Does protein in urine mean kidney damage? Are bubbles in urine normal?

[Music] all right hello everyone welcome back to plant-based kidney health my name is michelle krosmer and i'm here with dr shawn hashmi again and we have a very um important complex confusing topic to address today and it'll be again another one that's multiple episodes because it's i think so we're talking about protein area or protein in the urine and i think it's um there's it's confusing for people with kidney disease it's confusing for a lot of health care professionals for family members of kidney disease and so i think it's just going to be really beneficial to learn about what it is and what potentially causes it and eventually we'll get into you know how how it's treated or how we can help treat it what testing can be done so we are very very lucky that dr hashmi is going to um explain so much for us on this confusing topic because i i would not be able to explain it so um should we dive right into the questions okay um so first of all can you just explain for us what is proteinuria and what causes it yeah so you know today's topic guys is gonna be one i think you guys are gonna probably have to watch this video a couple of times use it as a reference in the future so with that let's dive in there are two types of proteinuria i want you to remember one is albuminuria which is just one type of protein and one is proteinuria which is all types of protein so in general there are two references i want you to remember the first reference is how much protein should you actually be spilling in the urine if you're healthy so it turns out the answer is not zero it's about 150 milligrams per day so that's the first reference you want to remember is should be up to 150 milligrams per day that's the normal range the second is how much albumin remember albumin is one type so it should be less than the total protein you're spelling that's less than 20. now we have a few definitions that we talked about in the past so the first definition is what we call we used in the back in the day we had different names for it so i'll give you all the names because your doctors and your renal dietitians your kidney care team may use different terms so the first term is micro albuminuria microalbuminer is a older term now we say moderately increased albuminuria or moderately increase albumin in the urine what that basically means is that you're spilling anywhere between 30 to 300 milligrams per day of albumin in the urine so remember normal is 20 or less this is moderate which means it's 30 to 300. if you're more than 300 we call that severely increased albuminuria or previously called macroalbuminuria so it's already starting to get a little complex but hang in there now sometimes your kidney team will say well you know mrs jones you have nephrotic syndrome so that's just a fancy way of saying is is that they're looking at the total amount of protein you're spilling and it's greater than 3.5 grams per day so if they say nephrotic syndrome is greater than 3.5 non-nephrotic is less than why should you care because your risk factors for things like blood clots in the legs the severity of the disease and all those things go up if you're greater than 3.5 or nephrotic so now we know when we talk about severity if it's nephrotic it's greater than 3.5 or if we're just looking at albumin is greater than 300 now let's talk about what does it mean when we talk about proteinuria specifically in the kidneys so if you look at the kidneys think of the kidneys as a this is probably not the best example but when i explained to medical students for the very first time this is how i describe it it's like a ball and chain so there are very tiny structures in the kidneys called a glomerulus which is the ball portion of it and then you have the tubular component that comes out and so the tubular component is kind of like the chain that comes out of it so when you look at protein in the urine the protein in the urine can come out because there's damage in any one of those areas so the first portion of the kidney is that glomerulus or the ball and if there is damage in that glomerular portion going on we call that proteinuria coming from the glomerular protein now if it's that structure that's being damaged you're gonna see that very simply on the urine dipstick so you know the most simple test for protein in the urine is urine dipstick it's not the best test and we're going to get into that why in a second but the urine dipstick is where literally they dip a stick in your urine they pull it out and they say aha it's one plus two plus three plus or four plus and we'll talk about all of that so if it's glomerular it will show it right there now what if it's the damage is not happening in the ball portion what if it's later on what if it's happening in the tubulars well if it's happening in the tubulars then what happens there is it's other types of diseases and those diseases are where there's smaller proteins that are really doing the damage and those can be things like light chain diseases going on and the reason you should care is is because some of those things they don't show up on dipsticks so imagine you do a urine dipstick it comes out negative and you think you have nothing wrong with you in fact there could actually be a disease there but it just doesn't show up on a dipstick going on so now we covered glomerular we covered tubular so remember glomerular bigger types of protein tubular smaller types of proteins then there's something called overflow overflow protein area is just like it sounds there's so many types of protein that are being formed whether it's in the body going on that they're literally just overwhelming the system and they're flowing out what is the classic example is actually things like multiple myeloma a type of cancer and there there's so many light chains being formed in the body that they're just spilling out through the kidneys into the urine going on the last one that's really important the fourth type of proteinuria and this is the one that confuses everybody