1.Sauce-colored, proteinuria Main symptoms of IgA nephropathy
(1) What are the symptoms that may indicate IgA nephropathy?
Dr. Mei Changlin: I think IgA nephropathy mainly has the following symptoms.
a. The color of urine becomes darker, soy sauce color or like meat wash. We call it hematuria. Some patients with IgA nephropathy have a day or two after a cold, and the urine they solve is soy sauce color or meat wash color. If you encounter such a situation, you should go to the hospital for examination. Because this is likely to suggest IgA nephropathy or other nephritis.
b. Foamy urine. Everyone has foam when relieving urine. However, the foam caused by proteinuria in nephropathy tends to last longer, and the bubbles are larger and higher level. Just like when pouring beer, maybe only half a glass of wine is poured, but the foam can overflow to the top of the glass.
c. Edema. However, relatively speaking, edema caused by IgA nephropathy tends to appear in the later stages of the disease and occurs at a lower rate.
(2) Will the change of urine color or foamy urine appear in the early stage of IgA nephropathy?
Dr. Mei Changlin: Some of the patients will show up in the early stage. Most of the IgA hematuria is microscopic hematuria, but a few of them are visual hematuria.
In addition, hematuria is often seen after a day or two of cold or tonsillitis, and hematuria is seen when urine is relieved. If you take cold medicine for a day or two, the hematuria will disappear slowly.
3.Check urine routine once a year
(1) How to detect IgA nephropathy as early as possible?
Dr. Mei Changlin: The best and easiest way is to have a physical examination and regular urine test. In recent years, we found kidney disease in the clinic, mostly microscopic hematuria found by physical examination, or with proteinuria. However, the patients themselves do not feel the symptoms.
(2) What is the frequency of urine test on physical examination?
Dr. Mei Changlin: Generally, if you have not suffered from kidney disease, a physical examination once a year is enough. If the original Mr. had kidney disease, and later cured, you need to test the urine once every 6 months.
4.Diagnosis four steps: urine routine, kidney function, ultrasound, kidney biopsy
(1) What tests will be done to diagnose IgA nephropathy clinically?
Dr. Mei Changlin: If a patient has symptoms such as reddened urine and increased urine foam, and IgA nephropathy is suspected, the first thing to do is routine urine, the second thing to do is blood tests to check the relevant indicators of kidney function, and the third thing is to do ultrasound of the kidney.
If the results of these three tests cannot exclude IgA nephropathy, or to make a final diagnosis, the patient needs to do a fourth test, namely a kidney biopsy. It should be said that the final diagnosis of IgA nephropathy must be confirmed by kidney biopsy. Only when granular IgA deposits are seen in the glomerular tract can IgA nephropathy be said to be present.
(2) How long does it take to confirm the diagnosis of IgA nephropathy?
Dr. Mei Changlin: About a week.
5.The learning of urine test
(1) Is there any error in urine test?
Dr. Mei Changlin: Yes. Sometimes there are false positives in urine routine, whether it is microscopic hematuria or proteinuria, there may be deviations.
For example, proteinuria is physiological, transient and pathological. Most of the transient proteinuria is also in the physiological category. And like in women, microscopic pseudohematuria often occurs.
To avoid errors, we ask patients to have at least three routine urinalysis tests done and morning urine must be collected. If proteinuria and hematuria are present in two of the three tests, then the diagnosis is that they do have proteinuria and hematuria. If it is present only once out of three times, then it cannot be said to have proteinuria and hematuria. If they are present all three times, further tests are needed.
(2) Is morning urine the urine in the morning or the first urine after waking up in the morning?
Dr. Mei Changlin: It is the first urine in the morning after waking up.
(3) If I drink a glass of water after waking up, but go to pee immediately, will it have any effect?
Dr. Mei Changlin: Usually there is no effect, but it is still recommended to drink water after urination.
(4) Is there a difference between the anterior, middle and posterior segments of urine retention?
Dr. Mei Changlin: There is a difference. After a night’s sleep, a large amount of urine accumulates in the bladder. During the process of urination, the whole bladder needs to contract, which will squeeze the urinary secretions into the urine. For example, the anterior segment of urine will be interspersed with secretions from the urethra. Especially in female patients, vaginal secretions such as leukorrhea may be present in the anterior segment of urine. The bladder sphincter needs to use more force when urinating in the back part of the urine, and some secretions will be “piggybacked” on. The middle section of urine is less likely to contain other secretions, and the test is the most accurate.
