Decoding albuminuria by homoeopathy

Dr Ashritha B.A

ABSTRACT
Albuminuria is a condition where the kidneys leak excess albumin, a type of protein, into the urine. This may indicate: kidney disease or damage, diabetes or hypertension complications, cardiovascular disease risk, kidney function decline. Albuminuria can be diagnosed with urine test and may require lifestyle changes, medication, to manage and prevent further kidney damage. Management of the cases can be done effectively with Homoeopathic remedies.

KEY WORDS: Albuminuria, Kidney disease, Glomerular Filtration Rate, Urine Albumin-to-Creatinine Ratio

INTRODUCTIO
Albuminuria is defined as the abnormal loss of albumin in the urine. According to the nomenclature of kidney function and disease from the Kidney Disease Improving Global Outcomes (KDIGO) consensus conference, albuminuria is defined as a urinary albumin excretion rate (AER) >10 mg/d or an albumin–creatinine ratio (ACR) > 10 mg/g. ^[1]

Albumin is a small, negatively charged protein that represents 10% of total body protein and 50% of total plasma protein. The physiologic role of albumin is to maintain plasma oncotic pressure and to transport various endogenous and exogenous ligands through the bloodstream to target cells. In healthy individuals, the endothelial layer of the glomerulus serves as a barrier that minimizes albumin movement from the blood into the urine. A urine albumin level of <30 mg in a 24‐hour urine sample is considered normal. Pathologic albuminuria (≥30 mg in a 24‐hour urine sample) involves structural damage in the glomerulus, which is associated with an increased risk for undesirable cardiovascular and kidney outcomes. ^[2] 

Albuminuria is prevalent in a spectrum of pathologies impacting both the kidneys and the heart. It has traditionally been associated as a marker of kidney disease, independent of GFR, particularly in patients with diabetes mellitus. Furthermore, in recent years it has transcended its role solely as a biomarker for injury, emerging as a therapeutic target. ^[1]

Albuminuria is a risk factor for cardiovascular diseases (CVD) and incident chronic kidney disease (CKD). In adults ≥65 years (the age at which most CVD presents), albuminuria is present in ~15% to 20% of the population and in ~35% to 40% of similarly aged individuals with diabetes. Elevated CRP levels confer ~45% increased risk of CAD, and albuminuria is associated with ~40% increased risk of clinical CAD. ^[2]

RISK FACTORS ^[2]

1. Glomerular disease (such as IgA nephropathy, lupus nephritis, focal segmental glomerulosclerosis (FSGS), or glomerulonephritis)

2. Acute kidney Injury
3. Kidney failure
4. Progressive Chronic Kidney Disease
5. Cardiovascular disease: Coronary Artery Disease, Stroke, Arterial stiffness, Myocardial capillary disease, Heart Failure, Arrhythmia
6. Diabetes mellitus
7. Hypertension
8. Dehydration (not drinking enough water)
9. High-intensity exercise
10. Fever and/or infection

CLASSIFICATION
Albuminuria Categories in Chronic Kidney Disease. ^[3]

Category	Albumin Excretion Rate(mg/24hours)	Urine Albumin: Creatinine ratio mg/mmol            mg/g		Description	Previous terminology
A1	<30	<3	<30	Normal to mildly increased	Normal
A2	30-300	3-30	30-300	Moderately increased	Microalbuminuria
A3	>300	>30	>300	Severely increased	Proteinuria

This classification is intended to facilitate the assessment of CKD severity and to determine individual cardiovascular risk according to GFR and the presence of albuminuria. A recent meta-analysis showed that the presence of albuminuria is associated with numerous cardiovascular and renal events, even in people with normal renal function as estimated by creatinine and cystatin C. In addition, the nomenclature initiative suggests avoiding terms such as macroalbuminuria or microalbuminuria, which can lead to confusion about the size of the albumin in the urine. ^[1]  

PATHOGENESIS
Albumin is the main protein in the body, synthesized by hepatocytes and distributed mainly in the blood (10 to 15 g per day). Albumin serum half-life is 19 days; during the lifespan, the structure is modified by different reactions such as carbamylation and glycation. The main functions of albumin are:

1. Maintain colloid pressure;
2. Antioxidant activity and
3. Transport of endogenous substances (calcium, bilirubin, etc.) and exogenous substances such as drugs.

Albuminuria is a consequence of damage to the glomerular filtration barrier, leading to the passage of albumin into the urine.

