Conflict between urine microalbumin and creatinine levels

[Waise]

I am a 52 yrs old man, an engineer from Sudan. I am on Crestor 10mg since 2007 with controlled lipid profile except HDL around 40mg/dl, also on Telmisartan 40mg since 2010 which reduced urine microalbumin from 50 to 26 mcg/l. I am a neither diabetic nor hypertensive.

Recently my PB dropped down to 60/96 and serum creatinine elevated from 1.30 mg/dl to 1.49 mg/dl therefore a local nephrologist advised to stop taking Telmisartan so after few weeks my PB became 80/120 and serum creatinine reduced to 1.3 but urine microalbumin increased to 75.

My question is how to manage both urine microalbumin and creatinine to normal levels?

[userotc]

In our experience with mum, the 2 may need to be managed differently. Her serum creatinine has reduced in recent years (from 131 to 72 umol/L) whilst her urine microalbumin has increased ( from 1.9 to 43.3 ug/ml).

She's followed a natural protocol (diet and wellbeing only, no drugs) which we have now modified to try to reduce her proteinuria although nephrologist unconcerned at her level.

[Waise in reply to userotc]

Thanks for sharing info.What about PB before and after reducing creatinine from 131 to 72

[userotc in reply to Waise]

Her BP has remained stable at around 120/75 since the natural protocol. Before that, she had been on a bisoprol medication for many years but was then able to wean off it. So her steady BP is without medication.

[Waise in reply to userotc]

Yes eliminating PB reducing medication increases urine micro albumin and decreasing serum creatinine this is what I had been told by my doctor as when PB drops the blood stream feeding the kidney will be reduced thus creatinine as well as albumin clearance into urine by kidney filters (nephrons) will mechanically(hydraulically) decrease

[userotc]

Thanks but I find your long sentence confusing - please clarify. Do you mean:

1. Removing the blood pressure medication increases urine microalbumin (Ive read that ACE medication can do this if only by chance)? If so, will it continue to increase & if so, why?

2. Reducing blood pressure in any way decreases serum creatinine? This seems sensible since BP is one of the 2 main causes of CKD.

3. Reducing blood pressure in any way decreases proteinuria? Whilst that appears consistent with 1 in terms of medication reducing BP, my mum's has reduced naturally - but her proteinuria has not decreased.

[Waise in reply to userotc]

I was taking Micardis it is an ARBs type PB reducing medication but my PB reduced to a level slightly below normal for long time resulted in poor blood circulation for kidney and other body organs therefore serum creatinine increased and urine micro albumin decreased.

[userotc]

But mum's experience is the opposite. Her BP has effectively reduced (hence no need for medication) whilst her serum creatinine has DECREASED and proteinuria INCREASED?

[Waise in reply to userotc]

It is not opposite, it is typically same as my case, when I held Micardis(an ARBs BP reducing medication works on reducing urine micro-albumin) my serum creatinine reduced while my urine micro-albumin increased. It is typical case of your MUM.But I think the level of urine micro-albumin is also important therefore it is agreed with my nephrologist to attempt reducing Micardis dose from 40mg OD to 20mg OD then will repeat the kidney test after 3 month during which I will keep monitoring my BP on daily basis to avoid hypotension.

[userotc in reply to Waise]

Did your nephro explain why using an ARB (inhibitor) seemed to INCREASE your proteinuria instead of reducing it as such medication is said to do (although I think the mechanism is unclear)? You also previously indicated that the effect is that "albumin clearance into the urine by kidney filters (nephrons) will mechanically(hydraulically) decrease" which I interpret as proteinuria will DECREASE".

Maybe one of your posts was inaccurate or I misinterpreted?

[Waise in reply to userotc]

Use of ARBs medication decreases the urine micro-albumin but may increase the serum creatinine if it reduced the BP below normal level.The word "held" in my sentence is the past of hold (means stop using)

[Waise in reply to userotc]

Regarding filtration mechanism it works as follows:Consider kidney is membrane between blood & urine, when more pressure applied on blood side more filtrates(albumin and creatinine) will escape from blood to urine side, therefore increasing blood pressure on the short term will reduce serum creatinine and serum albumin hence increase their concentrations in urine. But there is a limit of pressure if exceeded the kidney membrane will damage.

[userotc in reply to Waise]

Yes I fully understand the mechanism and that may explain why reducing BP reduces proteinuria (as with ARBs). But mum's proteinuria has increased - not decreased - so that implies it is NOT the effect of her reduced BP in recent years.

[Waise in reply to userotc]

Why the doctor recommended to hold using bisoprolol?, may be he noticed that BP became very low with using bisoprolol, is it true? how much your MUM BP just before stop using bisiprolol?, Was it more than 120/75?

[userotc in reply to Waise]

Doctor didnt advise, we weaned mum off it gradually when she improved her diet & wellbeing. The difference between BP before & after bisoprolol is minimal or none. Initially it was slightly higher (<10%) at ~135/80 without medication and ~127/77 with. But there has been ~nil significant change for the past 2-3 years or more, within measurement error. It is ~124/78 nowadays.

[userotc]

OK so you mean reduced BP causes lower serum creatinine (which is good) and higher proteinuria (bad). This is what we see for mum whose BP is now consistently normal at ~120/75. As I asked earlier, would the proteinuria continue to increase (and serum creatinine decrease) or is it just transitory?

Note: mum's nephro not concerned and not even requested 24h urine protein check next. He requested urinary protein/creatinine which will likely have increased further even if protein stable (unilkely) as urinary creatinine dropped suddenly recently (which he said is good)

[Waise in reply to userotc]

Your MUM's nephrologist opinion is correct, when it comes to tradeoff between serum creatinine (SC) and urine-microalbumine (UmA) the doctors will little bit sacrifice the later(UmA) focussing on the former(SC), I think because SC is more sensitive to CKD than UmA. Keep monitoring UmA, if you found it is increasing then consult your doctor again as it is also important for maintaining a healthy kidney.

Your MUM case seems typical to mine, I would appreciate if you could advise me what diet your MUM followed to get rid of ACE medication hence improved SC.

[userotc in reply to Waise]

Mum has not had ACE medication, just bisoprol for a few years before weaning off in 2017 after her blood pressure improved. Her diet is almost free of processed food so mainly whole foods with significant veg and fruit and 1-2l water/dy. She also relaxes more.

We do plan to keep monitoring her proteinuria including imminent urine PCR. Nephro should retest 24h protein in ~9mths time otherwise we will arrange privately. I'm not sure he is trading serum v urine but rather he believes the urinary protein levels are not of concern at current levels (and that they never will be!). We are more cautious though so will monitor.

Feel free to keep in touch by private message to compare notes.