so you want to know this one is what we call post renal what does that mean it means it's not inside the kidney so it's not in the ball it's not in the chain it's after the kitten so where is it it could be in the urinary tract going on so for example let's say you had a urinary tract infection so there's inflammation along the urinary tract going on and so you have some protein spilling so in other words you actually don't have kidney disease you literally just had a uti and that's why they saw some white blood cells and they saw some protein so it's not uncommon that somebody comes to me and they're referred because they saw some protein and they're getting so scared they're like oh my god doc i have kidney disease but they don't the only reason they're there is because they saw some white blood cells and they have some protein so what do we do we repeat it that's it the other times that you can also see protein in the urine post renal is if they have kidney stones there because what will kidney stones do as they pass they can cause inflammation inflammation will cause some protein to spill there but there's another reason why that can happen and you can have tumors and those tumors whether they're in the urinary tract going on or lower down those tumors can also cause there to be some protein spilling so anytime we see protein spilling the first thing is is we want to make sure it's real so we'll go ahead and check it and we'll go ahead and repeat it to make sure going on but if you see it you can always see us or a urologist and we can check it to make sure now let's go ahead and flip that equation let's say you have protein in the urine and you're a young person or you're otherwise healthy and you're you know getting very nervous and you say you know what are some causes of protein in the urine that are not serious that are what we cause benign or basically essentially to just kind of go away well one of the most common causes which is something nobody ever talks about is dehydration just like that nobody really thinks about this but this is so common people come in they're really really dehydrated they give me a urine sample it looks like there's protein because when we measure protein in the urine it's a concentration if you're really dehydrated it looks like oh my god you have so much protein i make you drink some water i repeat it and guess what it's fine another one and now this is really interesting it's stress if you're under a lot of stress please don't go give me a urine sample because it'll look like you have protein in the urine you know when we're stressed we release all of these cytokines and inflammatory markers and they can cause you to spill protein in the urine if you calm down relax next thing you know you don't spill protein in the urine so if you're having a really hard time at work you're not sleeping enough and all that stuff going on believe it or not that can cause you to spill some protein in the urine and make the test look bad fever will do it heat will do it any kind of inflammation in the body will do it of course exercise will do it so we're not talking the couch potato gets up and walks to the fridge and back we're saying like any kind of intense activity right they'll go ahead and do it of course if you have like any kind of significant illness you got a severe fever or anything like that going on now here's a kicker i had a patient come to me who was a young guy um i think he had just turned 18 or 19 this is several years ago and nobody could figure out why this uh i'm going to say kid i'm not that old but i'm going to say kid why this kid had protein in the urine and they they wanted to do a kidney biopsy he was reluctant and he came and saw me and i said there's no reason to do a kp biopsy on you you have what's called orthostatic proteinuria what is it it's basically when you stand up you spill protein in the urine and how do you diagnose it so you do a urine sample basically and um you essentially wait till the end of the day so right before they go to bed in the evening you get a urine sample then and then you get another urine sample when they wake up first thing in the morning and you do it and so you get a spot urine sample and you check their protein in the urine and what you find is is because they're standing all day they actually spill protein if orthostatic is postural versus when they're laying down they don't spill protein their diagnosis is benign nothing happens and they're okay and you just follow them along so that's orthostatic so now you have all these causes for benign so now let's flip it what are some causes for not benign in other words what are some causes that actually are serious that you want to know so first let's talk about the ball area remember we said ball and chain so on the ball area there are certain diseases that we call primary glomerulo optics which means these are main things that affect the glomerulus those are things like minimal change disease autoimmune conditions membranous fsgs or focal segmental glomerulosclerosis that's a mouthful membranoplurificative ig nephropathy these are all types of diseases where essentially your immune system is turning on itself it's attacking the kidneys going on for a multitude of reasons some we understand some we don't a lot of times we use immunosuppressants to treat those but the thing that they all share is you're spilling protein in the urine going on now the secondary causes are usually because there's a secondary disease that's then attacking the kidneys for example the most common one is diabetes right diabetes will attack the kidneys and then cause you to spill protein in the urine lupus lupus is a collagen vascular disease lupus will attack the kidneys and cause the kidneys to spill protein amyloid people can have preeclampsia going on infections like hiv hepatitis syphilis malaria endocarditis these are all common things that will lead to protein spilling in the urine lots of cancer right there's uh lymphomas lung cancers can do it gi cancers can all lead to the kidneys and spill protein in the urine