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  Sunday, 14 June 2020
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I am concerned for my brother who is only 24 years old and is experiencing several symptoms that may suggest he has Kidney Disease or something of a similar nature. Even after several visits to the doctor, he remains undiagnosed.

Around 6 months ago, he experienced extreme pain in his ankle joint which lasted for about a week. His ankle was red, swollen, and warm. He had had high blood pressure for months but did not act to reduce it. His blood tests indicated that he had high uric acid levels (9.5), high creatinine levels (1.52), and high protein in urine levels. Accordingly, the lab estimated a GFR of 54.

Upon seeing his results, the first nephrologist he visited suggested that he cut all meat from his diet and drink up to 3L of water per day. About a week later, his creatinine, protein in urine, and uric acid levels decreased. His blood pressure was still relatively high, so his doctor prescribed Telmisartan 80. The doctor decreased the dose to 40 after two weeks.

After going on the diet for 3 months and with regulated blood pressure, his GFR went up to 89 and his creatinine as well protein levels were within the normal range.

Last month, his uric acid went up to 9.5 again, so his doctor started him on Goutex 100. He had been sneaking chicken and the occasional red meat into his diet. He had gone back to his poor eating habits which involved smoking tobacco and eating lots of junk food. He had drunk significantly less water, especially during Ramadan (where he fasted for 30 days). When he did his blood tests three days ago, he found that his creatinine level (1.49) and his protein in urine level (41.4 mg/dL) were high again. He also had WBC in his urine. Accordingly, the lab estimated a GFR of 59.

Upon seeing the most recent results, the doctor told him that he is severely dehydrated and must drink water again.

At this point, I am extremely uncertain and confused by the fluctuations. We have no idea how to move forward. I told him to go on a diet again, but that is the extent of my knowledge regarding what could help him.

Please advise. My worries are great. I don't want him to be going through renal failure or something serious like that.

Thank you for your time.

It is unlikely that uric acid elevation alone is causing kidney disease. In fact, it's more likely that reduced eGFR causes uric acid to accumulate and might lead to gout. I don't have enough information to comment on the nature of your brother's kidney disease but it is unusual that eGFR is fluctuating so widely (89 to 59). Was the drop from 89 to 59 coincidental with starting Telmisartan? Based on the limited information I have about his urine, he does have significant but not high grade proteinuria, which again does go along with a primary kidney disease. It would be important for your brother to have additional serologic tests in the blood to look for clues of the underlying cause for his kidney disease, an abdominal ultrasound and urine microscopic exam. With that information, we could comment further.

Dr. Jordan Weinstein
4 years ago
Thank you for your prompt reply, Dr. Weinstein.

To answer your question, yes - the drop in GFR was coincidental with starting Telmisartan. His blood pressure was high five months prior to the gout attack/drop in GFR.

His abdominal ultrasound indicated that his left kidney was slightly enlarged, but nothing else.

His most recent urine test is attached below.
Regarding the ultrasound, hopefully enlarged does not mean obstructed - where they might use a term like "hydronephrosis". If it does, that has to be addressed.

The urine the attached above suggests a modest but significant amount of proteinuria. An albumin to creatinine ratio would be more accurate but likely won't reveal much else.

The telmisartan might have contributed to a loss of eGFR but normally that will plateau and that drug class does have long-term benefits despite short term changes in GFR. This should be confirmed by watching the eGFR trend.

My original comments hold that there is likely primary cause of kidney disease (for example a type of glomerulonephritis). This can only be confirmed by a renal biopsy which is something that can be discussed with his nephrologist. I do not agree withe the statement that these findings are explained by "dehydration" as this should not cause an elevation in urinary protein unless the urine was simply extremely concentrated at the time. This can be assessed further with a urinary albumin to creatinine ratio which can accounts for the issue of urinary concentration.
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