Você está na página 1de 3

PROTEINURIA + eGFR > 60

P
CASE DEFINITION Urine ACR Urine
PCR
24hr urine
protein (g/
Box 1
HAEMATURIA R
O
(mg/
2x elevated ACRs (> 3.6mg/mmol) performed at least a mmol) (mg/ day) Persistant haematuria* plus proteinuria is
week apart and in the absence of urinary tract infection or mmol) glomerulonephritis (GN) until proven otherwise. Perform
STI (urethritis / cervicitis), PLUS eGFR > 60.
If eGFR is ≤ 60, refer to CHRONIC KIDNEY DISEASE protocol.
Microalbuminuria Male: Male: 0.05-0.5
investigations as detailed in principles of management
“ACR>3.6 plus haematuria” below => refer to Nephrologist. T
E
2.5-25 4-40
IF clinical picture is suggestive of a systemic disease (e.g.
eGFR (estimated Glomerular Filtration Rate) is Female: Female: facial rash, polyarthritis, lethargy, abnormal investigations)

I
automatically reported by the pathology laboratory when 3.5-35 => urgent discussion with Nephrologist.
6-60
a creatinine test is requested. eGFR values are sometimes
Persistant isolated haematuria and > 40 yo then need
reported only as “> 60” rather than an actual number.
N
Macroalbuminuria Male: Male: >0.5 to exclude malignancy. Should have cystoscopy and renal
Exact GFR can be calculated using Cockcroft-Gault or MDRD >25 >40 *nephrotic tract ultrasound +/- IVP/urine cytology as discussed with
urologist/surgeon.
U
(see: www.kidney.org.au). Note that eGFR is unreliable at range is
Female: Female:
extremes of age, of bodyweight or in acute renal failure. >35 >60 >2.5g/day NB recurrent UTIs with haematuria consider urinary tract
malignancy
Adapted from Chronic Kidney Disease Management in General Practice 2012
*
Haematuria on 2 separate occasions at least one week apart.
Not associated with current or recent infection or menstruation. R
Screening (refer to flowchart)
I
Determine Risk Annual screening tests SIGNIFICANCE:
A
Moderate Risk Aboriginal people ≥ 15 years MSU for dipstick. Then: • Proteinuria is predictive of cardiovascular disease.
BMI > 30
Smokers
• IF Protein and / or blood present in the absence of
infection => manage as high risk
• There is a strong correlation between proteinuria and +
e
progression to kidney failure.
Dyslipidaemia • IF blood => see Box 1 Haematuria • In people with proteinuria and hypertension or

G
Age >60 • IF Nitrites, leucocytes +/- blood detected => send: diabetes, drug treatment reduces mortality and
• MSU for MC&S progression to CKD.
• SOLVS (women) and FVU (men for STI PCR
(gonorrhea, chlamydia and trichomonas) PRINCIPLES OF MANAGEMENT: F
High Risk Diabetes
Established cardiovascular disease
• MSU for dipstick. IF nitrites, leucocytes +/- blood
present => exclude infection, send:
BASELINE ASSESSMENT: (Please document clearly within R
>
patient file for future easy reference)
Hypertension • MSU for MC&S
SOLVS (women) or FVU (men) for STI PCR (gonorrhea, If no proteinuria and no haematuria:
History of kidney disease
History of chronic kidney disease in
chlamydia and trichomonas) • Review and address lifestyle and cardiovascular risk
factors including blood pressure and diabetes.
6
0
• Urine ACR
first degree relative
• Serum urea, electrolytes and creatinine (UEC) • Repeat screening in 1 year.
• eGFR All patients with proteinuria:
• Review and address lifestyle and cardiovascular risk
factors including blood pressure and diabetes.

© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley VC - Last Modified: March 13, 2014 3:19 PM
PROTEINURIA + eGFR > 60

P


If eGFR <60 refer to Chronic Kidney Disease protocol.
Perform these baseline investigations: FBC, U&E, LFT,
DRUG TREAMENT FOR PROTEINURIA:
Drug treatment for proteinuria is recommended for patients
Points to note with ACEI or ARB Treatment:
R
fasting lipids profile, BSL (+/- HbA1c), urine MCS, ANA,
C3, C4.
with proteinuria (macroalbuminuria) and for patients with
microalbuminuria plus diabetes or HT or IHD.
• Some rise in urea, creatinine and potassium is expected
after commencing an ACE-I or ARB. O
• Serum and urine electrophoresis (serum QEP and urine
bence jones).
Aim of treatment is to reduce proteinuria and control
blood pressure without causing symptomatic hypotension.
• A rise in creatinine of up to 15-20% above baseline is
acceptable. T
• HepBsAg, HepC, syphilis serology, HIV serology. ACR/PCR may or may not return to normal range on ACE or
ARB - either way therapy needs to continue.