going on now what about drugs there's a number of drugs that can also do exactly the same thing most common things are nsaids right motrina leave etc if taken in excess over long periods of time they can do that some people can just have a reaction to them and that can do that lithium can cause you to spill protein in the urine you know when we talk about supplements and we say listen if you're going to take something be very careful about the capsules because oftentimes the capsules are unregulated and they can have heavy metals those heavy metals can cause you to spill protein in the urine going on other thing is drugs like heroin can do that as well so those are all things that can affect the ball or the glomerulus what about then the chain or what we call the tubular portion well tubulars are affected by very simple thing like blood pressure but another thing is is things like uric acid and what causes uric acid to go up a few things meat is a big culprit high fructose so when michelle is always talking about eat fruit don't drink your fruit meaning go don't start drinking juices there's a reason for it right juices it to get rid of the fiber gets rid of the water and all it does is concentrates all of the fructose together so you're just getting nothing but fructose that's why our motto is listen to michelle first so as you think about that stuff you want to avoid high fructose you don't want to avoid fruit there's a big distinction there and same thing with things like alcohol so uric acid nephropathy will lead to damage of the tubules and that will cause what protein to spill in the urine sickle cell disease will cause protein in the urine a lot of antibiotics will damage the kidneys specifically in the tubules going on and then of course cancers like multiple myeloma can do it too so that is your big overview of what causes protein to spill in the urine and as you think about it remember ball and chain is the kidney so damage can occur in the kidney but protein in the urine can occur not just because of kidneys but because of damage after the kidneys okay wow that's such that's so helpful and i think one of the things just to kind of go off what you're saying is and correct me if i'm wrong but obviously someone who has let's say they have ssgs and um it's you know damaging that ball but then they also have high blood pressure which can then be impacting the tubules so it's almost this it regardless of what form of kidney disease you have or what the initial cause of the of kidney disease is some of those secondary things like high blood pressure high blood sugar or inflammation are so important to control because it could be contributing to more protein spilling into the urine absolutely right it's such a complex topic because all of these things they lead to each other and a lot of this stuff then leads back to what are you eating how are you moving how are you sleeping because there's stuff that you can't control but then the stuff you can control if you're not watching out for that that's going to feed right back into making either things worse or making them a lot better yeah and someone asked a question and actually multiple people have asked this but um their question was is if you see bubbles in your urine um is that a sign that there's protein in your urine yeah so generally speaking the answer is yes but i will tell you a lot of people have bubbles in their urine i have bubbles in my urine so most people in general have bubbles in your unit so don't freak out number two is is you know if you haven't had a physical you should have a physical and part of your physical let's just get a urinalysis done and we'll talk about your analysis most likely either in this episode or another episode but when we do we'll talk about which type of stuff to do but a simple dipstick will go ahead and tell you if you're spilling protein or not but in general a lot of people have bubbles but if you have a lot of bubbles meaning it looks like you know those um when you're getting ready to wash dishes and there's like soap everywhere and it's all that means that most likely have protein in the urine and when we are treating patients what we tell them is is you will be able to see the severity of the bubbles go down as a way to tell the treatment is actually working so yes bubbles are a sign of proteinuria but at the same time also realize it's actually common for people to have bubbles okay got it but a lot of bubbles foamy and soapy type of bubbles are not good um and you already addressed on someone someone had also asked is there anything aside from you know kidney disease can you damage that can cause protein in the urine so you discuss that i guess especially since you mentioned um you know the importance of the urinalysis what's the difference then between or i guess what should how should someone know if they're getting the right urine test done like what are the different ones and what's the difference between like the protein urine and then creatine urine and then protein creatinine ratio and it can be so confusing yeah let's dive into this so let's start off with the two types of tests that you can do so there is the qualitative test and then there's the quantitative test we like to use fancy terms so qualitative just means that it gives you a plus minus kind of thing meaning you have something or you don't but it doesn't tell you how much quantitative gives you a number it tells you exactly how much so on the qualitative side is the urine dipstick that is the one that gives you one plus to four plus it's actually not true it's not one plus it's actually zero to four plus technically right because zero would be it you don't have anything so what it does is the urine dipstick is really only detecting albumin remember we said albumin is one type of protein but there are many types of proteins so it is only trying to detect albumin but remember where is albumin really coming from it is coming from what we define as the ball or the glomerulus right so if there's stuff in the tubules it might not actually be sensitive to that