Proteinuria

Issue critical for Patients with Kidney Complications  

Africa.skinny   rinon.sana.danada

Proteinuria describes the presence of protein in the urine. It is often defined as an amount in excess of 300 mg per day.

Proteinuria is associated with cardiovascular and renal disease and is a predictor of end organ damage in patients with hypertension. Detection of an increase in protein excretion is known to have both diagnostic and prognostic value in the initial detection and confirmation of renal disease.

kidney-PRC

What is Proteinuria? (pro-teen-yur-EE-uh)

Proteinuria is the name used by medical professional’s when a large amount of protein, that should remain circulating in a person’s blood, is “spilled” into their urine and eliminated from the body. Proteins are large molecules that our bodies need to function properly. Another name used to describe a lot of protein in the urine is albuminuria. There are different causes of proteinuria and some are more serious than others.

Microalbuminuria
Microalbuminuria is protein between 30 and 300 mg per 24 hours. This may occur with diabetes and is discussed in its own article. Standard dipsticks will show negative with microalbuminuria.

¿Qué significa la albúmina en la orina?

| National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

¿Qué significa la albúmina en la orina?

Page Content

La albúmina es una proteína que se encuentra en la sangre. Cuando los riñones están sanos, no dejan que la albúmina pase a la orina. Cuando los riñones no funcionan bien, la albúmina pasa a la orina. Cuanto menos albúmina haya en la orina, mejor. Si tiene riesgo de tener la enfermedad de los riñones, su proveedor de atención médica debe hacerle una prueba de orina para ver si hay albúmina, además de medir la prueba de sangre GFR.

Glomeruläre Filtrationsrate (GFR), Proteinurie und Risiko für akutes Nierenversagen, 2011

Akutes Nierenschaden erhöht das Risiko für chronische Niereninsuffienz im Endstadium.  Akute Nierenschäden sind häufig  iatrogen bedingt (z.B. Medikamente, Kontrastmittel). Daher ist es besonders wichtig, Patienten mit Risikofaktoren für akute Nierenschäden bzw.  für akutes Nierenversagen zu eruieren.

Eine aktuelle Studie (1) zeigte, dass Glomeruläre Filtrationsrate (GFR) und Proteinurie unabhängig voneinander mit einem Risiko für akutes Nierenversagen assoziiert sind, und sie könnten somit möglicherweise als Risiko-Indikatoren fungieren.

Clinical Information   Mayo Clinic

Protein in urine normally consists of plasma proteins that have been filtered by glomeruli and not reabsorbed by the proximal tubule, and proteins secreted by renal tubules or other accessory glands. Increased amounts of protein in the urine may be due to:

-Glomerular proteinuria: defects in permselectivity of the glomerular filtration barrier to plasma proteins (eg, glomerulonephritis or nephrotic syndrome)

-Tubular proteinuria: incomplete tubular reabsorption of proteins (eg, interstitial nephritis)

-Overflow proteinuria: increased plasma concentration of proteins that exceeds capacity for proximal tubular reabsorption (eg, multiple myeloma, myoglobinuria)

-Urinary tract inflammation or tumor

-Preeclampsia

-Orthostatic proteinuria

 

In pregnant women, a urinary protein excretion of >300 mg/24 hours is frequently cited as consistent with preeclampsia, and 12-hour total protein excretion highly correlates with 24-hour values in this patient population.(1,2)

 

Orthostatic proteinuria is characterized by increased protein excretion in the upright position, but normal levels when supine. This condition can be detected by comparing urine protein levels in a collection split between day and night (see OPTU / Orthostatic Protein, Timed Collection, Urine). Orthostatic proteinuria is common in childhood and adolescence, but rare after age 30.

Reference Values

<115 mg/12 hours (day or night collection)

Reference values have not been established for patients <18 years of age.

Reference values have not been established for patients >83 years of age.

Interpretation

Total urine protein determined to be >500 mg/24 hours should be evaluated by immunofixation to assess if there is a monoclonal immunoglobulin light chain and, if present, identify it as either kappa or lambda type.

 

Urinary protein levels may rise to 300 mg/24 hours in healthy individuals after vigorous exercise.

 

Low-grade proteinuria may be seen in inflammatory or neoplastic processes involving the urinary tract.

