What is proteinuria?

Proteinuria is the condition where the urine contains an abnormal amount of protein.

How protein leaks in the urine?

Protein is found in the blood and usually is not present in the urine. Protein is a long chain molecule made up of amino acids. Proteins have different functions; they can help digestion, fight infections, carry substances around the body and aid in blood clotting.

There are millions of tiny filters called glomeruli in the kidneys. As blood passes through healthy kidneys, the glomeruli filter the waste products. Proteins are large molecules and are unable to pass through the glomeruli into the urine. However, when the glomeruli are damaged by a disease process, proteins are then able to pass through them and escape into the urine.

Why is proteinuria dangerous?

Proteinuria is not a disease. However, it is an indicator that the kidneys have been damaged in some way.
Protein should not appear in the urine in large quantities. Doctors usually say there is proteinuria if more than 150 mg per day is detected in the urine.

What causes proteinuria?

Some of the causes of proteinuria are:
a) Primary kidney disease called nephritis
b) Secondary kidney diseases due to:
• Diabetes
• Hypertension or high blood pressure
• Cancers
• Pregnancy
• Medications
c) Others:
• Excessive weight gain
• Heart failure

Slightly higher excretion of protein may occur normally in certain circumstances such as pregnancy, during fever and after strenuous exercise. These are not clinically significant if the amount is only minimally raised and returns to normal levels soon after.

Are there different types of proteinuria?

There are essentially two types of protein: albumin which is a smaller molecule and globulin which is larger. When the disease is minor or early, albumin leaks out first. The quantity is then small and not detected by conventional methods used for detecting protein. This is called microalbuminuria implying that the amount leaked out is in small amounts. When the disease is more advanced, larger molecules other than albumin leaks out and we term this state collectively as “proteinuria”.

Who are at risk of proteinuria?

People with diabetes, hypertension, or certain family backgrounds are at risk for proteinuria. In both type 1 and type 2 diabetes, the first sign of deteriorating kidney function is the presence of small amounts of albumin in the urine (microalbuminuria). As kidney function declines, the amount of albumin in the urine increases, and microalbuminuria becomes full-fledged proteinuria.

What are the signs and symptoms of proteinuria?

By itself, proteinuria causes foamy or frothy urine. Patients may also say they see bubbles in the urine. If loss of protein is in very large quantities (more than 3 grams per day), a patient may have the nephrotic syndrome where he complains of swelling of legs, abdominal distention and breathlessness especially when lying down.

If a patient also has kidney failure, the complaints will be that experienced by other renal failure patients.

How can I test for proteinuria?

Urine dipstick: This is a simple method using a test strip immersed into a urine sample to detect presence of protein in the urine. However, it only measures the concentration in that specific specimen. The concentration of urine passed throughout the day actually varies so this is not very accurate.

24hrs urine collection for protein or microalbumin:
This test is used to assess how much protein or microalbumin is passed into the urine over 24 hours.

We can grade proteinuria as follows:

Because the methods used for albumin and protein are different, there will be some difference in the amounts when albumin and protein are tested on the same sample.

The amount of proteinuria may also be reported as a ratio of protein to creatinine in the urine – urine protein/creatinine ratio. If both are measured in grams, it will parallel the 24 hour results. The urine microalbumin/creatinine ratio (both measured in mg) will also be closely related to the 24 hour urine microalbumin result.

Investigating proteinuria

There are many reasons for having protein in the urine and the treatment will depend on the cause and amount of protein leak. The doctor will perform a series of investigation which include:
• Blood test to check on the kidney function.
• Urine test to determine amount of protein present in the urine.
• Ultrasound of the kidney and bladder to determine cause of proteinuria.
• Kidney biopsy may be indicated in some cases for more specific diagnosis and prognosis.

Natural course and prognosis of proteinuria

If left untreated, proteinuria on occasion could disappear or could remain stable for many months and years. It could also get worse and cause kidney failure especially:
• If it is associated with high blood pressure.
• If the proteinuria is heavy (more than 1 gm/day). The higher the proteinuria is the greater the risk of kidney failure.
• If medications that are not ‘kidney friendly’ are used indiscriminately.

Treating Proteinuria

Other than treatment for specific kidney diseases, the following needs to be observed to prevent deterioration to / of kidney failure:
• Good blood pressure control with any class of antihypertensive suited to the patient. In cases of heavy proteinuria, the target blood pressure is 125/75.
• Use of medications to specifically reduce proteinuria and stabilize the kidney function such as the Angiotensin Converting Enzyme (ACE inhibitors or Angiotensin Receptor Blockers (ARBs).
• Diet modifications for a low salt diet as recommended by the dietitian and if appropriate, a low protein diet for renal failure.

