Very Confusing Urine Test Results

[RickHow]

I thought I had a reasonable understanding of proteinuria, CKD, etc. But my latest test results (which I view online, will not see kidney doctor for another week) have confused the heck out of me. Stats:69 year old white male, only one kidney (other removed in July of 2017), blood pressure under control. So my confusion? My Urine protein was reported as negative in the urine test. My microalbumin was report as .5. This lab says anything below 3.0 is normal. So to me this indicates no type of protein outside the normal range was found. Good news, right? BUT, my Albumin/Creatinine Ratio (which is considered a most important test) was 31.1. This lab says the less than 30 is normal. 31.1 is above normal! Worse, is this measurement is getting progressively worse for me. In January 2018 it was 8.7. In July of 2018 it had climbed to 22.7. Now 6 months later it has climbed again to 31.1 (above normal). YET my protein and albumin measurements are excellent!!

[Jonquiljo]

My first question is microalbumin at .5 - what? Mine was reported in mg/L and anything less than 5 mg/L is undetectable (which is what my value was - undetectable).

But microalbumin has to be reported in some for like "mg/L" or "mg/dL" etc. All labs are different. Either way your one kidney is not leaking protein!

When it comes to ALC - you may fall on a different scale. You have one kidney for all of you. That means this kidney will work harder, filter more, etc. All of "RickHow's" creatinine must pass through one kidney. I am sure that different metabolites (creatinine, urea, everything!) pass through your kidney at different rates.

The scale they give you is a "normal average" scale - not a "RickHow" scale. Your numbers will likely be different. For people with two kidneys - normal is less than 30. If ALC is 30-300 (big range!) - it indicated microalbuminaria. Over 300 is macroalbuminaria. You aren't even close here.

What was the absolute urine creatinine concentration during each of these tests? if your creatinine was different, it will make ALC different. Even at 31.1 - you are essentially "normal". When you were around 8 - it wasn't much different than 31. if you go to 158 - then that is a big jump. But without the creatinine values, it's hard to figure out what is going on here.

[RickHow in reply to Jonquiljo]

Hi. Thanks for posting on my concern. Your opinion and knowledge is one I always look for on every post. I admire it. It was stupid of me not to post the measurements with more detail. Here are what was on my tests.

--Microalbumin .5mg/dl Reference range <= 3.0mg/dl

--Alb/Creatinine Ratio <31.1 mcg/mg Normal <30 mcg/mg

They do not show the actual measurement of Creatinine in the urine. I have tests ordered by different doctors, at different labs, occasionally. None of them report the actual creatinine in urine measurement.

You think these numbers do NOT indicate protein leakage? My concern in addition to the number itself for the ratio is how it has grown in the past 18 months from 8.7, to 22.7, now to 31.1.

Let me know your thoughts. Thanks.

[Jonquiljo in reply to RickHow]

Hi. Sorry I'm so late to get back to you. I've been out all day - west coast time!

Boy, are these labs lame! They obviously measured your albumin, but they can't print it out? Well, we'll just have to go with ACR.

Basically (for ACR) you are 31.1 when "normal" is 30. First off, any reference range for "normal" is a statistical average of what "normal people" have when ACR is determined. I've read in the literature that the limit of 30 for "normal" is another simplification. We both know what happens when people oversimplify things. Given the next "range is 30-300 --- that's a whole LOT of a wide range of values. 30-300 (microalbuminaria) is one big guess - and even then it is associated with "mild" CKD. Only when you get over 300 is it considered moderate CKD and you have a long way from 31.1 to over 300!

Even the degree of accuracy of the test can be enough to put you solidly in "normal". If you gave two samples on two days - you could end up as 25 on one day and 31.1 on the second day. The test is not that accurate - and you can expect a lot of variation.

Most importantly, the ACR test, like all kidney tests, does not account for the fact that you have one kidney. So you're leaking a tiny little bit of protein - but not enough to even be statistically significant. And this protein is leaking from a single kidney which has to do the work of two. You are not normal, and they don't give ranges for people with one kidney. It's like running a marathon with one leg - of course you are not going to finish in the top group of people! But that is far from saying you are abnormal.

Why the ratio has grown in the past few months is beyond me - but I wouldn't worry about it. Without the creatinine numbers, you really can't tell. If I were to take a guess - given that your second kidney was removed 1 1/2 years ago, your kidney may be slowly adjusting to doing twice the work. That's also why I said creatinine was important. Your creatinine clearance may be changing. You don't really know if all substances are passed through the kidney at the same rate. In fact, if I were to guess, I would expect that different substances pass through the kidney at different rates. It is, after all, a very complex filtration system.

But given that this is all a simplification - I would say that being at "close to normal" is pretty damn good. If you were 120 in another 6 months, you may need to talk to your nephrologist. I personally doubt you are going to get there.