so tubular proteins it might not be sensitive so the other thing is is really in terms of the smaller proteins it's not going to pick it up so the other part of this is is in terms of what does 1 plus mean what is 2 plus 3 plus 4 plus mean you know we don't have a very good idea what a good estimate is is that a two plus on a urine dipstick would actually be equivalent to about 500 milligrams of protein to creatine ratio that's what it would be about equivalent to so that's just to give you an idea and when we look at patients who have kidney disease or spilling protein what we want to target is a target of less than 500 so in other words normal protein to creatinine ratio we're trying to get them less than 200 but when they already have protein if we can get them less than 500 what the data shows is their risk of progression goes down a lot so less than 500 is really where we want to be now what is the problem with urine dipstick well a few things first if you're spilling blood so for example in women if they have their monthly cycle going on if there's blood in the urine it will give you a false positive so it will look like there's protein in the urine when there isn't so you don't want to do a urine dipstick if there's blood in the urine number two if the ph of the urine is high let's say the urine ph is like greater than eight if that's the case you don't want to do it if you've had any kind of imaging done on the body where they had to give you any kind of contrast what we call iodinated contrast you want to wait at least 24 hours because the contrast will affect the dipstick urine itself so you don't want to have your dipstick urine done within 24 hours of getting any kind of contrast study so that's really important going on now the gold standard when it comes to doing any kind of urine test is a 24-hour urine collection that is the gold standard but how come we don't do the gold standard all the time because frankly 9 out of 10 patients do it wrong this is really important to understand you can truly mess it up so what is the right way and i'll i'll tell you this and you want to make sure that if you do it for your doctor please do it correctly number one you wake up in the morning you go use the restroom you let all of that urine go into the toilet you flush it you're done from that point on that is time zero after that every time you pee it goes into the jug because when you wake up in the morning that is all the urine from overnight that has to be discarded so that's time zero now you collect throughout the day it has to be refrigerated then you wake up in the next morning remember that got collected overnight that has to then when you pee the next morning has to go into the jug you have to go ahead and store it and you have to bring it to the doctor's office now it's really hard for people because imagine even if you do it on a friday like who the heck wants to you know carry a jug to work and so forth and you know if you do it on a sunday and you got to bring it in so forth so it's difficult and we understand but there's a reason why we ask people to do it now what's the next best thing before we come back to this gold standard so the spot protein to creatine ratio or the spot micro albumin to react in ratio is the alternative the reason that we use that is is because it gives us an idea about as close as we can get but it has a lot of limitations so if you want to get the best results out of it please please please do it first thing in the morning okay so in order to get the best results do it first thing in the morning now there are limitations to this test and the limitations are that it is really this this spot protein to creatine ratio or the spot microalbumin to creatine ratio it is heavily dependent on the creatinine concentration so imagine if you're a bodybuilder like me that's a total joke i am nowhere near a bodybuilder i'm actually quite skinny so i should give you the other estimate but let's imagine that i am a bodybuilder and i'm like 250 pounds which is pure muscle like four percent body fat all that good stuff right because of that i produce a lot of creatinine so as a result of it my bottom number is actually going to be very high so what's that going to do to my ratio it's going to make the ratio smaller so i'm going to underestimate my total protein to create me let's do the opposite let's say i'm somebody who is elderly and frail i don't have a lot of muscle so because i don't have a lot of muscle i don't produce a lot of creatinine i make that bottom number very small therefore it makes it seem like oh my god i'm spilling so much protein in the urine why should you care because imagine if you overestimate how much protein you're spilling you scare the bajeebies out of your doctor your doctor gives you too much medicine or if you're a bodybuilder and you truly are spilling a lot of protein but your doctor doesn't give you enough medicine and he or she under treats you and now your kidneys continue to get worse isn't either one of those situations bad so when you first go see a guy like me or a gal like me when you first see a kidney specialist i think it's very very important that when we ask you the first time please do a 24-hour urine collection the first time do it because that first time will give us an idea of what's your starting point after that you can do the spot protein creatinine or micro albumin creatine ratio and is perfectly okay but in order for us to make sure that we know where you're starting and so we give you the right amount of medicine it's going to be very very important so that's how you end up deciding you're in dipstick or microalbumin to creatinine or protein to create and remember a dipstick is looking at albumin which is one type of protein but imagine if you have multiple myeloma which is a type of cancer it's putting out light chains which are not albumin protein they are immunoglobulin proteins those would not be picked up by a dipstick so dipstick will only pick up albumin type proteins nothing else so this is why we do uh you know microalbumin creatinine or