Female patients should be reminded to wash their perineum before holding urine, and to lower the cup they use to catch urine so that vaginal secretions such as leukorrhea do not drip into the cup.
(5) Does holding urine for a long time affect the quality of morning urine?
Dr. Mei Changlin: In principle, we want the morning urine to be stored inside the bladder for more than 8 hours, at least 6 hours. For example, if you go to bed at 10 p.m., by 6 a.m. the next morning, that’s 8 hours. However, it may be that this sleep time is harder to guarantee, so storing urine for as long as possible is much better and more accurate than temporary urine collection.
(6) Can taking medication affect the urine?
Dr. Mei Changlin: It depends on what kind of medication. Like vitamin C, if you take too much, it may affect the occult blood test. There are also anti-tuberculosis drugs such as rifampin, which can cause red urine after eating, but microscopic examination of urine red blood cells and hemoglobin should not increase.
(7) In order to ensure the accuracy of the next day’s morning urine, is it required to not take any medication the night before?
Dr. Mei Changlin: No. It is enough to take it before 5 or 6 pm. In addition, some anti-hypertensives and hypoglycemic drugs that need to be taken for a long time do not affect the urine test and do not need to be stopped.
(8) How long is the interval between the three urine tests?
Dr. Mei Changlin: Three consecutive days, this morning, tomorrow morning, and the morning after. You can also do it today and come back the next morning.
6.The learning of kidney biopsy
(1) All patients have to have a kidney biopsy to confirm the diagnosis of IgA?
Dr. Mei Changlin: Yes. Because IgA nephropathy is a pathological change in the structure of the kidney, it needs to be diagnosed pathologically.
(2) How does the hospital nephrology department operate kidney biopsy?
Dr. Mei Changlin: The kidney biopsy in our hospital is performed under ultrasound guidance, which can clearly see the kidney structure and accurately puncture to the “target” site. Therefore, we have arranged a professor of nephrology and an ultrasonographer to do the kidney biopsy together. We do about 3000 kidney biopsies every year.
(3) How is a kidney biopsy done? Is a fine hollow needle used to extract it?
Dr. Mei Changlin: Kidney biopsy is to use different methods to take out a little kidney tissue for pathological examination. The more commonly performed technique is percutaneous renal puncture biopsy, or “nephrotomy”.
There are various ways to perform a kidney biopsy. One is a cutting needle, in which a needle is inserted and then a sleeve is placed over the outside of the needle. When removed, a portion of the kidney tissue is stored in the sleeve.
Another type is a negative pressure suction needle. This needle is hollow. After the needle is pierced into the surface of the kidney, negative pressure will be created to attract the kidney tissue inside the hollow needle, and almost about 1 cm of kidney tissue will be extracted.
The success rate of both methods is about the same and takes about 2-3 seconds.
(4) Is the result of kidney biopsy accurate if only one side is done?
Dr. Mei Changlin: Kidney biopsy usually takes the kidney tissue from the lower right kidney, where there are fewer large blood vessels and high safety. Most of the kidney diseases are diffuse lesions, and there are less cases that one side of the kidney disease is heavier than the other, and there is no significant difference between the upper and lower end. Therefore, it is OK to do only one side.
(5) Are there any risks associated with kidney puncture? Which method has higher risk?
Dr. Changlin Mei: The main risk of kidney puncture is bleeding. The incidence of both puncture methods is similar, and both are done under ultrasound guidance. As long as the doctor is skilled, there is basically no major risk. Patients and families can rest assured.
(6) Will kidney biopsy damage normal kidney tissue?
Dr. Mei Changlin: There are 800,000-1,000,000 glomeruli in each side of normal human kidney. In order to make a clear or accurate diagnosis, the kidney tissue we take out has an average of 20 to 30 glomeruli.
Moreover, a normal person only needs 1 million glomeruli to meet the body’s needs, and the other 1 million can be understood as a “strategic reserve”. This is why some people have only one kidney, but they can still study, live and have children.
Further, the kidney units are normally discarded every year as we age. Even more kidney glomeruli are discarded than removed every day. Therefore, patients and their families do not have to worry at all that having a kidney puncture will damage the kidney structure and function.
(7) Is the amount of tissue removed by kidney biopsy related to age?
Dr. Mei Changlin: No, the amount of tissue removed is the same no matter young or old.
(8) Do I need anesthesia for kidney biopsy?
Dr. Mei Changlin: Local anesthesia is needed.
