Presence Of Significant Proteinuria Research Articles

Adrenocorticotropic hormone: Therapeutic use and effects in nephrotic syndrome

Background: NS is defined by the presence of significant proteinuria, which leads to low levels of albumin in the blood and the development of edema. This occurs as a result of damage to the glomerular filtration barrier. Corticosteroids are the main therapeutic approach for NS. Prolonged usage of steroids can result in numerous side effects, including steroid resistant NS, which poses a difficult challenge for treatment and can cause substantial morbidity and mortality. Although efforts have been made to decrease the use of steroids by employing non-steroidal immunosuppressive drugs for rapid recovery, these treatments have also exhibited adverse consequences. These difficulties have prompted the notion of utilizing ACTH in these situations. Objective: This study seeks to analyze the efficacy of ACTH by thoroughly examining its mechanism and comparing it to conventional treatment for NS. Summary and important messages: The study demonstrates that ACTH has the potential to not only decrease protein loss but also reduce the occurrence of relapses and the amount of glucosteroids required. This suggests that ACTH could be a viable treatment alternative. The exact mechanism is currently unidentified, while the MCR1 agonism linked to ACTH suggest a renoprotective mechanism that is beneficial in NS. A comprehensive analysis using a large-scale randomized controlled trial is necessary to fully comprehend the effectiveness and safety profile of ACTH in improving the quality of care for patients.

Comparing Spot Urine Protein: Creatinine Ratio 24-Hour Urinary Protein Estimation in Type 2 Diabetes Mellitus Patients

Background & Objective: A simple blood test (urea and creatinine) and a urine test may indicate renal function deterioration and presence of microalbuminuria, which is also the first clinical signs of renal dysfunction in patients with diabetes mellitus. This cost effective test easy to perform even in the absence of advance facilities in a hospital. That is why we planned to conducted this study to assess the comparison between of spot urine protein:creatinine ratio with 24-hour urinary protein in patients with type 2 diabetes mellitus.
 Materials and Methods: This prospective hospital based clinical study was conducted in the Department of General Medicine, Liaquat University of Medical & Health Sciences, Jamshoro, over a period of six months from 10th May 2018 to 9th November 2019 through a consecutive sampling technique. All the patients having age more than 18 years of both gender, and type 2 diabetes mellitus were enrolled in this study. Three cc blood was taken to determine the serum creatinine levels and twenty-four hour 2ml urine sample was also collected to determine the urinary protein levels. The proteinuria ≥300mg/dl in 24-hour urine sample was considered as significant proteinuria. Kappa statistics was used to find agreement between spot urine protein and 24 hours urinary protein.
 Results: A total 95 patients were evaluated and their mean age was 41.91±14.29 years, with male predominance (n = 66, 69.4%). Average 24 hour urinary protein was 1216.99±949.51mg and spot-urine evaluation of protein was 1919.12±2129.25mg. The agreement between spot urinary protein creatinine ratio and 24 hour urinary protein was found in 82.1% of cases through Kappa statistics and the calculated agreement between the two procedures was 0.975 which provides sufficient agreement to use spot urine protein:creatinine ratio in routine diagnosis of proteinuria.
 Conclusion: The study have shown that the protein:creatinine ratio for a random urine sample might be used to rule out the presence of significant proteinuria as defined by a quantitative measure of the 24-hour urine protein excretion.

