here's a case for you...

[marie337]

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First off, let me say that I have scheduled an appointment and am not looking for medical advice.

So, I had some labwork done for a life insurance application and I got denied. I'm almost 29, pretty healthy. Total cholesterol was high, but mostly because HDL was 80. That's the good news. My UA shows microalbumin/creatinine ratio of 2136 mg/g with the normal range being 0-21 mg/g. Total urine albumin was 151 mg/dL. Glucose was 48 mg/dL and average BP 100/60. I had a very small breakfast about 4 hours beforehand and ran about 3 miles one hour before.

So, I'm studying for boards anyways, I might as well try to figure this out. I do have a family hx of diabetes, but my glucose has always been low. I had a UA done in the fall that didn't show anything. Could the exercise have thrown things off this badly? My blood albumin was on the high end of normal. All other blood chemistries were good. Any ideas ?

 

[Gastrapathy]

First off, let me say that I have scheduled an appointment and am not looking for medical advice.

So, I had some labwork done for a life insurance application and I got denied. I'm almost 29, pretty healthy. Total cholesterol was high, but mostly because HDL was 80. That's the good news. My UA shows microalbumin/creatinine ratio of 2136 mg/g with the normal range being 0-21 mg/g. Total urine albumin was 151 mg/dL. Glucose was 48 mg/dL and average BP 100/60. I had a very small breakfast about 4 hours beforehand and ran about 3 miles one hour before.

So, I'm studying for boards anyways, I might as well try to figure this out. I do have a family hx of diabetes, but my glucose has always been low. I had a UA done in the fall that didn't show anything. Could the exercise have thrown things off this badly? My blood albumin was on the high end of normal. All other blood chemistries were good. Any ideas ?

sorry

 

[Sharn Penndroen]

Disclaimer: I don't have any letters at the end of my name like M.D. or D.O. So don't take any of this as medical advice as for all you know I don't know what the crap I'm talking about. I'm only replying because you said you are studying for your boards and so am I. I'm doing this more for presumed educational purposes as you hinted at that being the reason for your post. Please ask this question to a real doctor face to face.

One of the caveats to the albumin/crea ratio in determining microalbuminuria is excercise. I'm not familiar with how much that will throw it off. I believe the usual recommendation is to avoid excercise for 24 hours before doing that test.

Also with respect to your Total Cholesterol being high, your breakfast may or may not have affected it by raising your TG.

 

[marie337]

Thanks for replying Sharn. Yeah, I'm a ***** for exercising before the test. But, they scheduled my exam for noon and I didn't want to skip the workout! I don't remember it being a very strenuous run, though. I'm guessing my doctor will just repeat the UA on monday, or maybe a 24 hour urine. But, now I"ll have to answer yes whenever someone asks if I've ever been denied life insurance. I just thought all of this was interesting since I've been reviewing my renal pathology this week anyhow.

 

[tum]

Don't worry about it. Just have it redone another visit. Exercise can throw everything off. Here's the reference if you're interested (yes, I was pimped on this).

Mogensen CE, Vittinghus E, Solling K. Abnormal albumin excretion after two provocative tests in diabetes: physical exercise and lysine injection. Kidney Int 1979; 16: 385–393.

 

[marie337]

Well, I saw a doctor today and she was a little concerned. She said that it shouldn't be that high unless I was training for a marathon! She thought the lab must have mixed up my urine with someone else's. But, I'm sure it was just a fluke thing. So, I'm doing a 24 hour urine 😱, which ought to be fun. Also, my mom has lupus so we're running labs for that just to be safe. Hopefully it's nothing. I'm too busy to deal with any health problems right now 😡!

 

[carrigallen]

(Disclaimer: this is not medical advice.) I would consider repeating the original labs and then seeing a nephrologist. I would avoid being aggressive with your workup until you see the actual nephrologist.

 

[marie337]

(Disclaimer: this is not medical advice.) I would consider repeating the original labs and then seeing a nephrologist. I would avoid being aggressive with your workup until you see the actual nephrologist.

Thanks, that's pretty much what I'm thinking. Unfortunately with my lovely student insurance everything has to go through my main clinic. But, if the 24hour urine shows anything weird I"m going to ask to see the nephrologist just to get an expert opinion and put it behind me.

