin carrier protein losses, which are associated with decreased megalin expression. This developmental expression of megalin in the kidney has clinical implications in the prevention of vitamin deficiencies in preterm babies.

Structural assembly of the megadalton-sized receptor for intestinal vitamin B12 uptake and kidney protein reabsorption

The endocytic receptor cubam formed by the 460-kDa protein cubilin and the 45-kDa transmembrane protein amnionless (AMN), is essential for intestinal vitamin B12 (B12) uptake and for protein (e.g. albumin) reabsorption from the kidney filtrate. Loss of function of any of the two components ultimately leads to serious B12 deficiency and urinary protein loss in humans (Imerslund-Gräsbeck’s syndrome, IGS). Here, we present the crystal structure of AMN in complex with the amino-terminal region of cubilin, revealing a sophisticated assembly of three cubilin subunits combining into a single intertwined β-helix domain that docks to a corresponding three-faced β-helix domain in AMN. This β-helix-β-helix association thereby anchors three ligand-binding cubilin subunits to the transmembrane AMN. Electron microscopy of full-length cubam reveals a 700–800 Å long tree-like structure with the potential of dimerization into an even larger complex. Furthermore, effects of known human mutations causing IGS are explained by the structural information.

A narrative review of proteinuria and albuminuria as clinical biomarkers in children.

Proteinuria is an important biomarker commonly used to detect and manage kidney disease in children. There are now a variety of methods available to measure urinary protein loss, and physicians are faced with several contrasting strategies: 24-h or timed collection versus spot samples (first-morning or random), measurement of total urinary protein versus selective measurement of urinary albumin, unadjusted urine protein concentration versus protein-to-creatinine ratio and the use of dipstick versus laboratory-based methods. In this review, we will discuss the advantages and disadvantages of these different approaches. We will then summarise the evidence base for proteinuria as a clinical biomarker in different settings, including discussion of the current and potential role of measuring low-level albuminuria. Finally, we will highlight gaps in the literature and opportunities for further research into proteinuria among children.

Correlation of electrophoretic urine protein banding patterns with severity of renal damage in dogs with proteinuric chronic kidney disease.

Urine protein loss is common in dogs with chronic kidney disease (CKD). Currently available noninvasive means of evaluating CKD in dogs cannot accurately predict the severity of glomerular and tubulointerstitial damage. Electrophoretic analysis of urine proteins can indicate the compromised renal compartment (glomerular vs tubular), but extensive evaluation of protein banding pattern associations with histologic damage severity has not been performed in dogs. We aimed to evaluate electrophoretic banding patterns as indicators of the presence and severity of glomerular and tubulointerstitial damage in dogs with naturally occurring, predominantly proteinuric CKD. We performed a retrospective study using urine and renal tissue from 207 dogs with CKD. Urine protein banding patterns were correlated with histologic severity of renal damage. Sensitivity and specificity of banding patterns for the detection of glomerular and tubulointerstitial damage were determined. Banding patterns were 97% sensitive and 100% specific for the detection of glomerular damage and 90% sensitive and 100% specific for the detection of tubulointerstitial damage. Correlations between composite banding patterns and the severity of renal damage were strong, while glomerular banding patterns correlated moderately with glomerular damage severity, and tubular gel scores correlated weakly to moderately with the severity of tubulointerstitial damage. Urine protein banding patterns are useful for the detection of glomerular and tubulointerstitial damage in dogs with proteinuric CKD.