If you want to test your blood earlier than what your Dr's want to do, Quest Diagnostics has a "self-pay" method. You can get a metabolic panel, CBC w/differential, or urinalysis done for less than $35-$50 each. I can give you the link if you'd like. I'm personally about to use this service because all my Dr.'s want to test me for blood counts because of my leukemia. They get cheap and don't throw in a metabolic panel or urinalysis. So a few $$ and voila! It's processed the same if you had used Quest as an insured patient. In fact they do a lot of other tests - no Dr. required.

The bottom line is that you are so close to normal, you are normal. And I bet your Dr. will agree. Good luck.

[RickHow in reply to Jonquiljo]

Thank you so much for the detailed response. As I said, the slow increase has been confusing to me also. Then I got looking more closely. I have no idea if this could be a reason or not. But I will share it. When I was measured initially last year and ACR was 8.7 I was taking 20mg of lisinopril daily, and while drinking water, certainly not large amounts. Then because my blood pressure was dropping, my doctors lowered me to 10mg of lisinopril and I started drinking 60 to 70 ounces of water daily. At that next test my ACR went to 22.7. The kidney doctor told me to be sure to drink water, even more than 70 ounces if I could. I continued on 10mg lisinopril and went up to 100 ounces per day of water. Then the ACR test went to 31.1. I have no clue, but I am wondering if the reduction in lisinopril in addition to increase of water, has anything to do with the ACR increase. I will ask kidney doctor Friday. More importantly I see my gp mid February (blood tests prior) (who I have more faith in than the kidney doctor) and see what he thinks. He is one who likes to try different approaches and see if it helps or hurts. So I am thinking he would be interested in trying going back to the 20mg of lisinopril and after a month or so see if ACR improves. I also want to speak to him about my Lipitor. So many on here, and a few articles on the internet have indicated that 80mg daily has negative effects on the kidney. But slightly lower doses do not have these bad effects.

[Jonquiljo in reply to RickHow]

Well, what I do know is that ACE inhibitors (and ARB's) will lower your GFR a bit (sometimes not, but commonly a few points). It's not considered bad unless it raises your creatinine 20-30% (which it will do in some, but not many patients). ACE inhibitors (Lisinopril) and (ARB's - I'm on Olmesartan), are considered good BP medications and kidney protective.

That will make your serum creatinine a bit high (not much) and I would suspect a small bit for urine creatinine. I don't know how that would affect an ACR test. Drinking more water seems strange to me. I think 80 Oz would be fine. Going to 100 might increase filtration, but all these things are dependent on another so I couldn't guess. I've gone up to as much as 100oz at times. If you exercise a lot, it probably helps. Sounds like your Dr. thinks about you - which is a good thing. Either way, it matters more about whether your BP is controlled. It's probably more complicated with one kidney too.

80 mg of Lipitor seem excessive to me. I am on 20, and have VERY low Cholesterol now. But, though it is controversial, it is thought that statins like Lipitor will not affect protein leakage. I am just a "use as much as needed" kind of guy. So it's personal preference. As long as your nephrologist agrees. If you get muscle aches (other than the typical ones), you are taking too much - and need to talk to your Dr about it ASAP.

Sorry I can't be of more help with this. Either way, your ACR is fine. The changes every 6 months are probably negligible. With one kidney, you can't use the lab reference ranges, so you are dependent on a physician to tell you if something is OK or not. Good luck.

[WYOAnne]

My nephrologist would probably be repeating these labs since they don't make a lot of sense. He would tell me it could be lab error. Over the years this has happened to me more than once. See what he says at your appt in a week. Ask about error in the results.

[citronc3]

I do know that kidney tests can fluctuate on the day and I presume it is down to your diet and how it's absorbed within a time frame up to the test....you shouldn't worry too much about this as long as the average number of tests return to what is usual for you...best wishes

[RickHow in reply to citronc3]

Hi. Well I had my appointment with doctor. The parts that made no sense to me, she advised to not worry about one bit. That a person with one kidney can NOT expect to have each category fall into the "normal" range. Also that I have to realize that I am asking one kidney to do the work of two, at age 69. That even if I had both kidney's, at this stage of life, the kidney function starts to lessen at least 1% per year, and greater each year as we age. She was quite pleased with my result. She said for my condition (solitary kidney, age, etc., etc.) the key factors to watch are Microalbumin in urine (mine was .5 which is within normal), creatinine in blood (for one kidney the "normal" us generally around 1.7 or 1.8, with some fluctuation as you mentioned. My test revealed this time a drop to 1.5 which she attributed to consume excess water, not actual improvement in the kidney), BUN (which is about 30 for a solitary kidney), and general levels of potassium, etc. I asked about albumin in urine specifically, as we all read and hear about protein in urine. She said it will definitely happen eventually, but this too is not alarming. Especially for one kidney. That you could check urine of any elderly person 75 or older and find at least traces of protein. So in general she was pleased with my results, that I was unnecessarily worried about.