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Glomerular proteinuria results from a breakdown in the integrity of the glomerular basement membrane and, more specifically, damage to podocytes in the membrane.

Proteinuria is associated with an increased risk of cardiovascular disease and is an independent risk factor for progression of renal disease All CKD patients should be checked for proteinuria.

The opposite is true among diabetologists, who more commonly use ACR so that they can detect the very earliest stages of diabetic nephropathy, which may be amenable to treatment • If the initial ACR is 3.5 mg/mmol in women to be clinically significant Key Point: Glomerular protein largely consists of albumin, and levels of proteinuria greater than 1 g/L usually indicates glomerular proteinuria.

This is equivalent to a PCR of 100 mg/mmol Key Point: Concerning PCR, an approximation to the protein excretion (in mg/L) can be obtained by multiplying the ratio (in mg/mmol) × 10 Eg PCR 100 approx = 1000 mg/L = 1 g/L (upto 0.2 g/L is normal) With a typical Western diet, humans consume 80 g of protein per day Key Point: A nephrological referral should be considered (a) if there is significant proteinuria (ACR 50 with haematuria Haematuria can either be glomerular (from the kidney) or extra-glomerular (from a urological source).

Until recently, the care of kidney patients has been largely under the domain of nephrologists in secondary care However, the increasing number of people diagnosed with chronic kidney disease (CKD; previously termed chronic renal failure) along with the more active treatment of end-stage renal disease (many more people have access to dialysis now than even a decade or so ago) means that: (i) more of the care has been streamlined into nurse-led clinics (ii) the earlier stages of renal disease are now being managed in the community by GPs This latter strategy means that an ever-wider group of healthcare professionals is obliged to have an understanding and basic knowledge of issues in relation to patients with CKD.

In the United Kingdom, the absolute cost per patient is around £30,000 - £35,000 per year for haemodialysis patients, and around £20,000 - £25,000 per year for peritoneal dialysis patients In order to help in the early identification of patients, and enable stratification of risk and management, CKD has been categorised into stages dependent on the e GFR, whether other evidence of kidney damage is present and whether or not there is proteinuria.

The two most common causes of this scenario are hypertensive nephropathy and Ig A nephropathy Microscopic haematuria is seen in 3-6% of the normal population.

A recent 22-year retrospective study of over 1.2 million young adults found a substantially increased risk for treated ESRD attributed to primary glomerular disease in individuals with persistent asymptomatic isolated microscopic haematuria compared to those without.

This is partly because of the lack of availability of access to quality microscopic techniques with skilled operators and partly because of the need for the microscopy testing to be performed on a relatively fresh sample of urine.

Dipstick urinalysis has the advantages of simplicity and accessibility If there is a positive urinary reagent strip test of 1 or more of blood, microscopic confirmation (ie an MSU, with M, C and S) should be made, and further evaluation will be necessary. ' Blood' on the dipstick represents the reaction observed when the 'peroxidase-like' activity inherent in molecules of haem (iron within a porphyrin ring) reacts with a peroxidase substrate in the pad.

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