(9) Some patients with IgA nephropathy are young children. Will the kidney biopsy affect the child’s daily development and growth?
Dr. Mei Changlin: Absolutely not. A kidney puncture is just like giving a muscle shot to a child, it is just a little bit. Only the muscle shot is on the buttocks, and the kidney puncture is on the kidneys.
With the improvement of the puncture needle, positioning technology and the maturity of the technology, the success rate and safety of kidney biopsy, can be guaranteed. Regardless of the age, kidney biopsy will be done only after the doctor has performed the necessary tests and evaluations and is fully prepared.
(10) Is there any restriction on the age of children for kidney biopsy?
Dr. Mei Changlin: Generally there is no strict limit. The youngest child we have done in our hospital is a 3-month-old baby. For older children, we do it up to 80 years old. All are safe.
(11) Are there any special rehabilitation matters after kidney biopsy?
Dr. Mei Changlin: Within half a month after the kidney biopsy, do not engage in heavy physical labor, do not run, do not do things with high intra-abdominal pressure, such as sit-ups. After half a month, there is nothing wrong.
7.Teach you to understand the kidney disease laboratory test
(1) What are the main indicators that patients with IgA nephropathy look for when they get their labs?
Dr. Mei Changlin: IgA nephropathy get the laboratory test, a, is a routine urine test, the most important indicators are proteinuria, red blood cell count and red blood cell tube type. If there are more proteinuria plus signs and high red blood cell count, it means the disease is serious.
The main indicators are creatinine, urea nitrogen, uric acid and cystatin C. Some large hospitals will do glomerular filtration rate, which is a better indicator, more sensitive than creatinine and more reflective of changes in kidney function. For example, if the glomerular filtration rate drops to 50%, the blood creatinine will rise.
c. It is to look at the ultrasound report card to understand the size and structure of the kidney. For IgA nephropathy, a small kidney is not a good thing.
(2) What can the report of kidney biopsy tell?
Dr. Mei Changlin: Pathological changes are the gold standard for the diagnosis of IgA nephropathy and other glomerular diseases. The pathology report of kidney biopsy should answer three questions: first, to diagnose whether it is IgA nephropathy; second, to understand the severity of kidney disease; this is mainly achieved by grading various IgA nephropathies. By classifying and analyzing different types of disease to decide whether treatment is needed and how to treat it. Thirdly, to determine the prognosis of the disease; this is mainly based on the severity of the pathological damage, to predict its disease progression and to predict the treatment effect.
(3) What are the criteria used by the nephrology department of the hospital in grading IgA nephropathy?
Dr. Mei Changlin: There is no one classification method for IgA nephropathy that is fully accepted by everyone, so each typing or grading method has its own advantages and disadvantages. Therefore, we need to combine multiple indicators to separate the severity of the disease.
We mainly use two classification methods, one is the traditional Lee’s classification method and the other is the Oxford IgA nephropathy classification method.
(4) Which IgA nephropathies have a better prognosis according to the classification of pathology report?
Dr. Mei Changlin: IgA nephropathy has a good prognosis, including mild proliferation in the glomerulus alone. Those with poor prognosis include glomerulosclerosis, tubular atrophy, and tubular fibrosis. If the number of glomerulosclerosis is high and the degree of tubular fibrosis is heavy, the treatment will be difficult and the prognosis will be unsatisfactory.
(5) Does the higher the value on the laboratory test, the more plus signs, the more serious the disease is?
Dr. Mei Changlin: In general, this is true. If there are three or four “+” signs in proteinuria, it is definitely more serious than one “+” sign. However, there are a few cases where this is not the case. For example, if the proteinuria has 3 “+” signs, but the pathological changes are mild and the patient responds well to hormones, then the effect of drug treatment is good and the proteinuria disappears soon after the drug is administered. Therefore, the severity of the disease should be seen in conjunction with the pathology.
8.Frequency of review
(1) The diagnosis of IgA nephropathy is confirmed and drug treatment is started. How often should I be rechecked and what should I check?
Dr. Mei Changlin: If you have started the treatment, you should review at least once a month to do a urine routine, including 24-hour protein quantification; and every 3 months thereafter, also to see the urine routine, but also blood tests to see the changes in kidney function, and then an ultrasound to see the changes in the volume of the kidney.
In addition, if treated with immunosuppressive drugs, the doctor needs to observe the drug concentration. Then, after three or five days of medication, the drug concentration in the blood should be measured at the hospital, and the treatment should be maintained if the target value is reached, and the drug dose should be adjusted if it is higher or lower.
