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PROTEÎNÜRÎ: TANISI, HASAR MEKANİZMALARI VE TEDAVÎSÎ

PROTEINURIA : DIAGNOSIS, PATHOPHYSIOLOGY AND TREATMENT

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Abstract (Original Language): 
Fizyolojik koşullarda idrarla günlük protein atılımı 150 mgr'ın altındadır. Tekrarlanan ölçümlerde bu değerin üzerinde protein atılımının saptanması, yani proteinüri, gözardı edilmemeli ve ileri değerlendirme yapılmalıdır. Bu düzeyin üzerindeki protein atılımı genel olarak altta yatan böbrek hasarının önemli bir göstergesidir. İdrarda protein atılımının normal sınırlarda olup olmadığının değerlendirilmesi için yaygın olarak kullanılan yöntem 24 saatlik idrarda protein ölçümüdür. Son dönemde ise bu yönteme alternatif olarak spot idrarda kreatinin ve total protein oranının hesaplanması gündeme gelmiştir. Bu oran 1,73 m2 vücut alanına sahip bir bireyde günlük protein atılımının yaklaşık bir göstergesi olabilmektedir. Bu yöntemde elde edilen oran rakamsal olarak günlük protein atılımına denk gelmektedir (Örn: İdrarda total protein / kreatinin oranının 4,9 saptanması günlük protein atılımının 4,9 g/1,73 m2 olduğunu gösterir)(l). Bu yöntemin sağlıklı sonuçlar vermeyeceği durumlar da mevcuttur. İdrarda atılan kreatinin miktarının bekleneden farklı olduğu durumlar bunlardan biridir. Örneğin kas kitlesi yüksek ve buna bağlı olarak da idrarda atılan kreatinin miktarı fazla olan bireyde protein atılımı az görülürken, tersine kaşektik bireyde mevcutdan daha fazla protein atılımı hesaplanacaktır. Yine bu yöntemle iyi huylu proteinüri durumları (ortostatik proteinüri vb) tanımak mümkün değildir. Bu yöntemin diabetik nefropatili hastalarda uygulanması halinde de yanlış sonuçlar alınmaktadır. Klinikte, proteinüri varlığı çoğunlukla bu yöntemlerden önce, idrar çubukları vasıtasıyla farkedilmektedir. Bu çubuklar albumine karşı duyarlıdırlar ve bu nedenle albumin dışındaki moleküllerin atılımının arttığı iyi huylu durumlarda, multipl myelomda ve mikroalbuminüri düzeyindeki diabetik hastalarda tanı için yeterli olamamaktadırlar. Açıklanamayan böbrek yetmezliği varlığında idrarın sulfasalisilik asit ile test edilmesi halinde mevcut olan bütün protein miktarı tespit edilebilir. Bu yöntem Glomerüler hipertansiyonun, artmış angiotensin-II'nin de katkısıyla, glomerül duvarını gererek zarar görmesine ve 'pore'ların genişleyip protein filtrasyonundaki boyut-seçiciliği özelliğini kaybederek, multipl myelom tanısında faydalıdır. Diabetik nefropatili hastalarda ise idrar çubuğunda proteinin pozitifleşmesi hastalığın geç bir bulgusudur. Bunun nedeni bu çubukların ancak günlük 300-500 mg üzerinde albumin atılımı varlığında pozitifleşiyor olmasıdır. Bundan daha düşük düzeylerdeki proteinürinin tanısında faydasızdırlar.
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REFERENCES

References: 

1. Stcinhauslin F, Wauters JP. Quantification of proteinuria in kidney transplant recipients: Accuracy of the urine protein/creatinine ratio. Clin Nephrol 1995; 43:110.
2. Robinson RR. Isolated proteinuria in asymptomatic patients. Kidney Int 1980; 18:395.
3. Poortmans JR. Postexercise proteinuria in humans. Facts and mechanisms. JAMA 1985; 253:236.
4. Poortmans JR, Brauman H, StaroukineM et al. Indi¬rect evidence of glomerular/tubular mixed-type post-exercise proteinuria in healthy humans. Am J Physiol 1988;254:F277.
5. Carrie BJ, Hilberman M, Schroeder JS, Myers BD. Albuminuria and permselective properties of glomeru-lus in cardiac failure. Kidney Int 1980; 17:507
6. Cameron JS, Turner DS, Ogg GS, Chantler C, Wil¬liams DG. The long term prognosis of patients with focal segmental glomerulosclerosis. Clin Nephrol
1978; 10:213-18.
7. Row PG, Cameron JS, Turner DR, Evans DJ, White RHR, Ogg CS, et al. Membranous nephropathy. Long term follow-up and association with neoplasia. Q J Med 1975;44:207-9.
8. Brenner BM, Meyer TW, Hostetter TH. Dietary pro¬tein intake and the progressive nature of kidney dis¬ease: the role of hemodynamically mediated glomeru-lar injury in the pathogenesis of progressive glomeru-lar sclerosis in aging, renal ablation and intrinsic renal
disease. N Eng J Med 1982; 307:652-9.