whatever other kinds of stuff but a dipstick is very very simple and it only is a limited type of test and then just just to clarify so with the 24-hour urine collection you're still testing the micro albumin creatinine ratio it's just that it's more accurate because okay so what's in the difference that you're testing that we're doing a quantitative amount of albumin and total protein in there so we can so in that total collection we will measure the total amount of reacting in there we will measure the total amount of protein in there we will measure the total amount of albumin in there from that we can do the ratios and do any other thing that we want to get an idea of so we can get the ratios but we can also get the total amount of protein you're spilling okay got it and it's more accurate because versus the spot one it's depending on the time of day and obviously your body mass then it's not going to be as accurate so so the word accurate is it's tricky right in the sense that are you really doing it 24 hours right in other words if if you know if you don't do it for the exact 24 hours and let's say that you only did it for 20 hours that could make a big difference yeah right so let's say that you know um you went and you peed at six in the morning and then you started collecting so that's fine that you did that but then the next morning when you woke up and you slept in later and you did the last sample and and you peed at like 10 a.m well now that's a like 30 hours you threw my entire 24-hour collection off so the problem with the 24-hour test is most of our patients they end up messing it up and that's why a lot of nephrologists they just throw their hands up and they say you know most patients don't do it right and as a result because we don't know we may actually mess up our treatment decisions and give them the wrong dosing based on that got it okay that makes a lot of sense and i one more question that um of course the next episode we're going to go in more of the treatments um but when you look at you know like the national kidney foundation has that you know grid that shows the stage you know based on your gfr and then how much protein is leaking in the urine they show kind of your prognosis for kidney disease so why is the presence of protein in the urine and the amount of protein in the urine linked with someone's like prognosis or progression or severity of kidney disease yeah so the single most powerful predictor the single most powerful predictor of going on to dialysis over 10 years is protein in the urine study after study so there was a study in 2013 by chowdhury and colleagues and what they showed was that in a 40 year old men and women who had no protein in the urine they lived 15 and 17 years longer than those that had heavy protein in the urine just think about that for one second you're talking 15 and 17 years longer that's a long time and then those that actually had mild protein in the urine versus those that actually had heavy protein in the urine the ones that had mild protein in the urine lived eight years and 10 years longer the men lived eight years longer and the women lived 10 years longer than those that had heavy protein in the urine so in other words protein in the urine not only is it the biggest risk factor for dialysis it is the biggest risk factor for death that's significant because of inflammation or is that just because of the amount of damage like it's showing the level of damage or or do we know this is a great question you know i think it's probably all of the above meaning there are so many things that happen inside of our bodies and that's why whenever you have protein in the urine you have to see your nephrologist and the entire team and you have to get it under control it is absolutely vital simply because it cuts into your life so much yeah okay well i think that's a good place to wrap up i just like you said in the beginning i think that this is a really good episode for people to listen to multiple times or watch multiple times because really understanding what proteinuria is in the different places of the kidneys or even post-renal that it can occur in the levels and the testing for it and then just why it's so important i think is is really good to understand because it's just an extra step of you know knowledge is power and taking control of your health and having that be part of you know your spreadsheet of your blood work and labs you also have your spreadsheet of your urinalysis and your test results that you're monitoring trends of so thank you for explaining that to us um you know in such a way that's you know as simple to understand as possible and we are going to have at least one but maybe two more episodes on proteinuria and we'll dive into you know treatments and food and nutrition um with that but again just in general if you guys have questions that you want to submit for us to talk about in upcoming episodes you can email that to plant based kidney health gmail.com um you know of course we can't answer individualized you know give individualized advice or recommendations but um topics and questions um you know just like this episode we get a lot of questions about about proteinuria and bubbles in the urine and and what the tests even mean and then we can turn it into one or multiple episodes so that's plant-based kidney health gmail.com and do you have any final thoughts oh just you know we would really appreciate it if you guys would spread the word yeah if you guys can share this subscribe like leave a comment um rate us we would appreciate that and we will see you guys next week with more on protein area you

Channel: Plant Based Kidney Health

Views: 946,066

Keywords: sean hashmi, michele crosmer, plant based kidney health, chronic kidney disease, ckd, esrd, renal nutrition, kidney nutrition, ckd diet, kidney health tips, healthy foods healthy kidneys, healthy kidneys, kidney health, renal dietitian, dialysis, hemodialysis, peritoneal dialysis, chronic kidney disease diet

Id: sX7mxSK4BTI

Length: 33min 16sec (1996 seconds)

Published: Thu Mar 31 2022