The pathophysiological mechanisms involve:

1. Increased glomerular permeability ^[4]: The ultrafiltration of water and small molecules is initiated in the GFB, comprising three layers: the inner layer of fenestrated endothelium, the glomerular basement membrane, and an outer layer of podocytes with their interdigitating processes. The disruption of any of these layers leads to a loss of selective glomerular ultrafiltration, permitting albumin to pass through.
2. Loss of negative charge on the glomerular basement membrane ^[5] : The glomerular basement membrane’s negative charge helps repel negatively charged proteins like albumin. Damage to the membrane reduces this charge, enabling albumin to pass through.
3. Podocyte injury and loss ^[6]: Hemodynamic alterations induced by hyperglycemia (in Diabetic Nephropathy) and hypertension lead to mechanical stretch and shear stress on endothelial cells, initiating processes that damage the glomerular filtration barrier. Albuminuria reflects damage to these structures and is characterized by mesangial expansion (mesangial cell proliferation and excess production of matrix proteins in the central region of the glomerulus provide a supporting framework to the glomerular capillaries), basement membrane thickening, and podocyte apoptosis. Subsequent podocyte injury and detachment further increase albuminuria, decreasing the capillary filtration surface and ultimately leading to glomerulosclerosis.
4. Increased intraglomerular pressure ^[7]: Elevated blood pressure or resistance in the glomerular capillaries forces more fluid and protein through the damaged barrier.
5. Inflammation and fibrosis ^[8]: Alteration of the GFB leads to increased tubular reabsorption of albumin, which, in turn, is associated with increased mesangial activity and intrarenal complement activation, resulting in inflammation and tubular damage. This, in turn, triggers neurohormonal activation, increasing the activity of the renin–angiotensin–aldosterone system, which promotes sodium and water retention, resulting in volume overload. Thus chronic damage leads to inflammation and scarring, further disrupting the filtration barrier and exacerbating albuminuria.

These mechanisms contribute to the development of albuminuria in various kidney diseases, including diabetic nephropathy, hypertensive nephrosclerosis, and glomerulonephritis.

The presence of albuminuria is often linked to the mechanism of hyperfiltration. Examples of such instances include healthy individuals experiencing a heightened glomerular filtration rate after a high protein intake or during pregnancy. Additionally, hyperfiltration may occur in patients with conditions such as obesity, diabetes mellitus, or autosomal dominant renal polycystic disease. It can also be observed in cases where there is a reduced number of nephrons. In both scenarios—whether there is a normal or reduced number of nephrons—the objective is to elevate the GFR, resulting in glomerular hypertension. This increase in pressure may be correlated with albuminuria, glomerulosclerosis, and compromised renal function. ^[2]

CLINICAL FEATURES
Albuminuria, in itself, has not been associated with any specific symptoms. However, due to its link with diabetes, obesity, hypertension, and cardiovascular events, providers should focus on history and physical examination to assess for these complications. Specifically, paying attention to any personal or family history of renal, cardiac, and systemic diseases could reveal pertinent information. Additionally, patients with diabetes may present with symptoms of cardiac disease, vision difficulties, and urinary tract disorders. On physical exam, it is particularly important to evaluate for elevated blood pressure, abnormal cardiac exam, carotid pulse for bruits, and lower extremity swelling. ^[9]

The majority of patients do not have any symptoms, and albuminuria is picked up on routine laboratory testing that is carried out to evaluate systemic diseases, such as diabetes mellitus or hypertension, or when a well-person examination is conducted.

COMPLICATIONS

Albuminuria is a significant risk factor for developing complications. Some of these complications include:

• Kidney failure
• Cardiovascular disease (heart failure, heart attack, or stroke)
• Heart failure
• Decreased life expectancy (early death)

DIAGNOSIS

1. Urine Dipstick Test: A positive dipstick test for proteinuria is a convenient and inexpensive way to screen for albuminuria. ^[10]
2. Urine Albumin-to-Creatinine Ratio (UACR): UACR is a sensitive and specific test for detecting albuminuria, and is recommended as the primary test for diagnosis. ^[11] A UACR ≥30 mg/g is diagnostic for albuminuria. ^[12]
3. 24-hour Urine Protein Test: The 24-hour urine protein test is a reliable method for quantifying proteinuria, including albuminuria. Measures the total amount of protein (including albumin) excreted in the urine over a 24-hour period.