 

[Big Ben]

With that degree proteinuria, very unlikely to be 2/2 exercise or orthostatic proteinuria.

You should have a 12 hour split urine sample done though just to exclude this as orthostatic proteinuria is relatively common in your age group.

Your lipids may be real and reflect early nephrotic syndrome.

You need someone to look at your urine, check for dysmorphics, etc. You need a full serologic w/u and unless you truly have orthostatic proteinuria, likely a kidney biopsy.

You may have lucked out and caught this when you can spare your beans by getting on ACEi and making an early diagnosis.

 

[marie337]

For the sake of learning something from all of this, if the liver is responding to loss of albumin via the kidney, wouldn't there be hypoalbuminemia? Could the liver over compensate and crank out too much albumin?

 

[tum]

You need someone to look at your urine, check for dysmorphics, etc. You need a full serologic w/u and unless you truly have orthostatic proteinuria, likely a kidney biopsy.

wow, little quick to the draw.

before the biopsy is even considered, you u/s the kidney. And before you u/s the kidney, you take a 24 hour urine to see what the excretion actually is (ie if its 1.5g or 3.5 g).

and they'd probably want to do some blood tests like an A1c first and urine microalbumin with the family hx. and ANA.

pathology might muddle or confuse the picture far more than some more simple blood tests and possibly a scan, as well as a more clear understanding of the actual amount of protein being lost. to be trite, the invasive answer is not always the best one.

and marie, the short answer to your question is no. the real answer is even if it did, we'd never be able to tell clinically. we send our labs to quest, not the NIH. 🙂

 

[Big Ben]

Sure...you'll get an USN. Without a history of ADPKD, 99% of the time it is going to be normal. You're basically screening for this disease.

Hopefully, you have orthostatic proteinuria or something benign but that's often difficult to prove.

24h urines are reasonable but not really necessary. Repeat a urine protein/creatinine ratio to make sure things are elevated. If you have 4 limbs, aren't pregnant, and don't weight 400 pounds, a urine protein/creatinine ratio is going to give you the same information. It is extremely accurate and reproducible in this setting.

Something real is here...whether it's new neprhitic/nephrotic, it's going to be real. Diabetes as presentation without having declared along the way is nearly unheard of. It takes years to develop this degree of proteinuria from DM. Your A1c will be nl.

When you see a nephrologist, you're likely going to have an SPEP sent (not for myeloma given your age but to eval tubular vs glomerular proteinuria), Complements, serologies for SLE and vasculitis (ANCA), anti-GBM, RPR, HIV testing, hepatitis serologies, etc etc

In the end, if SLE or vasculitis labs come back positive, you'll need a biopsy. If they're negative, you'll need a biopsy. And in a young person, even rare things like lymphoma can present a membranous disease.

Some would argue holding on biopsy until you develop renal insufficiency as long as no active evidence nephritis but at your age, I'd like to know if I have something easily treatable like minimal change disease or smoltering SLE nephritis.

 

[Adcadet]

I was wondering if there could be a UTI causing this. But apparently not:

Does urinary tract infection cause proteinuria or microalbuminuria? A systematic review

Joanne L. Carter1, Charles R. V. Tomson3, Paul E. Stevens2 and Edmund J. Lamb
Nephrol Dial Transplant. 2006 Nov;21(11):3031-7. Epub 2006 Jul 22.
PMID: 16861738

Despite the practice of excluding UTI in patients found to have proteinuria being universally recommended in management guidelines, we have found no evidence of an association between asymptomatic UTI and proteinuria. Further, among patients with diabetes there is evidence, based on sensitive and specific immunoassay technology, that asymptomatic bacteriuria does not cause albuminuria...

Proteinuria is a common observation in symptomatic UTI, although the nature of the proteinuria is poorly defined. Further, we were unable to find evidence of a threshold beyond which proteinuria could be definitively attributed to intrinsic renal disease as distinct from a superimposed UTI. It is a widely held view that positive reagent-strip tests may occur as a consequence of the reaction of the protein test pad with leucocytes and bacterial proteins present in the bladder of individuals harbouring infections, with sloughed bladder cells or as a result of pH changes (alkalinization) in the urine, rather than due to intrinsic renal leakage (glomerular or tubular) of proteins. We were unable to find reports confirming the non-renal nature of the proteins reacting with the test pads. This area warrants further research, in particular using specific immunoassay methods which are not susceptible to the problems of reagent-strip tests. In the interim, it is prudent to treat and eradicate symptomatic UTI prior to investigating protein excretion. Tubular proteinuria is a well-characterized feature of febrile UTI.