  • BUN (Blood Urea Nitrogen) and Creatinine – blood tests used to evaluate kidney function; urea and creatinine are nitrogen-containing waste products that healthy kidneys move from the blood to the urine. If the kidneys are not functioning properly, urea and creatinine will remain in the blood and the levels will increase. (Note: Although creatinine may be measured in urine samples, a blood sample is also measured to be included as part of the evaluation.)
  • eGFR (estimated Glomerular Filtration Rate) – uses a blood creatinine level along with age and values assigned for sex and race to calculate the estimated rate of urine filtration; the eGFR rate decreases with progressive kidney damage.
  • Creatinine clearance – measures creatinine in a 24-hour urine sample and a blood sample to calculate the amount of creatinine that has been cleared from the blood and passed into the urine; this calculation allows for a general evaluation of kidney function based on the rate of creatinine excretion from the body.
  • Total Protein (TP) – a blood test that measures all of the protein in the serum
  • Albumin – a blood test that measures the concentration of albumin (the most prevalent protein in blood serum)
  • Serum protein electrophoresis – determines the types and relative amounts of protein in blood serum and is compared to the urine electrophoresis pattern to determine if blood is the source of the protein seen in the urine
  • Serum Free Light Chains (SFLC) – a blood test used to help diagnose and monitor conditions associated with an increased production of free light chains such as multiple myeloma

A healthcare practitioner may also order a kidney biopsy. In a kidney biopsy, a small sample of the kidney tissue is examined with a microscope by a pathologist and may be used to look for evidence of kidney disease or damage

Interpretive Handbook Mayo Clinic

 Protein, Total, 12 Hour, Urine

Reference Values

<115 mg/12 hours (day or night collection)

Clinical Information

Protein in urine normally consists of plasma proteins that have been filtered by glomeruli and not reabsorbed by the proximal tubule, and proteins secreted by renal tubules or other accessory glands. Increased amounts of protein in the urine may be due to:

-Glomerular proteinuria: defects in permselectivity of the glomerular filtration barrier to plasma proteins (eg, glomerulonephritis or nephrotic syndrome)

-Tubular proteinuria: incomplete tubular reabsorption of proteins (eg, interstitial nephritis)

-Overflow proteinuria: increased plasma concentration of proteins that exceeds capacity for proximal tubular reabsorption (eg, multiple myeloma, myoglobinuria)

-Urinary tract inflammation or tumor

-Preeclampsia

-Orthostatic proteinuria

 

In pregnant women, a urinary protein excretion of >300 mg/24 hours is frequently cited as consistent with preeclampsia, and 12-hour total protein excretion highly correlates with 24-hour values in this patient population.(1,2)

Orthostatic proteinuria is characterized by increased protein excretion in the upright position, but normal levels when supine. This condition can be detected by comparing urine protein levels in a collection split between day and night (see OPTU / Orthostatic Protein, Timed Collection, Urine). Orthostatic proteinuria is common in childhood and adolescence, but rare after age 30.

Useful For

Evaluation of renal disease

 

Screening for monoclonal gammopathy

 

Screening for postural (orthostatic) proteinuria

 

In select clinical situations, collection of a 12-hour specimen may allow more rapid detection of proteinuria states (eg, screening pregnant patients for preeclampsia)

Interpretation

Total urine protein determined to be >500 mg/24 hours should be evaluated by immunofixation to assess if there is a monoclonal immunoglobulin light chain and, if present, identify it as either kappa or lambda type.

 

Urinary protein levels may rise to 300 mg/24 hours in healthy individuals after vigorous exercise.

 

Low-grade proteinuria may be seen in inflammatory or neoplastic processes involving the urinary tract.

Cautions

False proteinuria may be due to contamination of urine with menstrual blood, prostatic secretions, or semen.

 

Protein electrophoresis and immunofixation may be required to characterize and interpret the proteinuria.

Reference Values

<115 mg/12 hours (day or night collection)

MedScape

Background

Normal urinary protein excretion is <150 mg/24 hour, with majority consisting of secreted proteins such as Tamm-Horsfall protein. Daily albumin excretion in a normal person is <30 mg.

Proteinuria can occur in various forms and at different levels of severity. It can be classified on the basis of the amount of protein (nephrotic or non-nephrotic), the type of protein (albuminuria or low molecular weight proteinuria), or the underlying pathological damage (glomerular vs non-glomerular). Most cases of proteinuria can be classified as tubular, overflow, or glomerular.