Specifically, after receiving treatment for IgA nephropathy, patients should strictly follow the medical advice and regular follow-ups.
(2) Do I need to review IgA nephropathy after stopping the medication?
Dr. Mei Changlin: Yes. Some people are clinically cured, doctors will slowly stop his medication, and the patients keep well. However, the symptoms may come back after cold or exertion, because the pathological changes in the kidney are still there. Therefore, after stopping the medication, you still need to maintain a period of follow-up, almost 2 years or so.
9.Clinical cure
(1) What is clinical cure?
Dr. Mei Changlin: To determine whether it is cured, we mainly refer to whether some abnormal manifestations have disappeared, such as proteinuria has disappeared, hematuria is gone, and kidney function and kidney size examination are normal. If all these conditions are met, we will consider it clinically cured. Generally, proteinuria disappears a little earlier and faster than hematuria.
If all the symptoms disappear, the doctor can gradually stop the drug at his discretion.
(2) After a period of treatment, is it necessary to do another kidney biopsy to judge the effect of treatment?
Dr. Mei Changlin: Generally, it is not necessary. The remission of clinical symptoms and disappearance of abnormal manifestations does not mean that the pathological changes in the kidney have completely faded, and repeated kidney biopsies may still suggest pathological changes.
There are generally only two situations in which IgA nephropathy requires repeat kidney biopsy. One is to participate in a large clinical drug trial, to assess how effective the treatment of a drug is and how much it improves the kidney pathology. Second, the condition has deteriorated, and suddenly the kidney function declines rapidly, with hematuria, proteinuria, edema, hypertension, etc., then another kidney biopsy is needed.
(3) What are the changes in laboratory indicators that mean the disease is deteriorating?
Dr. Mei Changlin: Proteinuria has increased, which was negative or one plus, but now it becomes three or four plus. Originally there were no red blood cells, but now there are; the body was not swollen, but now there is swelling, a measurement of blood pressure is high, the blood creatinine is also elevated. These often indicate an acute exacerbation and should be rushed to the hospital.
(4) Do I need to pay attention to the blood pressure status of IgA patients during daily follow-up?
Dr. Mei Changlin: There are two types of IgA nephropathy, one is like general hypertension, in the early stages of the disease may have high blood pressure. The second is malignant hypertension, which means that the blood pressure is not serious at the beginning of the disease, that is, there is proteinuria and hematuria, and then suddenly a stimulating factor, such as a cold, excessive exertion, etc., causes a sudden increase in blood pressure. There are two criteria for diagnosing malignant hypertension, one is diastolic blood pressure over 130 mmHg and systolic blood pressure at 220-240 mmHg, and the other is blurred vision.
Malignant hypertension risks and hazards are great, can affect the brain, the eyes, heart and kidneys also have malignant effects. If you do not get it right, many people will develop chronic uremia as a result, which progresses very quickly. Therefore, if you find that your blood pressure is elevated, especially if it is malignant hypertension, you should not delay and seek medical attention as soon as possible.
(5) What is the cure rate of IgA nephropathy?
Dr. Mei Changlin: In the Department of Nephrology of Shanghai Changzheng Hospital, there are three 1/3, i.e. more than 1/3 of people are completely cured, almost 40%. Another 1/3 or so can basically maintain the status quo, such as a little more red blood cells and microscopic hematuria, but the patient can maintain the disease for more than ten years without progression, and can continue to maintain after stopping the medication. In the third case, probably less than 1/3 of patients will progress to chronic renal failure in about 15 years.
(6) Why does chronic renal failure develop?
Dr. Mei Changlin: First, the disease is not effectively controlled, and the condition has been deteriorating. Second, the nature of the pathology itself determines, such as patients with genetic background exists, the disease is difficult to treat, or itself is refractory IgA nephropathy. Third, there is no timely consultation, or to get the correct diagnosis and treatment guidance.
Find the right doctor, under the supervision of the, adhere to treatment, for IgA nephropathy cure, is vital.
Dr. Mei Changlin: Very important, the result is completely different. I have a patient who was 13 or 14 years old when he was first seen, a junior high school student. Later, he entered maintenance treatment. He graduated from high school and went to college, and graduated from college and went to graduate school. Now he is married and has children, and his health is very good and well maintained. There are many other patients like him in our hospital. Therefore, patients should have confidence that most of them can be cured as long as they adhere to the right treatment.