Protein in urine
Our previous articles in the “Proteinuria (Protein in urine) Series” explained The “What, How & Why of Proteinuria” & “Clinical & Lab Workup of Proteinuria“
Keeping in sync with the focus of this series, today’s article covers the basic tenets that guide the Treatment of Sustained Proteinuria in kidney disease.
TREATMENT APPROACHES FOR PROTEINURIA
1. Treatment of the underlying cause
TREATMENT OF THE UNDERLYING CAUSE
After confirming the presence of plasma protein in Urine, it is a logical progression for your medical team to try and find out the “root cause” that has been making your kidneys leak protein in the urine.
This calls for a battery of blood tests, imaging studies (Ultrasonography, CT scan and/or MRI of kidneys) and if required, a Renal (kidney) biopsy, to get to the underlying condition.
For instance, let’s take the case of Diabetic Nephropathy (Diabetic Kidney Disease)
Uncontrolled high blood glucose in Diabetes is a leading cause of chronic kidney disease & kidney failure worldwide. It is marked by significant protein loss in urine over time. Once the urine of such a patient tests positive for Protein, a simple blood test can reveal if a person is Diabetic or not, and if yes, whether a Type1 or Type2 Diabetic.
Once such a patient is confirmed to have Diabetic Kidney Disease, the respective medical team starts the patient on specific medicines for intensive blood glucose control & maintenance. Such patients need to be thoroughly explained the importance of taking their medicines regularly to avoid sudden abnormal spikes in blood glucose levels which could otherwise propagate further kidney damage rapidly.
During the course of blood glucose-lowering treatments, the medical team may also perform imaging scans such as an Ultrasonography of the patient’s kidneys to assess the extent of kidney damage that has been already done. This, along with separate blood work for kidney function can help the doctor understand the stage of chronic kidney disease that the patient is currently at. This serves as a guide for planning the patient’s further treatment.
Similarly, blood work can help doctors broadly identify whether the cause for damage to kidney filters (& the resulting Proteinuria) has stemmed from a defect in your immune system.
In such cases, doctors may further order an ultrasound scan to understand the extent & pattern (patchy or uniform) of kidney damage. When this category of patients presents early enough, such that they are clinically stable and still have greater than 40% of kidney function remaining, doctors may want to order a Kidney Biopsy.
This is a test where doctors draw-out a tiny portion of the patient’s kidney tissue with a special syringe under local anaesthesia. A pathologist studies this kidney tissue specimen under a microscope to precisely confirm the immune system defect that has brought about kidney damage.
Such measures help differentiate kidney damage in Lupus (Lupus nephritis) from IgA nephropathy or FSGS. Each of these is immune system-mediated kidney damage but has a separate combination of medicines when diagnosed early on.
Identifying the root cause & initiating appropriate disease-specific treatment aims to contain the “assault” to kidney filters by the respective disease process. Blood glucose-lowering drugs for Diabetics, Medicines dampening the Immune System for patients with Immune-mediated kidney damage falls under this category. This helps to prevent the rapid & progressive increase in protein loss in urine over time.
ADDED MEDICATION
Along with the root cause, patients with Sustained Proteinuria are also started on other medicines that are common for all CKD patients with Proteinuria irrespective of the root cause. These may include:-
Blood Pressure lowering medication for specific Kidney Disease
Chronic sustained high blood pressure due to a cardiac or hormonal condition can cause Chronic Kidney Disease (CKD). Conversely, CKD raises blood pressure over time as well, although by a separate kidney-based mechanism.
Whatever be the method, when patients have a high BP, blood gushes with great force towards the delicate kidney filters and literally shoves & pushes through them. This badly damages the intricate filtration layers in the kidney and causes Plasma Protein to leak out in urine. Hence BP lowering meds have a crucial role to play in helping contain the extent of Plasma Protein Loss in Urine per day.
Commonly used BP-lowering medicines in CKD belong to either of the following classes:
◾Angiotensin Converting Enzyme(ACE) Inhibitors (ACEI)
Medicines whose generic name ends with the suffix “-pril”. Examples (common brand names within brackets) include the following:
- Ramipril (Altace, Cardace)
- Benazepril (Lotensin)
- Captopril
- Enalapril (Vasotec)
- Fosinopril
- Lisinopril (Prinivil, Zestril)
- Moexipril
- Perindopril (Aceon)
- Quinapril (Accupril)
- Trandolapril (Mavik)
◾Angiotensin II Receptor Blockers (ARBs)
Medicines whose generic name ends with the suffix “-sartan”. Examples (common brand names within brackets) include the following:
- Losartan (Cozaar)
- Olmesartan (Benicar)
- Telmisartan (Micardis)
- Valsartan (Diovan)
- Azilsartan (Edarbi)
- Candesartan (Atacand)
- Eprosartan
- Irbesartan (Avapro)
Please note, only one of the above classes of medicine is used in a CKD patient at a time.
Both the above medicine classes are taken by mouth.
These work by helping the Glomerulus (specialized blood vessels that act as kidney filters) relax & widen. This, in turn, reduces the force with which blood from the rest of the body thumps against kidney filters and decreases the extent of protein loss in urine.
DIET MODIFICATIONS
Apart from Medicines, doctors would refer the patient to a Renal Dietitian. Such professionals undergo special training to guide on specific nutritional requirements and their safe limits of consumption with CKD.
A Renal Diet or Medical Nutrition Therapy (MNT) involves reducing salt (sodium ) Intake in food among other things.
Reducing overall Sodium intake — a mineral commonly found in table salt helps to control Blood Pressure. Maintaining healthy blood pressure levels helps reduce proteinuria as explained in the above section. Read more here.
LIFESTYLE CHANGES
In addition to all the above measures, your medical team will advise you on a host of lifestyle modifications. These are primarily targeted at reducing your overall blood pressure and thereby, restricting Protein loss in Urine for the longest possible time.
Such measures include, but are not limited to:
Starting a fitness regimen to attain/maintain healthy body weight
Avoid intense exercise (heavy weight training, high intensity interval training (HIIT) or excess protein intake for body sculpting)
Stop smoking
The earlier the doctors trace Proteinuria, the earlier they can advise their patients to adopt the above measures. This ensures that the rate of progression of kidney damage will markedly slow down and the patient will be able to keep the inevitable kidney failure at bay for a longer time period.
We use the term “inevitable” here because that is how Chronic Kidney Disease (CKD) works. Kidney Failure is, unfortunately, an unavoidable consequence of CKD. All available treatments only aim to dampen the symptoms or attenuate and halt disease progression. They CANNOT reverse/cure kidney failure from CKD.
Therefore, we at ATK re-iterate the importance of being vigilant about your health (Urine health in particular) to arrive at a potential diagnosis in good time.
Now, it may be tempting to avoid medical tests lest you should test positive for a disease condition that’s damaging your kidneys. And we understand where this kind of psychology stems from, in patients.
But to be honest, delaying a diagnosis harms you physically, psychologically and financially a lot more, when compared with patients who started receiving treatments early on.
So what are you waiting for? Pledge to be truly vigilant about your health today.
Stay Well, all of you!
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REFERENCES
This is good. It will make you religious in looking after your health.