Tubular proteinuria

Tubular proteinuria occurs most commonly in disease processes affecting the tubulo-interstitial component of the kidney. It comprises low molecular proteins such as beta-2 microglobulin, which in normal conditions are completely reabsorbed by proximal tubules. The amount of proteinuria is <2 g and dipstick may be negative.

Overflow proteinuria

Overflow proteinuria is most commonly associated with increased production of abnormal low molecular weight proteins (eg, light chains in multiple myeloma, myoglobin in rhabdomyolysis) that exceeds the reabsorption capacity of the tubules, leading to spilling of the protein into the urine. These low molecular proteins can be toxic to the tubules and can cause acute kidney injury.

Glomerular proteinuria

Glomerular proteinuria can be categorized according to whether pathological damage of the glomerulus is present. Types in which the patient has no pathological damage to the glomerulus include transient and orthostatic proteinuria.

Transient proteinuria occurs in patients with normal renal function, bland urine sediment, and normal blood pressure. The quantitative protein excretion is less than 1 g/day. The proteinuria is not indicative of significant underlying renal disease; it may be precipitated by high fever or heavy exercise, and it disappears upon repeat testing.

Orthostatic proteinuria is diagnosed if the patient has no proteinuria in early morning samples but has low-grade proteinuria at the end of the day. It usually occurs in tall, thin adolescents or adults younger than 30 years (and may be associated with severe lordosis). Patients have normal renal function and proteinuria usually is less than 1 g/day with no hematuria.[1]

Glomerular proteinuria associated with pathological damage to the glomerulus is categorized by protein quantity. In non-nephrotic proteinuria, the amount of proteinuria is <3.5 g/24 h and is persistent. These patients require close follow-up and may need a kidney biopsy if they have abnormal urine microscopy results and/or impairment of kidney function.

Nephrotic-range proteinuria is defined as >3.5 g of proteinuria on a spot urine protein–to-creatinine ratio. This finding denotes significant glomerular disease and requires a kidney biopsy for diagnosis and management.

Accompanying findings in patients with glomerular damage may include the following: (see Workup):

  • Active urine sediment – Dysmorphic red blood cells and red cell casts
  • Hypoalbuminemia
  • Lipiduria
  • Hyperlipidemia
  • Edema
  • Abnormal renal function
  • Hypertension

Physiology

Plasma proteins are essential components of any living being. The kidneys play a major role in the retention of plasma proteins, using renal tubules to reabsorb them as the proteins pass through the glomerular filtration barrier. Normal urine protein excretion is up to 150 mg/day. Therefore, the detection of abnormal quantities or types of protein in the urine is considered an early sign of significant renal or systemic disease. (See Pathophysiology and Etiology.)

Microalbuminuria

The detection of various types of proteins excreted in the urine has been extensively used in the assessment of renal diseases. The detection of low levels of albumin excretion (termed microalbuminuria) has been linked to the identification of the early stages of diabetic kidney disease.

Normally, excretion of albumin in the urine is less than 30 mg per day. When expressed as an excretion rate (ie, urine albumin excretion rate [UAER]), this concentration averages 2.6-12.6 µg/min in males and 1.1-21.9 µg/min in females. Microalbuminuria is referred to as the excretion of 30-300 mg of albumin daily or 20-200 µg of albumin per minute. (See Workup, Treatment, and Medication.)

Complications

Complications of proteinuria include the following (see Prognosis):

  • Pulmonary edema due to fluid overload
  • Acute renal failure due to intravascular depletion
  • Increased risk of bacterial infection, including spontaneous bacterial peritonitis
  • Increased risk of arterial and venous thrombosis, including renal vein thrombosis
  • Increased risk of cardiovascular disease

Nota. We will soon publish a suggested Clinical Diet / Nutrition program for patients with kidney problems.

Proximamente publicamos una guia para paciente com nefropatia incipiente.

How does protein stay on the serum side of the glomerulus and not empty into the urine?