Modified Grading of Postnatal Urinary Tract Dilation

Source: Melo FF, Vasconcelos MA, Mak RH, et al. Postnatal urinary tract dilatation classification: improvement of the accuracy in predicting kidney injury [pubished online ahead of print August 28, 2021]. Pediatr Nephrol. doi: 101007/s00467-021-05254-xInvestigators from the Federal University of Minas Geraos (UFMG), Belo Horizonte, Brazil, and Rady Children’s Hospital, San Diego, CA, conducted a study to assess the accuracy of multiple classification systems for urinary tract dilatation (UTD) on postnatal ultrasound (US) in predicting future need for surgical intervention and/or kidney injury among neonates diagnosed with antenatal hydronephrosis (ANH). Study participants were infants with isolated ANH, defined as anteroposterior renal pelvis diameter ≥5 mm on a third trimester ultrasound, who were seen at the Pediatric Nephrology Unit at UFMG and followed prospectively from 1989 to 2019. The initial postnatal US was performed at approximately 14 days of age. A standard protocol was used to manage these patients. Study outcomes were surgical intervention and kidney injury. The need for surgery was determined using a protocol with markers indicative of severe obstruction, and kidney injury was defined as the presence of significant proteinuria, hypertension, or presence of chronic kidney disease (CKD). Using the results of the first postnatal US, severity of UTD was categorized using 5 grading systems: renal pelvic diameter (RPD), renal parenchyma thickness (RPT), a grading system developed by the Society of Fetal Urology (SFU), the UTD grading system, and a modified UTD system (UTDm). The accuracy of each system for predicting each outcome was assessed by generating receiver operating curves (ROC) and measuring the area under the curve (AUC). In addition, using the ROC analysis, the threshold (measurement with RPD and RPT and grade with the other tests) that maximized sensitivity and specificity was identified.Data were analyzed on 447 children, including 318 (71.1%) boys. Median follow-up was 9 years. Overall, 131 (29%) underwent surgical intervention at a median age of 8 months. The AUC for all grading systems in predicting surgical intervention were all >0.90, but the AUC for RPT statistically was significantly worse than that of the other tests. Using a threshold of >grade 2 with UTDm, the sensitivity for surgery was 85.5% and specificity was 89.9%. For RPD, a cutoff value of >15 mm had a sensitivity of 99.2% and specificity of 82.3%. A total of 26 children (5.8%) met criteria for kidney injury. The highest AUCs for predicting kidney injury were achieved with RPT (AUC = 0.921) and UTDm (AUC = 0.913); RPD and SFU had significantly worse AUCs. The sensitivity and specificity of UTDm, with a threshold at grade 2 or higher for predicting kidney injury, were 100% and 71.9%, respectively, and for RPT, with a cutoff at ≤8.9 mm, 96.1% and 80.0%, respectively.The authors conclude that several grading systems for UTD in newborns with ANH have good accuracy in predicting need for surgery and/or kidney injury.Dr Sanchez-Kazi has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Hydronephrosis as a congenital anomaly of the kidney and urinary tract can affect up to 14% of all pregnancies.1 Kidney and bladder US is used for grading the degree of UTD and for measurement of the RPT. Several grading systems are used today, including the SFU, UTD Consensus Recommendations, and Onen’s (2–4). The researchers in the current study combined the grading systems with some modifications to enhance the sensitivity and specificity of using hydronephrosis and RPT in predicting long-term kidney injury.The current study is 1 of the few with long-term follow-up of the hydronephrotic kidney and the participants’ blood pressure, urine protein, and kidney function. As with previous reports, kidney outcomes are easier to predict with mild and severe hydronephrosis (See AAP Grand Rounds. 2020;43[4]:42.)5 Moderate degree of hydronephrosis needs more follow-up and requires further imaging to assess if and when surgical intervention is required. Quantitative information such as RPT is useful in addition to grading of UTD. The difficulty in using the grading systems, however, is not the quantification, but standardization of where the measurements should be obtained since dilation can be affected by hydration and bladder fullness.Past studies have shown significant intra- and interobserver variability between clinicians.6,7 It is interesting to note that the number of surgical interventions was higher in the early years of the current study period. Does this reflect changes in indications for surgery, improvement in grading and measurement of the urinary dilation, or changing attitudes toward early surgical intervention?Modifications of the current postnatal US grading systems are useful in prognostication of kidney health in infants with antenatal onset of hydronephrosis.Recall that isolated ANH has a high rate of spontaneous resolution, thus abrogating the need for extensive imaging or urological intervention.5

Graft dysfunction in simultaneous pancreas kidney transplantation (SPK): Results of concurrent kidney and pancreas allograft biopsies.

Simultaneous pancreas and kidney transplants offer significant therapeutic advantages but present a diagnostic approach dilemma in the diagnosis of rejection. Because both organs are from the same donor, the kidney has been treated traditionally as the "sentinel" organ to biopsy, presumably representing the status of both allografts. Truly concurrent biopsy studies, however, are needed to confirm this hypothesis. We examined 101 concurrent biopsies from 70 patients with dysfunction in either or both organs. Results showed concurrent rejection in 23 of 57 (40%) of cases with rejection; 19 of 57 (33.5%) and 15 of 57 (26.5%) showed kidney or pancreas only rejection, respectively. The degree and type of rejection differed in the majority (13 of 23, 56.5%) of cases with concurrent rejection, with the pancreas more often showing higher rejection grade. Taking into account pancreas dysfunction, a positive kidney biopsy should correctly predict pancreas rejection in 86% of the instances. However, the lack of complete concordance between the 2 organs, the discrepancies in grade and type of rejection, and the tendency for higher rejection grades in concurrent or pancreas only rejections, all support the rationale for pancreas biopsies. The latter provide additional data on the overall status of the organ, as well as information on nonrejection-related pathologies.