Some Useful Hints:

• Proteinuria may be a sign that your kidneys are damaged and that you are at risk of kidney failure.
• It is recommended that people in the high risk group be regularly checked for proteinuria so that kidney disease can be detected and prevented from progressing.
• Those at risk of proteinuria and kidney failure include people who have diabetes or hypertension and who have a family history of kidney disease.
• If you have diabetes or high blood pressure or both, the first goal of treatment will be to control your blood glucose and blood pressure.

What is haematuria?

‘Haematuria’ is the presence of red blood cells in the urine. Under normal conditions, urine would not contain red blood cells.

Types of Haematuria
Blood is not always visible. When present in very small quantities, the urine looks normal. This is called microscopic haematuria or microhaematuria. It can be detected only by a dipstick test or when red blood cells in the urine are seen under the microscope.

When blood is visible, the urine may look pinkish, red or smoky brown (tea-coloured). This is called macro or gross haematuria. It often causes considerable concern, and just a few millilitres of blood can turn a whole bladder full of urine red.

What causes haematuria?

Haematuria has many causes. It can arise from any condition that results in inflammation or injury along the urinary tract. The urinary tract system consists of a pair of kidneys, ureters, the urinary bladder and urethra. Sometimes, we can tell the site of bleeding by observing the colour of the urine stream:

Initial - at the beginning of the stream only, generally indicates bleeding from the urethra that is flushed out by the first passage of urine.

Terminal - at the end of the stream only, localizes the bleeding area to the posterior urethra, bladder neck or base of the bladder, and is noticed at the end of urination.

Throughout the entire stream - indicating that bleeding occurs at the level of the bladder or higher in the urinary tract, so that all of the urine is mixed with the blood.

Some common causes are:
• Kidney stones
• Urinary Tract Infection
• Growths (cancerous and non-cancerous)
• Inflammation of the kidney of which glomerulonephritis is one cause
• Inherited causes such as polycystic kidney disease
• Medications which thin blood such as warfarin

Sometimes urine can be coloured pink or red without bleeding from the urine tract being present. This may be due to:
• Food and food colouring such as beetroot and blackberries (anthrocyanin pigment)
• Medications such as phenothiazines, certain laxatives and pain medications
• Menstrual blood – which can accidentally contaminate a urine specimen

What are the symptoms?

Blood in the urine is itself a symptom. Other symptoms related to the underlying cause of the bleeding may also be present.
These include:
• Pain in the back, lower abdomen or groin
• Burning sensation or pain when passing urine
• Fever
• Nausea or vomiting

How can we differentiate the various conditions that cause haematuria?

As with all medical conditions, it is very important that you tell your doctor what you know about your previous experiences with haematuria and the circumstances surrounding it. This, together with the physical examination and certain targeted investigations, will permit more accurate diagnosis of the underlying problem.

Some of the commonly ordered tests are:

• Urine protein test using the urine test strips (dipstick) or a more specific laboratory test to quantify the amount of protein present in the urine.
• Urinalysis for white blood cells and chemical constituents
• Urine culture
• Blood tests for kidney function
• Radiological investigations:
- Intravenous pyelography (IVP) which involves injecting a dye into the bloodstream through a vein and taking a series of X-rays.
- Ultrasound scan which uses high frequency sound waves to ‘see’ structures inside the body. This does not involve any radiation and is safe even in pregnancy.
- CT scan is like an X-ray but gives more details.
• Cystoscopy involves inserting a flexible tube with a camera at the tip to examine the bladder wall. It is performed under local anaesthetic by a urologist.
• Renal biopsy may be suggested if moderateor severe grade inflammation of the kidney (glomerulonephritis) is diagnosed. This test involves taking a very small piece of kidney tissue and examining it under the microscope. You will need admission to hospital for this.

How is Haematuria Treated?

This would depend on the cause. Treatment may be very different. That is why investigation is necessary before your doctor can treat you.

Some useful hints:

• If you have visible blood in your urine, do not attempt to treat yourself with home remedies.
See a doctor without delay.
• If you have a urinary tract infection, you will need to take antibiotics. Be sure to finish the course.
• If you have kidney stones, be sure to drink plenty of water to help pass the stones and prevent stones from forming. You may need to take pain relievers.
• If a medication is causing haematuria, stop the medication after talking it over with your health care provider.
• If you have glomerulonephritis, you will need long term follow-up to ensure the disease is under control. Glomerulonephritis may lead to kidney failure but kidney failure is often preventable so the opportunity should not be missed.

Remember that it is always important to find out the cause of blood in the urine.

What is a renal biopsy?

Renal or kidney biopsy is a medical procedure in which a very small sample piece of tissue is removed from the kidney for microscopic examination using a biopsy needle. The thickness of the piece removed is approximately that of the thin “bee hoon”. Usually two pieces, each slightly less than 1 cm in length, are taken.

Why would I need a renal biopsy?