9. Boher MP, Deen WM, Robertson CR, Brenner BM.
Mechanism of angiotensin II induced proteinuria in
the rat. Am J Physiol 1977; 233:F13-21.
10. Remuzzi G, Bertani T. Is glomerulosclerosis a conse¬quence of altered glomerular permeability to macro-
molecules? Kidney Int 1990; 38:384-94.
11. D'Amico G, Ferrario F, Rastaldi MP. Tubulointersti-tial damage in glomerular diseases: it's role in pro¬gression of renal damage. Am J Kidney Dis 1995; 26:124-32.
12. Kees-Folts D, Sadow JL, Schreiner GF. Tubular ca-tabolism of albumin is associated with release of an
inflammatory lipid. Kidney Int 1994; 45:1697-1709.
13. Biancone L, David S, Delia Pietra V, Montrucchio G, Cambi V, Camussi G. Alternative pathway activation of complement by cultured human proximal tubular
epithelial cells. Kidney Int 1994; 45:451-60.
14. Burton C, Harris KPG. The role of proteinuria in the progression of chronic renal failure. Am J Kidney Dis
1996; 27:765.
15. Zoja C, Morigi M, Figliuzzi M, Bruzzi I, Oldroyd S, Benigni A et al. Proximal tubular cell synthesis and secretion of endothelin-1 on challenge with albumin and other proteins. Am J Kidney Dis 1995; 26:934-41.
16. Wang Y, Chen J, Chen L, Tay Y-C, Rangan GK, Har¬ris DCH. Induction of monocyte chemoattractant pro-
131
tein-
1 in proximal tubule cells by urinary protein. J Am Soc Nephrol 1997; 8:1537-45.
17. Zoja C. Donadelli R, Colleoni S, Figliuzzi M. Bonaz-zola S, Morigi M, Remuzzi G. Protein overload stimu¬lates RANTES production by proximal tubular cells depending on NF-kB activation. Kidney Int 1998: 53:1608-15.
18. Remuzzi G, Bertani T. Pathophysiology of progres¬sive nephropathies. N Eng J Med 1998; 339:1448-56.
19. Barnes PJ, Karin M. Nuclear factor-kB: a pivotal transcription factor in chronic inflammatory disease. N Eng J Med 1997;336:1066-1071.
20. Van Kooten C, Gerritsma JSJ, Paape MA, Van Es LA, Banchereau J, Daha MR. Possible role for CD40-CD40L in the regulation of interstitial infiltration in
the kidney. Kidney Int 1997; 51:711 -721.
21. Ruggenenti P, Perna A, Mosconi L, Matalone M, Pisoni R, Gaspari F, Remuzzi G, on behalf of the "Gruppo Italiano Di Studi Epidemiologici In Nefrolo-gia" (GISEN). Proteinuria predicts end-stage renal failure in non-diabetic chronic nephropathies. Kidney Int 1997; 52 (SuppI 63):S54-57.
22. Modification of diet in renal disease study group. Effect of dietary protein restriction on nutritional status in the Modification of Diet in Renal Disease
study. Kidney Int 1997; 52:778.
23. Maschio G, Alberti D, Janin G, Locatelli F, Mann JFE, Motolese M et al. ACE Inhibition in Progressive Renal Insufficiency study group. Effect of the angio-tensin-converting-enzyme inhibitor benazepril on the progression of chronic renal insufficiency: the Angio-tensin-Converting Enzyme Inhibition in Progressive Renal Insufficiency Study Group. N Engl J Med 1996;
334: 939-945.
24. Meyer TW, Anderson SA, Renke HG, Brenner BM.
Reversing glomerular hypertension stabilizes estab¬lished glomerular injury. Kidney Int 1987; 31:752.
25. Zatz R, Meyer TW, Renke HG, Brenner BM. Pre¬dominance of hemodynamic rather than metabolic factors in the pathogenesis of diabetic nephropathy
Proc Natl Acad Sci USA1985; 82:5963.
26. Miller PL, Scholey JW, Renke HG, Meyer TW.
Glomerular hypertrophy aggravates epithelial cell injury in nephrotic rats. J Clin Invest 1990; 85:1119.
27. Fukui, M, Nakamura, T, Ebihara, I, et al. Low-protein diet attenuates increased gene expression of platelet-derived growth factor and transforming growth factor-B in experimental glomerular sclerosis. J Lab Clin
Med 1993; 121:224.
28. Nakamura T, Fukui M, Ebihara I, et al. Low protein diet blunts the rise in glomerular gene expression in focal glomerulosclerosis. Kidney Int 1994; 45:1593.
29. Mitch WE. Dietary protein restriction in chronic renal failure: Nutritional efficacy, compliance, and progres¬sion of renal insufficiency. J Am Soc Nephrol 1991;
2:823. t
30. - Walser M, Mitch WE, Maroni BJ, Kopple JD. Should
protein intake be restricted in predialysis patients?