Phenotype 2 Familial Mediterranean Fever: Evaluation of 22 Case Series and Review of the Literature on Phenotype 2 FMF

Familial Mediterranean fever (FMF) is an autosomal recessive autoimmune disorder characterized by recurrent bouts of fever and serosal inflammation. FMF may be complicated by AA-type amyloidosis, worsening the prognosis, with associated renal failure in some patients. Complication rate varies with race, being as high as 60% in Turks and as low as 2% in Armenians. In a few cases of patients with FMF (phenotype 2), amyloid nephropathy may be the presenting manifestation. This study included 420 patients who were admitted to the Nephrology and Rheumatology Departments of Atatürk Education and Research Hospital with unexplained proteinuria/nephrotic syndrome. The initial screening test for amyloidosis was the presence of significant proteinuria (300 mg/24 h). All MEFV gene exons were screened for causative mutations by direct DNA sequencing to check for any mutations. There were 22 phenotype 2 FMF patients with 27 allelic variants. The most prevalent allelic variants were M694V (10/27, 37%) and E148Q (7/27, 26%). Phenotype 2 FMF is not as rare as it was thought before; this should be kept in mind for all patients with unexplained proteinuria and/or acute phase response in high-risk ethnic groups for FMF.

IgG4-Related Tubulointerstitial Nephritis With Membranous Nephropathy

We describe a 67-year-old woman who presented with significant proteinuria and hematuria. Kidney biopsy showed immunoglobulin G4 (IgG4)-related tubulointerstitial nephritis (TIN) with concurrent membranous nephropathy. IgG4-related TIN is a recently described entity that presents with progressive decreased kidney function and is characterized by a plasma cell-rich infiltrate that is positive for IgG4. It is associated with patchy, often well-localized, tubular atrophy and interstitial fibrosis. Workup for circulating anti-phospholipase A(2) receptor antibodies was negative, suggesting that the membranous nephropathy was not "primary" and may be linked to the IgG4-related disease. The presence of significant proteinuria and hematuria in the setting of IgG4-related TIN should raise suspicion of a glomerular disease. It is important to correctly diagnose IgG4-related TIN and concurrent membranous nephropathy because the lesion responds well to steroid therapy.

Evaluación del índice proteína-creatinina en orina aislada para la predicción de proteinuria significativa durante la gestación

Introduction Diagnosis and follow-up of preeclampsia requires measurement of proteinuria and the gold standard for this evaluation is the 24-hour collection. However, this collection is cumbersome, time consuming and delays clinical diagnosis. The purpose of this study is assess the diagnostic performance of the spot urine protein/creatinine (P/C) ratio to predict the absence or presence of significant proteinuria (≥ 300 mg per 24 hours) among outpatient pregnant women with suspected or previous diagnosis of preeclampsia. Material and methods The P/C ratio was calculated in 106 single voided urine samples, obtained after the completion of the 24-hour collection, from 66 outpatient pregnant women admitted to the Maternal Fetal Care Unit at our Hospital to follow-up of hypertension gestational. Correlation between the spot urine P/C ratio with the 24-hour urine protein excretion was calculated. Receiver operator characteristic (ROC) curves analysis was used to evaluate the diagnostic performance and to determinate the best cutoff to predict the absence or presence of significant proteinuria. Results Significant proteinuria on 24 hour collection urine was identified in 31 urines from 22 pregnant women. There was a significant correlation between the spot urine P/C and 24-hour urine protein excretion (r Spearman = 0,658, p = 0,01). ROC curves analysis revealed an area under the curve for spot P/C ratio of 0,838, greater than urine dipstick (0,629). No single P/C ratio cutoff was appropriate to rule-out or predict significant proteinuria; however, use of dipstick and spot urine P/C ratio, with two cutoffs, 120 mg/g to predict the absence of significant proteinuria and 240 mg/g to confirm it, clasiffied correctly 44,3% of urines and avoided the collection of 24 hours urine in 51% of the cases. Conclusions Spot urine P/C ratio, in conjunction with dipstick urianalysis, is a useful test in the initial screen for rule-out and predict significant proteinuria in outpatient pregnant women with hypertensive pregnancy or preeclampsia, but it should not be used as an alternative to 24-hour total protein evaluation in midrange P/C ratio, requiring a full 24-hour urine for accurate results.