Pattern of Anaemia in Systemic Lupus Erythemetosus (Sle) Patients

Background: Anaemia of Chronic Disease (ACD) is the most common form of anaemia in patients with Systemic Lupus Erythemetosus (SLE) Autoimmune Hemolytic Anaemia (AIHA), Iron Deficiency Anemia (IDA) drug-induced myelotoxicity, and anaemia due to chronic renal failure are also often detected. Distinctly different therapeutic approaches are required for the multiple causes of anaemia in these patients. However, the pattern of anaemia among the SLE patient of this geographical area is less studied. Aim of this study was to investigate the pattern of anaemia in patients with SLE. Materials and methods: This study was carried out on the patients who had been admitted in the Departments of Medicine, Nephrology and also from outpatient Department of Chittagong Medical College Hospital (CMCH) Chittagong. SLE patients were selected consecutively as per inclusion and exclusion criteria. Detailed history and physical examinations were performed in every patient. Necessary investigations were carried out. Hematological manifestations with regards to anaemia were scrutinized and statistically analyzed. Results: A total of 42 patients (97.62% females, mean age 27.02 ±8.63 years) were studied. All the study population was anaemic (Mean±SD of Hb was 9.14±1.84 mg/dl).ACD was most prevalent (52.4%) types of anaemia 22(52.4%), followed by IDA10(23.8%), AIHA6 (14.3%) and 4(9.5%) of total patient is undetermined cause of anemia. No significant association was found between anaemia and Disease Activity Index (SLEDAI) score, fatigue and Coombs’ positivity. No association was found between the degrees of anaemia with urine protein loss. Conclusion: Anaemia is frequently encountered in SLE. A sound conception about the relative frequency of different types associated with systemic lupus erythematosus will help the clinician to take necessary measures for the wellbeing of the patient.&#x0D; JCMCTA 2017 ; 28 (2) : 105-110

Major Organic Involvement in Women with Fabry Disease in Argentina.

Fabry disease (FD) is an X-linked lysosomal storage disorder resulting from the deficiency or absence of the alpha galactosidase A enzyme. Organic involvement in men is well known, but in women it is controversial, partly due to the random X-chromosomes inactivation (Lyon hypothesis). The aim of this study was to describe the organic involvement in women at the time of FD diagnosis. A descriptive, cross-sectional and multicenter study was carried out. Thirty-five women with FD from three reference centers in Argentina were evaluated. The mean age of the whole group (n = 35) was 26.6 ± 16.9 years; 22 were adult (over 18) and 13 were paediatric patients. Enzymatic activity was performed in 29/35 patients, which was normal in 24/29 (82.8%). Seven different mutations of the GLA gene were found. The results showed urinary protein loss (45.7%) and decreased glomerular filtration rate (31.4%), mainly in adults. And also, cornea verticillata (56.5%), peripheral neuropathy (51.4%), cardiovascular manifestations (31.4%), hearing loss (20%), angiokeratomas (20%), central nervous system (17.1%), and gastrointestinal involvement (14.3%). Organic compromise in females with FD may be as severe as in men. This analysis has demonstrated a significant proportion of women with signs, symptoms, and major organic involvement at FD diagnosis.

Treatment of canine leishmaniasis with marbofloxacin in dogs with renal disease.

Treatment of canine leishmaniasis (CanL) represents a challenge. Due to the high prevalence of renal disease associated to CanL, it is important to find an effective drug that does not damage the kidneys. Marbofloxacin has been shown to be effective and well tolerated in non-azotemic dogs with leishmaniasis. To evaluate the safety and efficacy of marbofloxacin in dogs with leishmaniasis and decreased renal function, 28 dogs suffering from leishmaniasis and chronic kidney disease (CKD) were treated with oral marbofloxacin at 2 mg/Kg/day for 28 days. During treatment dogs were assessed by performing weekly physical exams, measuring blood pressure and evaluating blood and urine parameters. Lymph node aspirations were also obtained at days 0 and 28. The global clinical score decreased significantly, from 6.2±3.4 to 4.7±3.1 (p = 0.0001), after treatment. Marbofloxacin also decreased parasitic load in 72% of the dogs. No significant differences in plasma creatinine, urine specific gravity, urinary concentrations of cystatin C, ferritin and urinary protein loss were detected during treatment. A transient but significant decrease in blood pressure was detected up to day 14 (from 180.1±36.6 to 166.0±32.7 mmHg; p = 0.016). Moreover, dogs showed a significant increase in plasma albumin concentration (from 15.0±5.2 to 16.6±3.9 g/L; p = 0.014) and a significant decrease in globulin concentration (from 59.0±18.1 to 54.1±18.0 g/L; p = 0.005). The results demonstrate that, in addition to being effective for treatment of CanL, marbofloxacin is a very safe drug in dogs with CKD and leishmaniasis.