The glomerulus, enclosed in a capsule, Bowmans capsule, is the main filter of the nephron. The nephron is the functioning unit of the kidney. A tightly linked mesh of capillaries, make up the glomerulus of the kidney. Protein from the blood comes in contact with this linked mesh of capillaries. Studies show that these tightly l inked mesh of capillaries, making up the glomerulus, is what keeps the proteins albumin and immunoglobulin in the blood, and out of the urine. In addition, both the walls of the capillaries and the proteins that circulate in the blood are both negatively charged; so they naturally repel and this also prevents protein from passing through the glomerulus into the urine. It is this naturally repelling charge that further protects proteins from passing into the urine coupled with a tightly knit mesh of glomeruli capillaries. No one had previously appreciated this charge-and-mesh property.

When we see high protein levels in the urine, why has this typically tight barrier broken down?

Glomeruli have a charge-and-mesh property that is effected by an increase in pressure. Further studies demonstrated that, with proteinuria, the holes in the mesh get bigger and the negative charge disappeared. In the laboratory kidney disease was replicated by removing a kidney. This removes a large number of nephrons, which are made up of the filtering capillaries of the glomerulus and a tubular system essential for maintaining balance. Removing half of the nephrons causes the remaining nephrons to overwork, resulting in a progressively failing kidney. The more nephrons lost, the shorter the life span of the remaining kidney.

How do we slow disease progression?

Dr. Henry Christian, in 1913 prescribed low-protein diets. Lowering dietary protein enabled those with kidney disease to live longer. In the laboratory Dr. Barry Brenner discovered that increasing dietary protein increases glomerular pressure, and the glomerulus works best under a lower pressure. Animal proteins or an excess dietary proteins increases the kidney glomerular pressure. This increase in pressure causes circulating proteins to lose their negative charge and concurrently the linked mesh of capillaries that make up the glomerulus becomes bigger allowing more proteins to pass through to the urine from the circulating blood. Perhaps this can help explain how potassium citrate diminish proteinuria There have been clinical trials with potassium citrate concluding that it lowers pressure. As far back as 1913 we have known that low protein diets enable individuals with kidney disease to live longer, many were unwilling to follow such a diet. Doctors tried lowering glomerular pressure through lowering blood pressure.
Luckily, Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors) had just appeared. Kidney life was prolonged indefinitely by blocking the formation of Angiotensin II. It took 8 years from Dr. Brenners rat experiments to confirm these findings in humans, but today renal patients worldwide are treated with ACE inhibitors. In 1957 the late Dr. Mackenzie Walser took this further. By combining ACE inhibitors, low protein diets (0.3 grams/kilogram of body weight), alkalinity, correcting anemia, supplementing with essential amino acids he has had success in halting end stage renal disease. If individuals only dropped the protein intake and took the essential amino acids [Calwood Amines], 30% of individuals were affected positively. If they took ACE inhibitors 40% of individuals were affected. But with the combination of both this figure jumped to 90% decrease in proteinuria. Dr. Walser discovered that serum albumin can be increased by eliminating dietary proteins and supplementing with essential amino acids, useful for many dialysis patients.
Scientists took urine samples of the entire population of the city of Groningen, Netherlands and found that among 80,000 tested, 3000 people were discovered to have protein in the urine. They identified a renal risk factor and are now working towards prevention. Their research has led to 39 papers published in 5 years on the impact of microscopic amounts of protein in the urine. Dialysis and transplantation in the United States this year alone will cost $25 billion. Governments in 80% of the world cannot afford dialysis or transplantation at all; for them kidney failure is fatal for most of their citizens.
Dr. Lin in China has a huge clinical trial from 17 centers testing ACE blood pressure medications or ARB (ACE receptor site blockers) along with low protein no animal protein diets. Preliminary results are very good.

Diet PKD Diet

What is the PKD Diet?

The Polycystic Kidney Diet is simply a plant based diet with very limited animal proteins. Enjoy things that grow from the earth; discard the rest. PKD Diet is a neutral protein alkaline plant based diet. It is low in salt, neutral in protein, and allows for sufficient water to shut down vasopressin diminishing kidney cyst formation. It keeps a cystic body well hydrated important for decreasing symptoms and minimizing further cyst growth.

Plant Based Alkaline PKD‐PLD Diet

Enjoy eating foods from plants like fresh ripe fruits, green, yellow, orange, purple, brown or white vegetables, nuts, berries and grains. This whole foods plant based vegan alkaline diet is geared toward PKD kidney health and PLD liver health. Preparing all food yourself from locally grown in season produce goes a long way toward maintaining the health of cystic organs.