There are several reasons why renal biopsy may be required. One or more of the following reasons may apply to you:

• To identify a specific disease process in the kidney. This will then allow us to use the most appropriate medication. It also gives the doctors a better idea of what your response to treatment will be and assist in planning for an alternative course of action should you not respond to firstline medication.
• To evaluate the extent of damage that has occurred in the kidney.

The doctor would recommend for a renal biopsy only after a series of blood and urine tests done with abnormal results, or ultrasound and CT scans have failed to diagnose a kidney problem or define its severity.

The biopsy may be performed on your kidneys or a transplanted kidney.

Do I have to stay in the hospital?

Yes. You will be required to stay in the hospital overnight after the procedure. You will be able to go home the next day if there are no complications.

What preparation is needed before biopsy?

Before a biopsy, the doctor will explain why the procedure is required, how it is performed and the risks involved. Much of this discussion is usually held several days in advance unless the kidney disease is a sudden one. You will need to sign a consent form before the procedure is carried out confirming that you have understood and agreed for the procedure to be performed.

Within a week of the planned biopsy, you will be asked to undergo some tests to assess your clotting capability. This is important as the kidney has a lot of blood vessels and you must be able to clot normally to minimize complications from bleeding.

This procedure is usually not performed on patients in advanced stage of pregnancy.

Other precautionary measures taken to prevent complications especially post-biopsy bleeding include:

1) Your blood pressure must be controlled to at least 140/90 before the biopsy. This is important because uncontrolled blood pressure may increase the chance of bleeding.
2) Medicines that thin the blood, e.g. aspirin, warfarin has to be stopped at least two weeks prior to the biopsy to reduce chances of post-biopsy bleeding. You must therefore inform the doctor of all medications that you are taking regularly as you may not be aware if any of the drugs can affect the clotting capability of blood.

You will be given a week’s medical leave to recuperate at home after the biopsy. This is to reduce the intensity of daily activities so as to prevent high blood flow through the kidneys. Exercise should therefore be avoided during this period. So before admission, please plan to be away from work for at least a week.

How is the renal biopsy performed?

You will have to empty your bladder before the procedure to reduce any discomfort as this procedure may take at least 1 hour to complete. To help you relax, the doctor may prescribe sedatives, as you will need to remain in the same position throughout the procedure.

The doctor will ask you to lie face down on a bed or a couch with a pillow place under your abdomen. The doctor will use an ultrasound machine to locate the exact position of your kidney and mark where he is going to introduce the biopsy needle. The skin at and around that area is cleansed using a antiseptic solutions. A local anesthetic is then injected to numb the area where the needle will be inserted.

When the skin and tissues are completely numb, a thin needle is passed through the skin into the kidney. Inside the needle is a sharp cutting edge tip that will slice and remove small piece of the kidney tissue.

Because the kidney moves with breathing, you will be asked to hold your breath when the needle is advanced into the kidney. Most kidney departments now use a “gun” type of system where the cutting is automated. You will hear an obvious snapping sound when the “gun” is activated and the biopsy is taken. So as not to be alarmed by this sudden noise, you should familiarize yourself with the noise before the actual biopsy procedure.

After the needle is removed, pressure is applied onto the biopsy site for several minutes to stop bleeding. A pressure bandage is then applied. You will be asked to turn around and lie on your back. Your body weight will aid in applying pressure.

The tissue samples are sent to the laboratory for examination.

The entire procedure may last about 30 minutes to an hour but much of the time is spent in locating a good spot for taking the biopsy.

Is renal biopsy a painful procedure?

The amount of pain during and after the procedure depends on each individual. A local anesthetic is used during the procedure to minimise discomfort.

What are the risks of renal biopsy?

Complications after renal biopsies are rare. A potential complication from this procedure is bleeding.

Many patients have a small amount of bleeding into the space around the kidney but few are significant enough to require a blood transfusion. Almost all patients have some bleeding into the urine that can be seen and is usually temporary.

What happens after the procedure?

The ward nurse will monitor your blood pressure, pulse, respiration and temperature immediately after the biopsy and at regular intervals. You will be asked to lie on your back and remain in the position for at least 6 hours. This position will naturally apply pressure at the biopsy site and reduce the risk of bleeding.

You may also experience slight soreness at the area because of bleeding into the muscle where the needle was introduced. You can take some painkillers but many patients do not need them. Should the pain persist or gets worse, you must inform the nurse or doctor as this may mean significant bleeding from the kidney.

Discharge from hospital

After discharge, you must have plenty of rest, and stay at home for at least a week.

You must avoid lifting heavy objects, no vigorous exercise and do not involve in contact sports for at least one or two weeks.

When can I get the results?

Depending on the urgency, complexity of the problem, and tests needed on the specimen, the results may be ready the following day or as long as a few weeks. Your physician will decide when he will next see you to decide on the next course of action.

