Proteinuria. Edited by M. M. Avram The LOllg Islalld College Hospital Brooklyn, New York PLENUM MEDICAL BOOK COMPANY. New York and London

Transcription

1 Proteinuria

2 Proteinuria Edited by M. M. Avram The LOllg Islalld College Hospital Brooklyn, New York PLENUM MEDICAL BOOK COMPANY New York and London

3 Main entry under title: Proteinuria. Library of Congress Cataloging in Publication Data Includes bibliographies and index. 1. Proteinuria. 2. Kidney-Disease-Diagnosis. I. Avram, Morrell M. (Morrell Michael), JDNLM: 1. Proteinuria. WJ 343 P967j RC905.P ' ISBN-13: e-isbn-13: DOl: / Plenum Publishing Corporation Softcover reprint of the hardcover 1 st edition Spring Street. New York. N.Y Plenum Medical Book Company is an imprint of Plenum Publishing Corporation All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording. or otherwise, without written permission from the Publisher

4 To Maria, Rella, Marc, Eric, Mathew, and David with admiration for their relentless will, idealism, and hard work

5 Contribu tors A. J. ADLER, M.D., Chief, Home Dialysis, Associate Professor of Medicine, V. A. Hospital, Brooklyn, New York M. M. A VRAM, M.D., Chief, Division of Nephrology, Medical Director, The A vram Center for Kidney Diseases, The Long Island College Hospital, Clinical Professor of Medicine, Department of Medicine, Downstate Medical Center, Medical Director, Brooklyn Kidney Center and Nephrology Foundation of Brooklyn, Brooklyn, New York DAVID S. BALDWIN, M.D., Professor of Medicine, Department of Medicine, New York University Medical Center, New York, New York G. M. BERL YNE, M.D., Professor of Medicine, Department of Medicine, Downstate Medical Center, Chief, Nephrology Section, V.A. Hospital, Brooklyn, New York JOHN D. BOWER, M.D., Professor of Medicine, Department of Medicine, University of Mississippi Medical Center, Director, Artificial Kidney Unit, Medical Director, Kidney Care, Inc., Jackson, Mississippi BARRY M. BRENNER, M.D., Samuel A. Levine Professor of Medicine, Department of Medicine, Harvard Medical School, Director, Renal Division, Brigham & Women's Hospital, Boston, Massachusetts D. E. BROWN, M.D., Instructor, Department of Medicine, V. A. Hospital, Brooklyn, New York KHALID M. H. BUTT, M.D., Associate Professor of Surgery, Downstate Medical Center, Brooklyn, New York vii

6 viii Contributors MARIA JOSE F. CAMARGO, Research Associate, Department of Physiology, Cornell University Medical College, New York, New York GA Y CASE, R.N., Home Training Unit, Kidney Care, Inc., University of Mississippi Medical Center, Jackson, Mississippi JHOONG S. CHEIGH, M.D., Director, Inpatient Services, Assistant Professor of Medicine, Cornell University Medical Center, New York, New York PAUL D. DOOLAN, M.D., Professor of Medicine, Department of Medicine, Yale University Medical Center, Division of Nephrology, St. Mary's Hospital, Waterbury, Connecticut LANCE D. DWORKIN, M.D., Assistant Professor of Medicine, Department of Medicine, N.Y.U. Medical Center, New York, New York PIERRE F. FAUBERT, M.D., Assistant Professor of Medicine, Department of Medicine, Downstate Medical Center, Attending, Division of Nephrology, Brookdale Hospital and Medical Center, Brooklyn, New York ELI A. FRIEDMAN, M.D., Professor of Medicine, Department of Medicine, Chief, Renal Diseases Division, Downstate Medical Center, Brooklyn, New York RICHARD J. GLASSOCK, M.D., Professor and Chairman, Department of Medicine, Harbor U.C.L.A. Medical Center, Torrance, California CYRIL J. GODEC, M.D., Director, Department of Urology, The Long Island College Hospital, Brooklyn, New York JOHN P. HAYSLETT, M.D., Professor of Medicine, Department of Medicine, Chief, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut JOHN E. KILEY, M.D., Professor in Medicine & Nephrology, The University of Mississippi Medical Center, Jackson, Mississippi JAMES M. LUCIANO, M.D., Resident, Department of Medicine, Downstate Medical Center, State University of New York, Brooklyn, New York