– Normal: <150 mg/day

– Abnormal: >150 mg/day ^[13]

4. Immunoturbidimetry or Immunonephelometry: These tests are highly sensitive and specific for measuring urine albumin concentrations. ^[14]

Guideline Recommendations in Relation to Albuminuria Screening

• For population at risk for and with CKD to detect progression: First morning spot urine albumin: creatinine ratio (UACR) done annually, and 1–4 times per year depending on the stage of CKD. ^[15]
• For population with hypertension to detect hypertension‐mediated organ damage or screening for secondary hypertension: First morning spot UACR or urine dipstick. Done routinely. ^[16]
• For anyone with diabetic kidney disease or at risk of kidney disease (type 1 diabetes with duration of >5 y; type 2 diabetes regardless of treatment) to detect progression of disease: Random spot UACR, done annually, and 1–4 times per year depending on the stage of CKD. ^[17]

It is important to note that albuminuria can be a sign of underlying kidney disease or other conditions, so a proper diagnosis and evaluation by a healthcare professional is necessary to determine the underlying cause and develop an appropriate treatment plan.

GENERAL MANAGEMENT
Dietary management of albuminuria involves making changes to help reduce proteinuria and slow kidney damage.

1. Protein restriction: Limit protein intake to 0.8-1.2 grams per kilogram of body weight per day.
2. Salt restriction: Limit sodium intake to less than 5 grams per day.
3. Fluid intake: Drink enough water to stay hydrated, but avoid excessive fluid intake.
4. Dietary protein sources: Choose plant-based protein sources, such as legumes, nuts, and seeds, instead of animal-based sources.
5. Fat intake: Limit fat intake, especially saturated and trans fats.
6. Phosphorus restriction: Limit phosphorus intake to 800-1,000 mg per day.
7. Potassium intake: Maintain adequate potassium intake, as excessive potassium loss can occur with proteinuria.
8. Alcohol intake: Limit or avoid alcohol intake.
9. Glycemic control: Maintain good glycemic control if diabetic.
10. Consult a dietitian: Work with a registered dietitian or healthcare provider to develop a personalized diet plan.

HOMOEOPATHIC TREATMENT FOR ALBUMINURIA

UREA PURA

• Albuminuria, diabetes; uremia.
• Urine thin and of low specific gravity.
• A hydrogogue diuretic in the treatment of dropsies.
• Renal dropsy, with symptoms of general intoxication.^[18]
• Diseases – NEPHRITIS, kidneys, – parenchymous, chronic
• Diseases – DIABETES mellitus
• Kidneys – NEPHRITIS, infection, – parenchymous, chronic
• Kidneys – UREMIA
• Kidneys – UREMIA – coma, uremic
• Urine – ALBUMINOUS, proteinuria
• Urine – SUGAR, in urine ^[19]

SERUM ANGUILLAE/ EEL SERUM

• It has a toxic action on the blood, rapidly destroying its globules.
• The presence of albumin and renal elements in the urine, the hemoglobinuria, the prolonged anuria (24 and 26 hours), together with the results of the autopsy, plainly demonstrate its elective action on the kidneys.
• Secondarily, the liver and the heart are affected, and the alterations observed are those usually present in infectious diseases.
• Whenever the kidney becomes acutely affected, either from cold or infection or intoxication, and the attack is characterized by oliguria, anuria and albuminuria, we will find the eel’s serum eminently efficacious to re-establish diuresis, and in rapidly arresting albuminuria.
• The serum of the eel has given very small results in attacks of asystolia; but it has been very efficacious in cardiac uremia.
• But it’s really specific indication seems to be for acute nephritis a frigori.
• Subacute nephritis.^[18]
• Diseases – KIDNEY, remedies – inactive, kidneys
• Diseases – NEPHRITIS, kidneys, – parenchymatous, acute
• Diseases – UREMIA
• Diseases – VALVULAR heart disease, with murmurs
• Kidneys – INACTIVE
• Kidneys – NEPHRITIS, infection, – parenchymous, acute
• Kidneys – UREMIA^[19]

PLUMBUM METALLICUM

• Urine Albuminous; low specific gravity.
• Chronic interstitial nephritis, with great pain in abdomen.
• Urine scanty. ^[18]
• Urine – ALBUMINOUS, proteinuria
• Urine – ALBUMINOUS, proteinuria – amaurosis
• Urine – ALBUMINOUS, proteinuria – chronic
• Urine – ALKALINE
• Urine – SCANTY
• Urine – SPECIFIC gravity, urinary – decreased
• Urine – SUGAR, in urine ^[19]