Should any find it difficult to eat only plant based foods, try limiting animal products to occasional broths, lamb, flat white fish, soft white cheese, cottage cheese, egg yolk, while keeping quantities to less than 3 ounces per day and no more frequently than twice a week. There are inspired alternatives to animal proteins taking into account the methodology involved in marketing meat vs. vegetables. Some have looked at the carbon footprint differences of foods enabling a choice for their foods. A free living diet study exams some differences and some outcomes between diets.

Alkalinity is key to health. Enjoy these. One can be enjoy these items freely. Through maintaining alkalinity the integrity of ones own personal DNA is increased, (the replication of genes is kept intact), thus squelching the second hit mechanism that causes an increase in cyst numbers, symptoms and size. We have gathered this alkaline dietary information from amongst our mutual experiences enhancing the health of cystic kidneys, cystic liver, and cystic organs. Some have measured their girth eliminating a food for a week, then re-eating that same food again while making note of any symptoms, increase in girth, or pain that may occur. Girth is measured at the same spot, at the same time each day. These changes are then incorporated into a PKD Diet as a dietary information database. This is gleaned from each one of us, from our collective researchers, and from our own doctors as this information becomes available to us.

Lemons

Lemons are very good for creating alkalinity, helping PKD, helping with weight loss, reducing headaches, reducing pain, squelching a cough, and lowering blood pressure. Try the juice from one lemon diluted with enough water to make a half a cup of liquid. Drink this first thing in the morning before anything else. Try waiting 20 minutes before eating anything else. Citrus fruits are filled with naringenin said to be helpful to diminish cyst growth. Throughout the day it is possible to use as many as 6-7 lemons in one day. Try fresh lemon juice in water following a meal.

Neutral Protein 0.6 grams/kilogram

Neutral Protein in is equal to protein out. Calculate your daily protein. 3 ounces of fish is about the size of a deck of cards. 1 ounce of cheese is equal to one dice. Protein is set individually to maintain a neutral protein balance between 0.6 grams—0.8 grams per kilogram of body weight. Protein quantities from certain foods has been compiled into a chart by a fellow PKD’r. Some protein foods from a plant based diet are: spelt [the highest amount of protein among grains], cabbage juice, carrot juice, corn, chia seed, and of course nuts, beans, legumes, grains, and seeds. Soak nuts, seeds, beans, legumes, and grains prior to cooking to diminish their phytic acid content. By preparing food in this fashion, foods become alkaline and more digestible.

1200 mg Sodium

Sodium or salt intake is limited to 1/8 teaspoon per day or a 1200 mg sodium diet. Many have tried Himalayan pink crystal salt and have experienced no rise in their blood pressure when using small quantities (1200 mg) of this salt.

Recently there has been some conflicting information about Himalayan salt; our experience is that it is beneficial. If you have had a transplant, these individuals must restrict all salt or they swell.

Support for Less Salt, More Potassium is contained in this article. The idea that reducing salt intake — and increasing potassium intake — can lower blood pressure and improve disease PKD outcome has received additional support from several review articles .

4 Liters water or twice your daily output

Drinking enough water, to raise serum osmolality just above that of urine shuts down vasopressin, similar to the still-in-clinical-trials experimental drug, tolvaptan. Tolvaptan Slows Kidney Disease Progress.org
glomer.kidney.png

Low Fat

Limit oil or fat to one ounce per day. Vegetable oils that are beneficial are olive, almond, avocado, and coconut. Try to avoid animal fats such as butter and cheese. According to a study by Dr. Greg Germino, a low fat diet in the PKD animal model makes a difference in the expansion of cysts, kidney cysts. In other words in the animal PKD model, a low fat keeps cystic kidney size smaller.

In conclusion, we have shown a significant sexual difference in PKD progression in this mouse model, identified altered lipid metabolism as a possible underlying cause and confirmed that PKD has an intrinsic dysfunction in fatty acid oxidation. — from the Low Fat ↓ Cyst Growth article.

Fats contribute to the obesity epidemic.

When kidney functioning diminishes.

