Kidney Week

Abstract: TH-PO720

Nephrotic Range Proteinuria with White, Cloudy Urine

Session Information

• Glomerular Diseases: Case Reports
  November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
  Abstract Time: 10:00 AM - 12:00 PM

Category: Glomerular Diseases

• 1402 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

• Saha, Manish K., The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States

Manish K. Saha,

• Asher, Megan, University of Pennsylvania, Philadelphia, Pennsylvania, United States

Megan Asher,

• McInnis, Elizabeth A., The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States

Elizabeth A. McInnis,

• Keefe, Nicole, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States

Nicole Keefe,

• Friedlander, David, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States

David Friedlander,

• Derebail, Vimal K., The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States

Vimal K. Derebail,

Introduction

Nephrotic range proteinuria may be due to a myriad of glomerular pathologies. While rare, non-glomerular etiologies can produce high grade proteinuria in the absence of significant glomerular pathology.

Case Description

A 30-year-old male was evaluated for nephrotic range proteinuria and hypoalbuminemia. Physical examination was unremarkable. Laboratory data showed Creatinine 1.1 mg/dl (eGFR 100 ml/min/1.73m²), urine to protein creatinine (UPCR) ratio of 9 g/g, UACR at 183 ug/mg, serum albumin 2.7 g/dl. The urine was “cloudy,” and sediment analysis demonstrated no acanthocytes or lipid-laden oval fat bodies. Kidney biopsy showed normal glomeruli by light microscopy with unremarkable immunofluorescence staining and no significant glomerular abnormalities by electron microscopy. Additional studies were performed in our research laboratory to determine the cause of urinary turbidity. Upon addition of ether (a fat solvent), clearing of “cloudy” centrifuged urine occurred with layering of fat globules at the bottom. With addition of Sudan III stain, a red-stained fatty layer accumulated upon centrifugation. Urine assessed in a clinical laboratory showed elevated levels of triglyerceride , cholesterol, and chylomicrons . Filariasis serologies were negative.
The patient was diagnosed with chyluria based on the urine TG level and ether test. MR lympangiography showed abnormally dilated lymphatic channels in the left paraspinal region communicating with the left kidney. He underwent lymphangiogram with N-butyl cyanoacrylate glue embolization of the left perinephric lymphatic duct, and within 12 hours, the urine cleared to clear yellow.(Figure 1) Repeat labs 1 month after embolization showed UPCR of 0.07 g/g and serum albumin of 4.2 g/dl.

Discussion

Chyluria is a rare cause of nephrotic range proteinuria. Urine color and turbidity, absence of oval fat bodies, and non-selective proteinuria were early diagnostic clues, with urine TG confirming the diagnosis. Microscopic examination of the urine sediment is essential in evaluating patients with proteinuria.