Quiz yourself on the 5 Pearls we will be covering!

Time Stamps

  • 1:42 How good is a urine dipstick, urinalysis and UACR in detecting albuminuria?
  • 5:14 What are some conditions that lead to transient proteinuria? What is the appropriate interval to recheck and how should be it be repeated?
  • 7:47 Who should be screened for albuminuria and can it prognosticate risk for cardiovascular mortality?
  • 10:57 Does increasing RAAS inhibition improve renal outcomes?
  • 13:11 Throwback Question: How do you prescribe oral iron and what tips do you tell your patients?

Show Notes

Pearl 1;

  •   The UA and urine dipstick is not sensitive for albuminuria.
    • A urine dipstick will miss the majority of people with “moderately increased proteinuria” (30-300mg of albumin/day).
    • Sensitivity for moderately increased proteinuria by UA: 43.6%
    • Specificity of a UA is quite good (>95%) but false positives can occur in the setting of recent IV contrast, very alkaline urine, and gross hematuria
  • 24 hour urine protein is the gold standard for quantifying albuminuria, especially for patients at the extremes of body weight, but is cumbersome and time-consuming.
  • A urine albumin creatinine ratio (UACR) is recommended in detection of albuminuria and consistent with the gold standard 24 hour urine collection.
  • Dividing the urine albumin with urine creatinine is an attempt to adjust for the concentration of the urine on that particular sample, which varies throughout the day.

Pearl 2

  • Transient proteinuria is benign and should always be ruled out.  Defer testing if the pt has a strenuous exercise, febrile illness or UTI or other causes of transient proteinuria.
  • Orthostatic proteinuria is a benign condition in which albuminuria is present when standing but disappears when supine. These conditions are benign and require no treatment or further monitoring.
  • A good approach to a finding of proteinuria is to repeat the test in 3 months with a urine sample from the first morning void. Instruct patient to void before bed, then collect sample from first morning void.

Pearl 3

  • Albuminuria is an independent risk factor for CV mortality.
  • Screening for albuminuria is recommended in known CKD and diabetes
    • In non-diabetic population, recommendations for screening are less established, but screening likely to be helpful when directed toward populations at highest risk, such as the elderly or pt’s with hypertension.

Pearl 4

  • More RAAS inhibition = better renal outcomes, as long as blood pressure and K+ allows.
  • Higher doses of ACE/ARBs have shown to decreased progression to overt nephropathy, decreased the amount of albuminuria and even return to normoalbuminuria.

Pearl 5

  • When choosing a dose, one should consider the pharmacology of hepcidin-induced malabsorption and balance this with the patient’s side effect burden. There is more evidence to suggest every other day oral iron dosing.
  • Patients should be instructed to NOT take it with food and if possible with vitamin C or citrus food.

References