 

[marie337]

and marie, the short answer to your question is no. the real answer is even if it did, we'd never be able to tell clinically. we send our labs to quest, not the NIH. 🙂

I was just trying to point out that my blood albumin was 4.9. If we were going to blame the LDL elevation on a secondary liver response, wouldn't the albumin be low? That's all I was wondering. Thanks for helping me think through this though.

 

[ChildNeuro]

I was just trying to point out that my blood albumin was 4.9. If we were going to blame the LDL elevation on a secondary liver response, wouldn't the albumin be low? That's all I was wondering. Thanks for helping me think through this though.

Hi, I hope that they figure out what is wrong and that it is a self-limited process. Nephrotic range proteinuria is greater than 3.5 mg/day (or > 3 mg protein/creatinine). 1000 to 3000 mg protein/day is not nephrotic range yet, so you won't get the hypoalbuminemia or edema, but it is close, so you should definitely get the 24-urine protein collection. Have you had any recent illnesses, i.e. malaise, abdominal pain, fever, ? I doubt that you have diabetic nephropathy as I would expect to have had diabetes for a while before manifesting kidney damage. It is possible that you have a membranous nephropathy, which can be caused by a variety of etiologies, or perhaps even minimal changes disease which can occur in adults (but peak age is around 40 years old). Does anyone else in your family have any kidney problems or hx of SLE or other autoimmune disorders? If the proteinuria persists, and you don't have any identifiable etiology i.e. diabetes, SLE, then you would probably need to get a kidney biopsy, which is done under ultrasound. Do you take any medications on a chronic basis? Are you taking any medications right now? You should be referred to a nephrologist if after extensive physical exam and workup no etiology is found for greater than 2 mg/day. There are better and better treatment options too for various etiologies. Take care!

 

[lfcdoc]

"When you see a nephrologist, you're likely going to have an SPEP sent (not for myeloma given your age but to eval tubular vs glomerular proteinuria)"

How does the SPEP allow you to make this differentiation? Just asking to learn; I haven't heard of this before.

 

[Big Ben]

sorry, should have said UPEP

 

[Pisiform]

bump !!!! So my question was, you cannot get life insurance as a resident if you are obese or have DM? thats ridiculous! Or you could get it but for how much of a higher rate? Any insight?

 

[gutonc]

bump !!!! So my question was, you cannot get life insurance as a resident if you are obese or have DM? thats ridiculous! Or you could get it but for how much of a higher rate? Any insight?

Whatever the underwriter says. You have zero recourse in this. Life insurance isn't a right.

 

[Pisiform]

I am not arguing whether it is a right or not. But what is the criteria of denying life insurance? Half the Americans are obese or have DM

 

[Raryn]

I am not arguing whether it is a right or not. But what is the criteria of denying life insurance? Half the Americans are obese or have DM

You can (almost) always get life insurance.

Now, whether you can get it at a reasonable price... That's another question.

 

[MD Financial Services Scott]

It is rare that someone can not find life insurance but certainly health, occupation, avocations, weight, BMI, tobacco, alcohol, drug use all come into play when considering life expectancy of any one individual. It just makes sense that someone who watches their weight, exercises, eats health, does not smoke, does not drink excessively is going to live longer than someone who is overweight, drinks, smokes, eats fast food to often and the such. At the end of the day a life carrier is saying what is your life expectancy and thus how many years will we receive premiums prior to this person dying or going off of the contract. If we are talking term (which is probably what most people should have) then the question is really "is there a probability this person going to die in the next 10, 20, 30 years, if so then we need to really charge a lot more to cover our risk". Don't forget that this is a major leverage for the consumer, if you bought a $1 million dollar term policy for 10 years at a rate of $10,000 that is still only 1% premium to death benefit ratio per year. Now think that most residents are age 27-33 and at the best rates for them that premium annually is $250+/- per million of coverage or .00025 premium to death benefit ratio. That takes a lot of experience by the carriers to determine probabilities vs. possibilities on death.