Compromiso renal en mujeres con enfermedad de Fabry en Argentina. Estudio multicéntrico

IntroductionFabry disease (FD) is an X-linked lysosomal storage disorder resulting from the deficiency or absence of the alpha galactosidase A (α-galA) enzyme. Organ involvement in men is well known, but in women it is controversial, partly due to random X-chromosome inactivation (Lyon hypothesis). The aim of this study was to describe renal involvement in a population of 35 women at the time of FD diagnosis. MethodThirty-five females were evaluated in three reference centres in Argentina. The activity of the α-galA enzyme was determined on filter paper by a fluorometric method, and the mutational study by MLPA and sequencing. Glomerular filtration rate was calculated usinjg the CKD-EPI formula in adult patients and Schwartz formula in paediatric patients. Albuminuria and proteinuria were observed in at least two different urine samples in all cases, as well as the glomerular filtration rates categories according to KDIGO 2012 guidelines. ResultsMean age of the complete group (n=35) was 26.6±16.9 years, of whom 22 were adult women (over 18) and 13 were paediatric patients. Enzymatic activity of α-galA was performed in 29/35 patients, which was normal in 24/29 (82.8%). Seven different mutations of the GLA gene were found. The results showed glomerular hyperfiltration (42.9%), urinary protein loss (45.7%), and decreased glomerular filtration rate (31.4%). ConclusionsRenal involvement in females with FD may be as severe as in men. The analysis of this group of patients showed a significant proportion of females with early kidney damage demonstrated by renal hyperfiltration, albuminuria, proteinuria and glomerular filtration rate decreased, at the time of diagnosis of FD.

Impact of microbial efficiency to predict MP supply when estimating protein requirements of growing beef cattle from performance.

Data from 16 trials were compiled to calculate microbial CP (MCP) production and MP requirements of growing cattle on high-forage diets. All cattle were individually fed diets with 28% to 72% corn cobs in addition to either alfalfa, corn silage, or sorghum silage at 18% to 60% of the diet (DM basis). The remainder of the diet consisted of protein supplement. Source of protein within the supplement varied and included urea, blood meal, corn gluten meal, dry distillers grains, feather meal, meat and bone meal, poultry by-product meal, soybean meal, and wet distillers grains. All trials included a urea-only treatment. Intake of all cattle within an experiment was held constant, as a percentage of BW, established by the urea-supplemented group. In each trial the base diet (forage and urea supplement) was MP deficient. Treatments consisted of increasing amounts of test protein replacing the urea supplement. As protein in the diet increased, ADG plateaued. Among experiments, ADG ranged from 0.11 to 0.73 kg. Three methods of calculating microbial efficiency were used to determine MP supply. Gain was then regressed against calculated MP supply to determine MP requirement for maintenance and gain. Method 1 (based on a constant 13% microbial efficiency as used by the beef NRC model) predicted an MP maintenance requirement of 3.8 g/kg BW and 385 g MP/kg gain. Method 2 calculated microbial efficiency using low-quality forage diets and predicted MP requirements of 3.2 g/kg BW for maintenance and 448 g/kg for gain. Method 3 (based on an equation predicting MCP yield from TDN intake, proposed by the Beef Cattle Nutrient Requirements Model [BCNRM]) predicted MP requirements of 3.1 g/kg BW for maintenance and 342 g/kg for gain. The factorial method of calculating MP maintenance requirements accounts for scurf, endogenous urinary, and metabolic fecal protein losses and averaged 4.2 g/kg BW. Cattle performance data demonstrate formulating diets to meet the beef NRC model recommended MP maintenance requirement (3.8 g/kg S) works well when using 13% microbial efficiency. Therefore, a change in how microbial efficiency is calculated necessitates a change in the proposed MP maintenance requirement to not oversupply or undersupply RUP. Using the 2016 BCNRM to predict MCP production and formulate diets to meet MP requirements also requires changing the MP maintenance requirement to 3.1 g/kg BW.