7 Contributors ix THOMAS MAACK, M.D., Professor of Physiology, Cornell University Medical College, New York, New York JOHN F. MAHER, M.D., Professor of Medicine, Department of Medicine, Director, Nephrology Division, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland ARAM V. MANOUKIAN, M.D., Senior Medical Student, Department of Medicine, Downstate Medical Center, State University of New York, Brooklyn, New York ILENE MILLER, M.D., Instructor in Medicine, Department of Medicine, Assistant Attending Physician, Department of Medicine, Cornell University Medical Center, New York, New York JANET MOURADIAN, M.D., Clinical Professor of Pathology, Cornell University Medical Center, New York, New York BRYAN D. MYERS, M.D., Associate Professor of Medicine, Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California C. HYUNG PARK, M.D., Research Associate, Department of Physiology, Cornell University Medical College, New York, New York JEROME G. PORUSH, M.D., Chief, Division of Nephrology, Brookdale Hospital Medical Center, Professor of Medicine, Department of Medicine, Downstate Medical Center, Brooklyn, New York ROSCOE R. ROBINSON, M.D., Vice Chancellor, Medical Affairs, Vanderbilt University Medical Center, Professor of Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee J. E. RUBIN, M.D., Chief, Hemodialysis, V. A. Hospital, Brooklyn, New York GEORGE E. SCHREINER, M.D., Director, Nephrology Division, Professor of Medicine, Department of Medicine, Georgetown University School of Medicine, Washington, D.C. M. SEIDMAN, M.D., Attending Physician, Department of Medi-

8 x Contributors cine, Nephrology Section, V. A. Hospital, Assistant Professor of Medicine, Department of Medicine, Downstate Medical Center, Brooklyn, New York KURT H. STENZEL, M.D., Medical Director, Rogosin Kidney Center, Professor of Medicine, Biochemistry & Surgery, Chief, Division of Nephrology, The New York Hospital-Cornell Medical Center, New York, New York J. SUTION, M.D., Instructor, Department of Medicine, V. A. Hospital, Brooklyn, New York JOHN WANG, M.D., Department of Medicine, Cornell University Medical Center, New York, New York

9 Preface Decoding the significance of proteinuria as an indicator of severity or prognosis in kidney disease is a stimulating challenge to students and practitioners of nephrology. Sir Richard Bright in 1827 associated proteinuria with the disease that bears his name. In the subsequent more than a century and a half, however, the meaning of the linkage between proteinuria and renal disease remains elusive. Proteinuria is discovered on routine urinalysis in about 10 million Americans, most of whom express no symptoms of kidney disease, each year. From the studies of Robinson (updated in these pages), we know that proteinuria, per se, can be present for 20 years without change in renal function, as described in orthostatic proteinuria. By contrast, proteinuria may be the harbinger of swift kidney destruction, rarely culminating in clinical collapse, a syndrome typifying "malignant proteinuria" as detailed herein by Avram. Although proteinuria is ubiquitous, an orderly management strategy for rational handling of proteinuria of less than nephrotic range is lacking. Separation of tubular proteinuria and transient proteinuria of fever is now possible routinely. This book provides a record of the contributions of investigators and clinicians whose work forms the substrate for production of understanding and, ultimately, marching orders for practitioners seeking optimized management for their proteinuric patients. Generations of investigators have attempted to connect specific urinary proteins with distinct kidney disorders. This feat was the result of serendipity in the 1950 observation that Bence Jones proteins are present in most patients with multiple myeloma. Over the ensuing 20 years, it was learned that small amounts of Bence Jones protein may be present in normal urine and, more importantly, that the careful study of these urinary constituents and their precursors would serve as a Rosetta stone for clarification of modern immunology. Might we repeat the successes of the multiple myeloma story by readdressing superficially simple questions? What is proteinuria? What xi