Quantitation of Proteinuria in Women With Pregnancy Induced Hypertension: Is it Time to Abandon Use of Dipstick Strips for the Spot Urine Protein to Creatinine Ratio?

Context: The presence of significant proteinuria in Pregnancy Induced Hypertension is associated with worse maternal and fetal outcome. Unfortunately, Dipstick strips, currently used widely for detection and quantitation of proteinuria, have been shown to be unreliable. This creates the need for a more accurate method for early detection and quantitation of proteinuria. Objective:To compare the accuracy of the Spot urine Protein to Creatinine ratio with that of Dipstick Tests in the quantitation of proteinuria in Nigerian women with Pregnancy Induced Hypertension. Methods: A cross-sectional survey over a 6-month period involving 86 Nigerian women with Pregnancy Induced Hypertension. Outcome measures: False Positive rates, False Negative rates, Sensitivity, Specificity, Positive Predictive value, Negative Predictive value, and Accuracy. Result: The Spot urine Protein to Creatinine ratio showed better correlation with 24-hour urine protein measurement than Dipstick Tests. Comparatively, the False positive rates were 16.2% versus 53.7%, False Negative rates 6.1% versus 28.1%, Sensitivity 91.2% versus 73.5%, Specificity 88.5% versus 44.4%, Negative predictive values 93.9% versus 71.9%, and Accuracy 89.5% versus 55.8% respectively for the Spot urine Protein to Creatinine ratio and Dipstick Tests. Conclusion: The Spot Urine Protein to Creatinine ratio is much more accurate in the quantitation of proteinuria in Nigerian women with Pregnancy Induced Hypertension than the widely used Dipstick Tests. Key Words: Quantitation, Proteinuria, Pregnancy, Hypertension. [Trop J Obstet Gynaecol, 2004;21:136, 137, 140, 141]

The Association Between Nulliparity and Gestational Hypertension

The association between nulliparity and gestational hypertension was examined by analysis of the 1988 National Maternal and Infant Health Survey. Gestational hypertension was defined as the occurrence of two consecutive diastolic blood pressure readings ≥90 mm Hg after 20 completed weeks gestation in the absence of proteinuria in subjects normotensive prior to pregnancy. Preeclampsia was defined as gestational hypertension in the presence of significant proteinuria. Using logistic regression, 110 subjects with gestational hypertension and 34 subjects with preeclampsia were compared with 4371 subjects free of all hypertensive disorders. Nulliparity was weakly associated with an increase in the risk of gestational hypertension among whites (odds ratio, 95% confidence interval: 1.58 [0.92–2.74]) and not associated with risk among blacks (1.09 [0.51–2.35]). Preeclampsia was strongly associated with increased risk among whites (2.86 [0.94–8.73]) and blacks (2.94 [0.94–9.18]). The small increase in risk of gestational hypertension associated with nulliparity in contrast with the large increase in risk of preeclampsia suggests that these disorders may have a different etiology.

Serum thyroxine and thyroxine-binding proteins in chronic renal failure without nephrosis.

Total serum thyroxine (T4), free thyroxine index (FTI), thyroxine binding globulin (TBG) binding capacity, serum albumin, alpha-globulins and urinary protein excretion were measured in 50 patients with chronic renal failure, but without nephrotic syndrome. 25 patients were undergoing chronic hemodialysis. T4 was within the normal range in most patients. There was a tendency to lower T4 values as compared to an age and sex-matched control group, but this did not reach statistical significance. TBG was normal in most patients. 4 patients showed elevated TBG concomitant with elevation of other alpha-globulins. Serum albumin was significantly decreased. No correlation existed between daily protein excretion and TBG or alpha-globulins, but the correlation between serum albumin and proteinuria was highly significant. T4 and proteinuria correlated with borderline significance. A highly significant correlation between T4 and TBG-albumin values was found. No correlation existed between FTI and TBG-albumin levels. The data suggest that T4 and TBG are normal in most patients with renal failure, even in the presence of significant proteinuria. Low T4 values, when found in renal insufficiency, may be secondary to low serum albumin and possibly prealbumin.