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
•
•
If eGFR <60 refer to Chronic Kidney Disease protocol.
Perform these baseline investigations: FBC, U&E, LFT,
fasting lipids profile, BSL (+/- HbA1c), urine MCS, ANA,
C3, C4.
• Serum and urine electrophoresis (serum QEP and urine
bence jones).
• HepBsAg, HepC, syphilis serology, HIV serology.
• Baseline renal tract ultrasound (NB document clearly
that this has been done and result in patient file).
• Patients with heavy proteinuria (>2.5g/day or PCR/
ACR>250) and oedema / hypoalbuminaemia /
hyperlipidaemia may have Nephrotic syndrome and
urgent discussion with the Nephrologist is required.
If ACR>3.6 PLUS haematuria, investigations as
above and:
• ENA, ANCA, anti-glomerular basement membrane
antibodies.
• Discuss/refer to Nephrologist.
Note: Albumin:Creatinine Ratio (ACR) is a
screening tool. Protein:Creatinine Ratio (PCR)
is used for follow-up after macroalbuminuria
has been diagnosed.
MANAGEMENT:
• Document clearly in the patients medical history
and allocate a careplan in sites where these are
used.
• Encourage healthy diet, smoking cessation and
safe alcohol use (see HEALTHY LIVING protocol).
• Aim for optimal control of diabetes, hypertension and
dyslipidaemia (see protocols). NB BP target <130/80
and lower targets may be recommended in some
patients.
• Consider nephrotoxic potential when prescribing
drugs and advise patients to avoid over-the-counter
nephrotoxic drugs such as NSAIDs.
P
DRUG TREAMENT FOR PROTEINURIA:
Drug treatment for proteinuria is recommended for patients
Points to note with ACEI or ARB Treatment:
R
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
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
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
by > 15-20%, discuss with Nephrologist.
Target is BP <130/80 (or lower) and proteinuria as close as
possible to normal range. FOLLOW UP:
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
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.
without symptomatic hypotension.
If ACEI not tolerated change to ARB. Start with irbesartan
Once stable on treatment: R
and titrate to same targets. All patients: 6 monthly review smoking status,
alcohol use, weight, BP, UEC, eGFR, Urine PCR, optimise I
Ramipril
Starting dose
2.5mg
Maximum dose
10mg
management of comorbidities including diabetes.
If proteinuria >2g or not improving: A
Quinapril 10mg 40mg (2 tablets) Increase frequency of review to 3 monthly and discuss with
Renal GP / Nephrologist.
Enalapril*
Irbesartan
5mg
75mg
20mg
300mg WOMEN OF CHILD BEARING AGE:
+
*breastfeeding
• Women with proteinuria and/or CKD have a higher e
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
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
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
>
specific renal diseases may still benefit from dual ACEI/ARB needed.
therapy, but this is no longer considered standard care. • If ACEIs or ARBs are inadvertently taken in pregnancy,
6
It should only be considered in select patients following discuss with Regional Obstetrician.
discussion with a Nephrologist. • Encourage early antenatal care.
0
• New onset proteinuria at <20/40 should be investigated
as a possible glomerulonephritis and discussed with a
Nephrologist.
• 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