10 xii Preface does its presence mean? And how does its presence alter the biology of the patient or the function of the kidney? Despite its high prevalence, we do not know whether proteinuria is injurious to the kidney or is the product of renal damage, nor do we know (with limited exceptions such as the proteinuria of diabetes or uncontrolled hypertension) how to prevent or whether and in what way to treat it. Until the significance to the patient of documenting proteinuria is elucidated, it will continue as an under detected and inadequately studied mark of kidney disease. As our society reappraises health care costs, including billions spent on t~e treatment of renal insufficiency, it is appropriate to direct energy and resources in an attempt to prevent renal disease. Toward this goal, the Division of Nephrology's Avram Center for Kidney Diseases of The Long Island College Hospital in Brooklyn assembled these manuscripts on "Proteinuria." It is the editor's hope that this volume will convey the excitement and enthusiasm of the authors. It is the wish of all who contributed that the new information developed may benefit the many patients found to have proteinuria. This book is divided to consider first a description of proteinuria and its relationship to glomerular and tubular functions. Subsequently, the clinical consequences and management of proteinuria are reviewed. A unique variety of renal protein loss termed "malignant proteinuria" is described, along with its management by pharmacological functional desctruction of the kidneys, a desperate therapeutic maneuver for desperately ill patients, which is euphemistically called medical nephrectomy. In this tome, representing contributions by brilliant researchers from our prestigious national universities from coast to coast, we take a step in the direction of finding needed answers for the millions of Americans who have proteinuria. Converting tens of years of work by my colleagues and me into a synthesis of the state of the art of proteinuria research has been a fulfilling labor of joy. M. M. Avrarn, M.D.

11 Acknowledgments We wish to acknowledge the support of the National Kidney Foundation of New York, the Avram Center for Kidney Diseases of The Long Island College Hospital, and The Long Island College Hospital. Special thanks to Ms. Phyllis LeBeau for invaluable editorial and technical assistance. xiii

12 Contents Part I. Mechanisms of Proteinuria 1. Glomerular Permselectivity... 3 BARRY M. BRENNER, LANCE AND D. DWORKIN 2. In Vivo Evaluation of Glomerular Permselectivity in Normal and Nephrotic Man BRYAN D. MYERS 3. Tubular Handling of Proteins: Absorption of Albumin by Isolated Perfused Proximal Convoluted Tubules of the Rabbit C. HYUNG PARK, MARIA JOSE F. CAMARGO, AND THOMAS MAACK 4. Tubular Proteinuria: Clinical Implications JOHN F. MAHER 5. Clinical Significance of Isolated Proteinuria ROSCOE R. ROBINSON 67 Part II. Clinical Expressions of Proteinuria 6. Clinical Spectrum of Lipoid Nephrosis JOHN P. HAYSLEIT 7. Reversible Renal Failure in Minimal-Change Nephrotic Syndrome DAVID S. BALDWIN 8. Proteinuria in Diabetic Renal Allograft Recipients JAMES M. LUCIANO, ARAM V. MANOUKIAN, KHALID M. H. BUIT, AND ELI A. FRIEDMAN xv

13 xvi Contents 9. Proteinuria following Renal Transplantation KURT H. STENZEL, JHOONG S. CHEIGH, JANET MOURADIAN, JOHN WANG, AND ILENE MILLER 10. Proteinuria as Seen by the Urologist CiRIL J. GODEC 127 Part III. Pathophysiological Consequences and Management of Proteinuria 11. The Pathophysiological Consequences of Heavy Proteinuria 135 RICHARD J. GLASSOCK 12. Clinical Proteinuria GEORGE E. SCHREINER IV. Expectant or Aggressive Management 13. Water Immersion in Nephrotic Syndrome J. SUTTON, D. E. BROWN, A. J. ADLER, J. E. RUBIN, M. SEIDMAN, E. A. FRIEDMAN, AND G. M. BERLYNE 14. Treatment of Idiopathic Membranous Glomerulopathy 175 JEROME G. PORUSH AND PIERRE F. FAUBERT 15. Malignant Proteinuria: A Newly Described Syndrome and Its Management with Medical Nephrectomy M. M. AVRAM 16. Experience with Medical Nephrectomy JOHN E. KILEY, GAY CASE, AND JOHN D. BOWER 17. Medical Nephrectomy for Proteinuria PAUL D. DOOLAN Epilogue RICHARD J. GLASSOCK 217 Index