Diabetic rats present higher urinary loss of proteins and lower renal expression of megalin, cubilin, ClC-5, and CFTR.

Diabetic nephropathy (DN) occurs in around 40% of those with diabetes. Proteinuria is the main characteristic of DN and develops as a result of increased permeability of the glomerulus capillary wall and/or decreased proximal tubule endocytosis. The goal of this work was to evaluate renal function and the expression of megalin, cubilin, CFTR (cystic fibrosis transmembrane conductance regulator), and ClC‐5 in the proximal tubule and renal cortex of rats with type 1 diabetes. Male Wistar rats were randomly assigned to control (CTRL) and diabetic (DM) groups for 4 weeks. Renal function was assessed in 24‐h urine sample by calculating clearance and fractional excretion of solutes. The RNA and protein contents of ClC‐5, CFTR, megalin, and cubilin were determined in the renal proximal tubule and cortex using real‐time polymerase chain reaction and western blotting techniques, respectively. The results showed higher creatinine clearance and higher urinary excretion of proteins, albumin, and transferrin in the DM group than in the CTRL group. Furthermore, the renal cortex and proximal tubule of diabetic animals showed downregulation of megalin, cubilin, ClC‐5, and CFTR, critical components of the endocytic apparatus. These data suggest dysfunction in proximal tubule low‐molecular‐weight endocytosis and protein glomerulus filtration in the kidney of diabetic rats.

Vegetarian Diet in Chronic Kidney Disease-A Friend or Foe.

Healthy diet is highly important, especially in patients with chronic kidney disease (CKD). Proper nutrition provides the energy to perform everyday activities, prevents infection, builds muscle, and helps to prevent kidney disease from getting worse. However, what does a proper diet mean for a CKD patient? Nutrition requirements differ depending on the level of kidney function and the presence of co-morbid conditions, including hypertension, diabetes, and cardiovascular disease. The diet of CKD patients should help to slow the rate of progression of kidney failure, reduce uremic toxicity, decrease proteinuria, maintain good nutritional status, and lower the risk of kidney disease-related secondary complications (cardiovascular disease, bone disease, and hypertension). It has been suggested that plant proteins may exert beneficial effects on blood pressure, proteinuria, and glomerular filtration rate, as well as results in milder renal tissue damage when compared to animal proteins. The National Kidney Foundation recommends vegetarianism, or part-time vegetarian diet as being beneficial to CKD patients. Their recommendations are supported by the results of studies demonstrating that a plant-based diet may hamper the development or progression of some complications of chronic kidney disease, such as heart disease, protein loss in urine, and the progression of kidney damage. However, there are sparse reports suggesting that a vegan diet is not appropriate for CKD patients and those undergoing dialysis due to the difficulty in consuming enough protein and in maintaining proper potassium and phosphorus levels. Therefore, this review will focus on the problem as to whether vegetarian diet and its modifications are suitable for chronic kidney disease patients.

Anemia in nephrotic syndrome: approach to evaluation and treatment.

Nephrotic syndrome is one of the most common glomerular diseases that affect in children. Complications may occur in nephrotic syndrome as a result of the disease itself as well as its treatment. Most of these complications result from excessive urinary protein losses, and control of proteinuria is the most effective treatment strategy. Anemia is one of the many complications seen in patients with persistent nephrotic syndrome and may occur as a result of excessive urinary losses of iron, transferrin, erythropoietin, transcobalamin and/or metals. This leads to a deficiency of substrates necessary for effective erythropoiesis, requiring supplementation in order to correct the anemia. Supplementation of iron and erythropoietin alone often does not lead to correction of the anemia, suggesting other possible mechanisms which need further investigation. A clear understanding of the pathophysiologic mechanisms of anemia in nephrotic syndrome is necessary to guide appropriate therapy, but only limited evidence is currently available on the precise etiologic mechanisms of anemia in nephrotic syndrome. In this review we focus on the current state of knowledge on the pathogenesis of anemia in nephrotic syndrome.