Note: The information is only a general guide. Individual circumstance and the way test is performed may vary between hospitals and doctors. Always follow the instructions given by the hospital or doctors relating to any test or procedure.

Physical fitness plays a very important part in today’s lifestyle. It is common to hear this statement:

“A fit body improves a person‘s well-being.”

In line with the campaign of promoting exercises to maintain good health, it seems that exercise may be even more important for kidney patients than for the general population.

Why do kidney patients need to exercise?

Studies have shown that many dialysis and transplant patients who have undergone approved exercise programs show an increase in strength, stamina and energy. Other exercise-related benefits include better control of blood pressure, improved muscle strength, lowered level of body fats, better sleep pattern and better weight control. These help to reduce the risk of developing heart disease, especially for kidney patients who have a higher incidence of heart problems than the general population.

Exercise also helps to improve the psychological well-being. People who exercise are no longer leading a sedentary life. Exercise gives you the feeling of being able to do something. It clears your mind and helps to control some of the unpleasant emotional reactions that may occur from time to time. Emotional reactions such as depression, anger, fear and frustration can also be improved by exercising.

Exercise can also help to rebuild your self-confidence. Seeing improvement in your body conditions as a result of exercise can also build up self-esteem.

You will want to keep your muscles firm and toned. Exercise will help you to achieve this goal and keep your body healthy. Therefore, all these changes can improve the quality of life. It becomes easier to get around, perform activities of daily living and other tasks, and still have energy for your family and friends.

Before you start, you need to….

Before you start on any exercise program, you should consult your doctor first as you need to be stable with your treatment, whether it is haemodialysis, peritoneal dialysis or transplantation.

It is still very important to comply with the rest of your treatment even though you exercise. You should take your medications; follow your diet and fluid restriction. Failure to comply with your treatment will lead to instability of your condition, and exercise may only aggravate problems further. For example, fluid overload strains your heart and lungs; if you exercise, it will make you feel more breathless or even experience chest pain. Erythropoietin treatment will help increase your exercise tolerance, reduce fatigue and increase energy level and therefore enable you to exercise better.

What do I do?

Each person’s health and fitness levels, motivation and time constraints are different. Also, each person’s progress will vary. Consider these four things before you start exercising:
a) Type of exercise
b) Length of time for exercising
c) How often to exercise
d) How hard

Type of exercise
Start with the type of exercise that you like to do, for example walking, swimming, cycling. Always remember to begin with a warm up and finish off with a cool down after your chosen exercise. Gradually progress to a higher level when you are stronger.

Length of time for exercising
Duration of exercise will depend on your present fitness level. You should exercise within a time span that you can cope with.

How often to exercise
Slowly increase from once a week to three times a week on non-consecutive days.

How hard
Start with a pace you are comfortable with. Start slowly each session to warm up, pick up your pace, then slow down again when you are about to finish.

Ten Commandments To Remember

1) Schedule your exercise into your regular daily routine.
2) Wait one hour after a meal before exercising.
3) Avoid exercising during the hottest hours of the day i.e. noon and afternoon.
4) If you are feeling unwell e.g. fever, flu, under emotional stress, or having joint or bone aches, do not exercise. Give a period of rest before you resume your activity.
5) If you have changed the type of your regular medications or its schedule, or your medical status has changed, consult your doctor for advice regarding exercise.
6) If you are feeling excessively tired, stop exercising.
7) If you are suffering from cardiac problems e.g. chest pains or irregular or rapid heart beats, do not exercise. Consult your doctor first for advice.
8) Stop your exercise if you feel nausea, giddiness or leg cramps.
9) Any kind of exercise should be approached gradually.
10) Do not be ambitious with your exercise program, but exercise at a level appropriate to your age and fitness.

Recommended simple and light exercises

• Arm stretches – lift arms over your head. Try to stretch and reach for the ceiling. Repeat 10 times.
• Arm circles – put your hands on your shoulders. Lift your elbows out to the side and draw big circles with your elbows. Repeat 10 times.
• Trunk bends – place your hands on your hips. Bend body from side to side. Repeat 10 times.
• Trunk rotations – place your hands on your hips and twist trunk round from side to side. Repeat 10 times.
• Thigh stretch – stand, holding onto support with one hand and to ankle with other. Pull ankle to butt till a stretch is felt in the front of your thigh. Hold for 5 seconds. Repeat exercise for the other side.
• Back thigh stretch – sit and straighten one leg while bending the opposite knee. Reach forward and try to touch the toes of your straight leg, till you feel a stretch in the back of your thigh. Hold for 5 seconds. Repeat exercise for the other side.
• Calf stretch – stand with feet hip width apart and move forward. Transfer weight to the back foot, letting your heel touch the floor. Hold for 5 seconds. Repeat exercise for the other side.