An increase in potassium to ≤ 5.9 mmol/L is acceptable.
If potassium ≥ 6.0 mmol/L and/or creatinine increases E
I
• Baseline renal tract ultrasound (NB document clearly by > 15-20%, discuss with Nephrologist.
that this has been done and result in patient file). Target is BP <130/80 (or lower) and proteinuria as close as
possible to normal range. FOLLOW UP:
• Patients with heavy proteinuria (>2.5g/day or PCR/
ACR>250) and oedema / hypoalbuminaemia / Start ACEI (ramipril preferred) at low dose, doubling dose
every 2 weeks if tolerated. Check baseline UEC with every Not started on treatment: N
U
hyperlipidaemia may have Nephrotic syndrome and
urgent discussion with the Nephrologist is required. dose increase. Appropriate dose is that which achieves Annually: check smoking status, alcohol use, weight, BP,
target proteinuria as close as possible to normal range UEC, eGFR, urine ACR, screen for diabetes.
If ACR>3.6 PLUS haematuria, investigations as
above and:
without symptomatic hypotension.
If ACEI not tolerated change to ARB. Start with irbesartan
Once stable on treatment: R
• ENA, ANCA, anti-glomerular basement membrane
antibodies.
and titrate to same targets. All patients: 6 monthly review smoking status,
alcohol use, weight, BP, UEC, eGFR, Urine PCR, optimise I
• Discuss/refer to Nephrologist.
Ramipril
Starting dose
2.5mg
Maximum dose
10mg
management of comorbidities including diabetes.
If proteinuria >2g or not improving: A
Note: Albumin:Creatinine Ratio (ACR) is a Quinapril 10mg 40mg (2 tablets) Increase frequency of review to 3 monthly and discuss with
screening tool. Protein:Creatinine Ratio (PCR) Renal GP / Nephrologist.
is used for follow-up after macroalbuminuria
Enalapril*
Irbesartan
5mg
75mg
20mg
300mg WOMEN OF CHILD BEARING AGE:
+
has been diagnosed.
*breastfeeding
• Women with proteinuria and/or CKD have a higher e
MANAGEMENT:
Whilst titrating therapy, review patient every two weeks.
If proteinuria not at target and patient remains hypertensive,
risk of pre-eclampsia and fetal loss - consider early
referral to Obstetrician/Physician ANC G
• Document clearly in the patients medical history
and allocate a careplan in sites where these are
use other agents (not combination ACEI and ARB) to achieve
target BP and then reassess proteinuria.
• Encourage reliable contraception in those on an ACEI
or ARB because of risk of fetal malformations. F
used. Combination ACEI/ARB therapy is associated with increased
risk of acute kidney injury and hyperkalaemia. Patients with
• Stop all ACEIs and ARBs as soon as pregnancy planned
or suspected and use alternative anti-hypertensives as R
>
• Encourage healthy diet, smoking cessation and
specific renal diseases may still benefit from dual ACEI/ARB needed.
safe alcohol use (see HEALTHY LIVING protocol).
therapy, but this is no longer considered standard care. • If ACEIs or ARBs are inadvertently taken in pregnancy,

6
• Aim for optimal control of diabetes, hypertension and It should only be considered in select patients following discuss with Regional Obstetrician.
dyslipidaemia (see protocols). NB BP target <130/80 discussion with a Nephrologist. • Encourage early antenatal care.

0
and lower targets may be recommended in some
patients. • New onset proteinuria at <20/40 should be investigated
as a possible glomerulonephritis and discussed with a
• Consider nephrotoxic potential when prescribing Nephrologist.
drugs and advise patients to avoid over-the-counter
nephrotoxic drugs such as NSAIDs. • Breastfeeding: use enalapril 5 - 20mg daily (instead of
ramipril/ irbesartan).

© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley VC - Last Modified: March 13, 2014 3:19 PM
PROTEINURIA + eGFR > 60

P
REFER/DISCUSS: No testing required R
TO RENAL GP - Kimberley Renal Support
Low O
Services (KRSS)
A good first port of call: Renal GP; Phone: 9194 3280 (KSDC
Risk? T
E
reception - ask for Renal GP) renalgp@kamsc.org.au
Moderate/
• Macroalbuminuria High
• eGFR 30-60
I
N
TO NEPHROLOGIST: Annually:
Exclude infection: Treat as
• Haemoproteinuria Urine ACR appropriate
• Proteinuria >1g/day (PCR>100) eGFR
BP
ACR≥3.6 Urine MC&S, Urine STI PCR
(Chlamydia, gonorrhea,
Infection
present
and repeat
screen in 3 U
R
• URGENTdiscussion: months
trichomoniasis)
• Anyone with suspected acute/rapidly progressive

I
glomerulonephritis
• Anyone with suspected connective tissue disease

A
No
• eGFR <30 or decline by 15ml/min in 1 year infection
TO OBSTETRICIAN:
• If ACEI / ARBs are taken inadvertently in pregnancy for ACR<3.6
consideration of increased ultrasound monitoring and
counselling eGFR >60 2x ACR ≥ 3.6 without infection +
• Raised ACR/PCR at booking
e
G
TO SURGEON:
• Persisting haematuria may need further investigation PROTEINURIA


with cystoscopy - see Box 1 “Haematuria” on page 1
F
R
>
eGFR ≤ 60 eGFR > 60
Rescreen in one year

6
Manage per CKD
Manage per
Proteinuria
0
Guideline Guideline

© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley VC - Last Modified: March 13, 2014 3:19 PM