Kidney Int 1999; 55:771.
31. Aparicio M, Chauveau P, De Precigout, VD, et al. Nutrition and outcome on renal replacement therapy of patients with chronic renal failure treated by a sup¬plemented very low protein diet. J Am Soc Nephrol
2000; 11:708.
32. Kaysen GA, Davies RW, Hutchison FN. Effect of
dietary protein intake and angiotensin converting enzyme inhibition in Heymann nephritis. Kidney Int 1989;(Suppl27):S154.
33. Kaysen GA, Jones H, Jr Martin, V Hutchison, FN. A
low-protein diet restricts albumin synthesis in nephrotic rats. J Clin Invest 1989; 83:1623.
34. Choi EJ, Bailey J, May RC, et al. Metabolic responses to nephrosis: Effect of a low-protein diet. Am J
Physiol 1994;266:F432.
35. Maroni BJ, Staffeld C, Young VR, et al. Mechanisms permitting nephrotic patients to achieve nitrogen equi¬librium with a protein-restricted diet. J Clin Invest
1997; 99:2479.
36. ikizler TA, Greene JH, Wingard RL, et al. Spontane¬ous dietary protein intake during progression of chronic renal failure. J Am Soc Nephrol 1995; 6:1386.
37. Zeller K, Whittaker E, Sullivan L, et al. Effect of
restricting dietary protein on the progression of renal failure in patients with insulin-dependent diabetes
mellitus. N Engl J Med 1991; 324:78.
38. Walker JD, Bending JJ, Dodds RA, et al. Restriction
of dietary protein and progression of renal failure in diabetic nephropathy. Lancet 1989; 2:1411.
39. Ihle BU, Becker GJ, Whitworth JA, et al. The effect
of protein restriction on the progression of renal insuf¬ficiency. N Engl J Med 1989; 321:1773.
40. Locatelli F, Alberti D, Graziani G, et al. Prospective, randomized, multicentre trial of effect of protein re¬striction on progression of chronic renal insufficiency. Lancet 1991; 337:1299.
41. Pedrini MT, Levey AS, Lau J, et al. The effect of dietary protein restriction on the progression of diabetic and nondiabetic renal diseases: A meta-
analysis. Ann Intern Med 1996; 124:627.
42. Kasiske BL, Lakatua JD, Ma JZ, Louis TA. A meta-
analysis of the effects of dietary protein restriction on the rate of decline in renal function. Am J Kidney Dis
1998; 31:954.
43. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The
effect of angiotensin-converting enzyme inhibition on
diabetic nephropathy. N Engl J Med 1993; 329:1456.
44. Heeg JE, de Jong PE, van der Hem GK, de Zeeuw, D. Efficacy and variability of the antiproteinuric effect of ACE inhibition by lisinopril. Kidney Int 1989; 36:272.
45. Bedogna V, Valvo E, Casagrande P, et al. Effects of ACE inhibition in normotensive patients with chronic glomerular disease and normal renal function. Kidney Int 1990; 38:101.
132
46. Gansevoort RT, Sluiter WJ. Hemmelder MH, et al. Antiproteinuric effect of blood-pressure-lowering agents: A meta-analysis of comparative trials. Nephrol
Dial Transplant 1995; 10:1963.
47. Kloke HJ, Wefzels JF. van Hamersvelt HW, et al.
Angiotensin-converting enzyme inhibition and the combination of a beta-blocker and a diuretic are equally effective in lowering proteinuria in patients with glomerulonephritis. Nephrol Dial Transplant
1993:8:808.
48. Lafayette RA, Mayer G, Park SK, Meyer TW. Angio-
tensin II receptors blockade limits glomerular injury in rats with reduced renal mass. J Clin Invest 1992; 90:766.
49. Ichikawa I. Will angiotensin II receptor antagonists be renoprotective in humans. Kidney Int 1996; 50:684.
50. Hutchison FN, Cm X, Webster SK. The antiproteinu-ric action of angiotensin-converting enzyme in de¬pendent on kinin. J Am Soc Nephrol 1995; 6:1216.
51. Russo D, Pisani A, Balletta MM, et al. Additive anti-proteinuric effect of converting enzyme inhibitor and losartan in normotensive patients with IgA nephropa-
thy. Am J Kidney Dis 1999; 33:851.
52. Vriesendorp R, Donker AJ, de Zeeuw D, et al. Effects of nonsteroidal anti-inflammatory drugs on proteinu-
ria. Am J Med 1986:81:84.
53. Shemesh O, Ross JC, Deen WM, et al. Nature of the
glomerular capillary injury in human membranous glomerulopathy. J Clin Invest 1986; 77:868.
54. Heeg JE, de Jong PE de Zeeuw D. Additive antipro-leinuric effect of angiotensin-converting enzyme inhi¬bition and non-steroidal anti-inflammatory drug ther¬apy: A clue to the mechanism of action. Clin Sci 1991; 81:367.
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