SOLIDAGO VIRGAUREA

• Scanty, reddish brown, thick sediment, dysuria, gravel.
• Difficult and scanty.
• Albumen, blood, and slime in urine.
• Pain in kidneys extend forward to abdomen and bladder.
• Clear and offensive urine.
• Sometimes makes the use of the catheter unnecessary. ^[18]
• Diseases – KIDNEY, remedies
• Diseases – KIDNEY, remedies – function, derangement
• Diseases – KIDNEY, remedies – function, derangement – inactive
• Diseases – NEPHRITIS, kidneys,
• Urine – ODOR, general – ammoniacal
• Urine – SCANTY – agg. other complaints ^[19]

CALCAREA ARSENICUM

• Kidney region sensitive to pressure.
• Albuminuria, passes urine every hour. ^[18]
• Clinical: Albuminuria.
• Heart, disease of.
• Kidneys, affections of.
• Liver, affections of.
• In albuminuria cases there is great sensitiveness of the kidney region.^[20]
• Diseases – ALBUMINURIA, proteinuria,
• Diseases – ARTERIOSCLEROSIS
• Diseases – BRIGHT’S disease, kidneys,
• Diseases – BRIGHT’S disease, kidneys, – edema, with
• Diseases – NEPHRITIS, kidneys, – heart and liver affections, with
• Diseases – NEPHRITIS, kidneys, – parenchymous, chronic
• Kidneys – KIDNEYS, remedies
• Kidneys – ADDISON’S disease
• Kidneys – BRIGHT’S disease,
• Kidneys – BRIGHT’S disease, – edema, with
• Kidneys – NEPHRITIS, infection, – heart and liver affections, with
• Kidneys – NEPHRITIS, infection, – parenchymous, chronic
• Kidneys – SENSITIVE, region of
• Kidneys – SENSITIVE, region of – pressure, to – albuminuria, in
• Kidneys – SORE, pain
• Urine – ALBUMINOUS, proteinuria
• Urine – ALBUMINOUS, proteinuria – alcohol, after abuse of
• Urine – ALBUMINOUS, proteinuria – heart, disease, consecutive to
• Urine – SCANTY^[19]

CHELIDONIUM MAJUS

• Urine: Profuse, foaming, yellow urine, like beer.
• Dark, turbid urine.^[18]
• Urine – ACRID
• Urine – ALBUMINOUS, proteinuria
• Urine – BROWN – beer, like
• Urine – CASTS, containing – epithelial
• Urine – CLOUDY – morning – standing, on
• Urine – CLOUDY – passed, when
• Urine – CLOUDY – passed, when – soon after
• Urine – CLOUDY – standing, on
• Urine – CLOUDY – turning cloudy
• Urine – COPIOUS
• Urine – SUGAR, in urine,
• Urine – SUGAR, in urine, – gastro-hepatic origin
• Urine – WHITE
• Urine – YELLOW, general – dark
• Urine – SEDIMENT, urinary – chalk
• Urine – SEDIMENT, urinary – flocculent
• Urine – SEDIMENT, urinary – mucus

CUPRUM ARSENICOSUM

• A remedy for symptoms depending on deficient kidney action,
• Uraemic convulsions, headache, vertigo and unconscious conditions resulting from brain oedema.
• Nephritis of pregnancy.
• Renal inefficiency and uremia.
• Garlicky odor.
• Urine of high specific gravity; increased, acetones and diacetic acid.^[18]
• Urine – ACETONURIA
• Urine – ALBUMINOUS, proteinuria
• Urine – ALBUMINOUS, proteinuria – pregnancy, during
• Urine – ODOR, general – garlic, like
• Urine – ODOR, general – onions
• Urine – SUGAR, in urine,
• Urine – YELLOW, general – orange ^[19]