Dr. Mackenzie Walser’s book Coping with Kidney Disease outlines a plan to try with your nephrologist:

 

  • Eliminate all animal protein
  • Reduce dietary protein 0.3 grams/KG when ESRD
  • Supplement with essential amino acids from Calwood
  • Lower blood pressure 110/70 – 120/80
  • Maintain alkalinity with diet or alkalizer
  • Correct anemia

 

The kidneys’ function are to filter the blood. All the blood in our bodies passes through the kidneys several times a day. The kidneys remove wastes, control the body’s fluid balance, and regulate the balance of electrolytes. As the kidneys filter blood, they create urine, which collects in the kidneys’ pelvis — funnel-shaped structures that drain down tubes called ureters to the bladder.

rins

Each kidney contains around a million units called nephrons, each of which is a microscopic filter for blood. It’s possible to lose as much as 90% of kidney function without experiencing any symptoms or problems.

Causes of Proteinuriacouveflorframboesa
Transient proteinuria
  • Emotional stress.
  • Exercise.
  • Fever.
  • Urinary tract infection.
  • Orthostatic (postural) proteinuria.
  • Seizures.
  • Persistent prInitial investigations should then include the following:
    • Assess the history with special reference to drug history, family history, past medical history and occupational history.
    • Blood pressure must be recorded. Several readings over time may give a more accurate picture.
    • Blood tests for renal function include U&E and creatinine.
    • Check for diabetes mellitus with fasting blood glucose.
    • Check fasting cholesterol, as this is also elevated in nephrotic syndrome.
    • Check MSU for culture and microscopy. The latter is for casts and microscopic haematuria. Urinary dipstick testing can be suggestive of a urinary tract infection, but should not be regarded as diagnostic.[7]

    Proteinuria in excess of 3.5 g per day is likely to lead to a nephrotic syndrome. This usually indicates glomerular disease.[4]

    oteinuria.

  • Problemas renais

    Pesquisas apontam que cerca de 600 milhões de pessoas em todo o mundo têm alguma forma de lesão renal. De uma em cada 10 pessoas têm algum grau de Doença Renal Crônica (DRC), e para a próxima década está previsto um aumento de 17% dos casos.

    Praticar atividades físicas também melhora o funcionamento dos rins / Crédito: ThinkstockPraticar atividades físicas também melhora o funcionamento dos rins / Crédito: Thinkstock

    Como evitar

    Práticas simples podem ajudar a evitar doenças renais:

    • Beba água. Hidratar o corpo é essencial para o bom funcionamento dos rins e para evitar evita a formação de pedras
    • Mantenha uma dieta equilibrada e evite excessos de sal, gorduras, carnes vermelhas e doces
    • Fique sempre de olho na pressão arterial e no nível de açúcar no sangue
    • Pratique exercícios físicos regularmente, seja uma caminhada ou aulas de ginástica e natação sempre na companhia de uma garrafinha de água
    • Não use medicamentos sem orientação médica. Alguns medicamentos pode sobrecarregar os rins
    • Não fume e evite o consumo excessivo de bebidas alcoólicas
    • Faça periodicamente exames de urina e sangue que checam o funcionamento renal
  • Nutcracker syndrome associated with severe anemia and mild proteinuria.

    Abstract

    A 70-year-old man was referred to our hospital with the chief complaint of gross hematuria. Urinalysis revealed gross hematuria (3+, RBC 100/HPF or more) and mild proteinuria (3+, 1.8 g/day) with no urinary casts. Computed tomography of the abdomen showed compression of the left renal vein between the superior mesenteric artery and the aorta. Ultrasonography showed an increased flow velocity at the stenotic portion of the left renal vein. An aortography and selective left renal arteriography showed that there was no evidence of tumor vessels or arterial abnormalities in the arterial phase. However, the venous phase revealed a stenosis of the left renal vein just lateral to the aorta as well as a reflux of contrast material toward the left gonadal vein which was dilated. In addition, cystoscopy revealed left ureteral bleeding. Based on these findings, we made the diagnosis of gross hematuria caused by nutcracker syndrome (NCS). We concluded that the main cause of the anemia and proteinuria in our patient was leakage of blood and this is confirmed by the relationship of red blood cells to protein in the urine because we proved whole blood and plasma protein loss in the urine by calculation. Fourteen months after discharge, both the gross hematuria and proteinuria spontaneously disappeared. This case strongly suggested that the first therapy for hematuria and proteinuria with NCS should be observation.

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antioxidante GI … Dr. X. NIKO MS

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