Hello,

Ideally you should have a urine albumin to creatine ratio and blood creatinine level to answer your question more accurately. Also:

• Do you have any other health conditions?
  
• Do you take medication including supplements?
  
• What is your blood pressure?
  
• What is your ethnic background?
  
• Do you have family history of kidney disease?
  

Dr. Jordan Weinstein

The presence of foam in urine can be caused by several factors, some of which may be harmless while others may indicate an underlying medical condition. Here are some possible causes of foamy urine:

1. Normal variation: Foamy urine can sometimes occur due to normal factors, such as the force or speed of urination. If the foam quickly dissipates and is not consistently present, it is generally not a cause for concern.

2. Dehydration: Concentrated urine resulting from dehydration can create more bubbles and foam. Ensuring adequate hydration by drinking enough fluids throughout the day may help reduce foamy urine in such cases.

3. Proteinuria: One of the most common causes of persistent foamy urine is proteinuria, which is the presence of excess protein in the urine. This can be a sign of kidney damage or disease. Conditions like chronic kidney disease, glomerulonephritis, or diabetes can lead to proteinuria. If you consistently notice foamy urine, especially if accompanied by other symptoms like swelling, fatigue, or changes in urinary habits, it is advisable to consult a healthcare professional for further evaluation.

4. Urinary tract infection (UTI): In some cases, a urinary tract infection can cause foamy urine along with symptoms like frequent urination, pain or burning during urination, and cloudy urine. UTIs are typically caused by bacteria and can be treated with antibiotics. Consulting a healthcare professional for diagnosis and appropriate treatment is recommended.

5. Kidney stones: The presence of kidney stones can sometimes lead to foamy urine. Kidney stones are formed when certain substances in the urine crystallize and clump together. Additional symptoms of kidney stones may include severe pain in the back or side, blood in the urine, and frequent urination. If you suspect kidney stones, medical evaluation is necessary for proper diagnosis and management.

These are just a few possible causes of foamy urine. If you have concerns about foamy urine, it is important to consult a healthcare professional who can evaluate your symptoms, perform appropriate tests if necessary, and provide an accurate diagnosis and treatment plan.

Hello,

It is possible you did have some element of reduced kidney function during your episode in the hospital that is continuing to improve with blood work done outside the hospital. I don't know what your baseline level of GFR was, say one year ago, to compare this to what it is now. In general, when trying to make sense of kidney function tests that are close to the normal range, I would eliminate all supplements such as creatine and protein supplements from your diet. They have questionable benefit and can muddy the water when trying to interpret creatinine-based kidney function tests. I would also ensure that your urinary protein levels are normal and you could consider undergoing a kidney ultrasound to ensure your kidney morphology is normal as well.

Unfortunately I am operating very little information in your question but in general that would be some nonspecific advice I might give him his case.

Dr. Jordan Weinstein

Hello,

There is no absolute right answer here. However if we are to follow how clinical trials were designed in the chronic kidney disease space, I think it would make the most sense to start an ACEi or ARB first, followed by an SGLT2 inhibitor or a mineralocorticoid receptor antagonist. In the pivotal trials with SGLT2i, over 90% of patients were on an ACEi or ARB (RASi) prior to randomization. I don't believe it is an absolute however; In other words, I don't believe that the benefit of an SGLT2 inhibitor depends on the use of RASi.

Another unresolved issue is what to do in CKD patients already taking RASi and an SGLT2i in whom you contemplate starting an MRA. We don't really have trials to answer this question and in the pivotal studies with MRAs like Finerenone, a very small percentage of patients were taking SGLT2i at the time of enrolment. Once again, I don't believe there is a mechanistic reason to doubt the efficacy of an MRA in the context of SGLT2i. In terms of using MRAs for CKD, I generally reserve use of these drugs for diabetics where the data is most plentiful. In this population, I prefer finerenone over spironolactone. Spironolactone might be a good option in the same patients if blood pressure is a priority since finerenone has no real impact on blood pressure, however we do not have any significant CKD outcome data using spironolactone.

In general, I think all therapies will probably perform better in patients with significant albuminuria (at least microalbuminuria) in the sense that those patients have a higher event than those without albuminuria and therefore the impact of an intervention is likely greater over a shorter period of time. I do use SGLT2 inhibitors in patients without albuminuria but generally reserve doing so in younger patients with CKD who have a longer life expectancy and the same goes for MRA in my opinion. I don't prioritize the use of RASi in patients without proteinuria unless they have another indication such as hypertension, heart failure or previous MI. The evidence for SGLT2 inhibitor is more plentiful in this population but still not as robust as in those patients with significant proteinuria.

Regarding the issue of low blood pressure, I would be cautious using an RASi in such patients with CKD. I would be more eager to start this therapy in patients with significant proteinuria and in those individuals I might remove any other agents that do not have specific renal or cardiac benefits that may be lowering the blood pressure as well (such as calcium channel blockers or diuretics) - in this way we "make room" RASi.

Bottom line:

1. In CKD patients who have at least microalbuminuria I prioritize use of RASi. If blood pressure is low i these individuals, I add RASi cautiously and reduce or remove other drugs that do not have renal/vardiac protection but which do lower blood pressure (diuretics, CCBs)
   
2. In CKD patients without at least microalbuminuria, I do not prioritize the use of RASi unless they have another indication such as hypertension, heart failure or previous MI
   
3. In all patients with CKD especially those with at least microalbuminuria, I strongly consider using SGLT2i
   
4. In CKD patients without at least microalbuminuria, I reserve use of SGLT2i for younger patients with chronic kidney disease (<80 years old)
   
5. I generally add finerenone (or spironolactone) last in patients with diabetic chronic kidney disease (after SGLT2 and RASi). I reserve use of MRAs for those patients with a GFR of at least 25 cc/min and I have at least microalbuminuria.
   

Hello,

It depends how high is the level of albumin in your urine. Very high levels would likely not respond substantially to sugar control alone and might require the addition of an angiotensin receptor blocker or ACE inhibitor, SGLT2 or mineralocorticoid receptor antagonist. I am afraid I do not have sufficient information in your question to answer it more fully than this.

Dr. Jordan Weinstein

Simple cyst generally speaking do not need to be followed as they do not have significant malignant potential. Out of an abundance of caution, it would be optional if you wish to have monitoring done but guidelines would not suggest it was mandatory.

Estimated GFR above 60 ml/min is consistent with normal kidney function. If it is not declining, and if you do not have any significant proteinuria or suspicion of a systemic disease then this would a fairly benign finding.

Dr. Jordan Weinstein

Hello,

Renal cysts are very often harmless. However it depends very importantly on the description of the cyst itself and whether there is any complexity etc. I would need to see the report of the ultrasound itself to comment any further.

Thanks very much,

Dr. Jordan Weinstein

Quoted from Guest on Friday, 14 April 2023

Thanks so much for your response. I do not have polycystic kidney disease. Actually, I had exactly the same result last July as the 1st writer on this blog. I'm with the understanding that
eGFR can decline with age. As mentioned my eGFR score on Wed. was 82, and the creatinine was 64 which was well within the range. I haven't heard back from my Dr., so I'm assuming
everything is ok. I looked back into some of my blood work papers & over 2yrs ago, I had an eGFR score of 81, but last year the score was over 90 again.
I'm mildly concerned, but not worried. Yes, there is absence of evidence of kidney disease which likely diminishes the concern of the eGFR score.
Any comment to this? Thanks in advance!!!

From the information provided, these are normal results.

Dr. Jordan Weinstein