TEREBINTHINAE OLEUM

• Urinary symptoms very marked.
• Inflammation of kidneys, with hemorrhages-dark, passive, fetid.
• Bright’s disease preceded by dropsy.
• Scanty, suppressed, odor of violets.
• Urethritis, with painful erections.
• Inflamed kidneys following any acute disease.
• Constant tenesmus. ^[18]
• One of our most reliable and most frequently indicated remedies in the early stages of renal diseases when congestion is prominent, when there is much pain in the back of a dull character extending along the ureters.
• The great characteristic of dark smoky urine will be present.
• There is anasarca, and, of course, the urine is bloody and albuminous.
• It is recommended in post scarlatinal renal affections.^[21]
• Diseases – INFLAMMATION, tissues – internally
• Diseases – KIDNEY, remedies – dwellings, worse from living in damp
• Diseases – KIDNEY, remedies – inactive, kidneys
• Diseases – KIDNEY, remedies – inactive, kidneys – scanty, with, smoky urine, brain possessed by unexcreted urea
• Diseases – ALBUMINURIA, proteinuria,
• Diseases – ALBUMINURIA, proteinuria, – pregnancy, during
• Diseases – BRIGHT’S disease, kidneys,
• Diseases – BRIGHT’S disease, kidneys, – edema, with – followed by renal
• Diseases – BRIGHT’S disease, kidneys, – heart complications, with
• Diseases – NEPHRITIS, kidneys,
• Diseases – NEPHRITIS, kidneys, – bronchitis, with
• Diseases – NEPHRITIS, kidneys, – cold, from, or exposure to wet
• Diseases – NEPHRITIS, kidneys, – edema, with
• Diseases – NEPHRITIS, kidneys, – malaria, from
• Diseases – NEPHRITIS, kidneys, – parenchymatous, acute
• Diseases – NEPHRITIS, kidneys, – parenchymous, chronic
• Diseases – NEPHRITIS, kidneys, – pyelo-nephritis
• Diseases – NEPHRITIS, kidneys, – rheumatism, with
• Diseases – NEPHRITIS, kidneys, – scarlet fever, from
• Urine – ALBUMINOUS, proteinuria
• Urine – ALBUMINOUS, proteinuria – heart, disease, consecutive to
• Urine – ALBUMINOUS, proteinuria – pregnancy, during
• Urine – ALBUMINOUS, proteinuria – scarlet fever, after
• Urine – CLOUDY – passed, when
• Urine – CLOUDY – standing, on ^[19]

HELONIAS DIOICA

• Albuminuria during pregnancy.
• Urine: Albuminous, phosphatic; profuse and clear, saccharine.
• ^[18]
• Diseases – ALBUMINURIA, proteinuria,
• Diseases – ALBUMINURIA, proteinuria, – pregnancy, during
• Diseases – BRIGHT’S disease, kidneys,
• Diseases – BRIGHT’S disease, kidneys, – edema, with
• Diseases – BRIGHT’S disease, kidneys, – weakness, with great
• Diseases – DIABETES mellitus – melancholia, emaciation, thirst and restlessness, with4
• Diseases – KIDNEY, remedies
• Diseases – KIDNEY, remedies – function, derangement – inactive
• Diseases – NEPHRITIS, kidneys, – parenchymatous, acute
• Diseases – NEPHRITIS, kidneys, – parenchymous, chronic
• Diseases – NEPHRITIS, kidneys, – parenchymous, chronic – pregnancy, in, approaching convulsions
• Diseases – NEPHRITIS, kidneys, – pregnancy, during
• Urine – ALBUMINOUS, proteinuria
• Urine – ALBUMINOUS, proteinuria – menses, during
• Urine – ALBUMINOUS, proteinuria – pregnancy, during
• Urine – ALBUMINOUS, proteinuria – scarlet fever, after
• Urine – SPECIFIC gravity, urinary – decreased
• Urine – SPECIFIC gravity, urinary – increased
• Urine – SUGAR, in urine, – melancholia, emaciation, thirst and restlessness, with
• Kidneys – NEPHRITIS, infection, – parenchymous, acute
• Kidneys – NEPHRITIS, infection, – parenchymous, chronic
• Kidneys – NEPHRITIS, infection, – parenchymous, chronic – pregnancy, in, approaching convulsions
• Kidneys – NEPHRITIS, infection, – pregnancy, during
• Kidneys – PAIN, kidneys – albuminuria, with^[19]

 EUONYMUS ATROPURPUREA

• Brunettes more easily affected, producing headache, mental disturbances and much distress in hepatic and renal region; albuminuria.
• Urine scanty, high-colored; acidity increased, poured out rapidly^[18]

CONCLUSION
Albuminuria, characterized by the presence of albumin in the urine, is a significant indicator of kidney dysfunction or damage. Early detection and management are crucial in preventing further renal complications and preserving overall health. Homoeopathic medicine stimulates the body’s natural healing processes, addressing both the symptoms and underlying causes of albuminuria. This holistic method seeks to improve overall health and kidney function, thus found effective in the treatment of albuminuria.

REFERENCES

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Dr Ashritha.B.A
PG Scholar, Department of Practice of Medicine
Government Homoeopathic Medical College & Hospital. Bengaluru, 560079
drashrithaba3@gmail.com

Under the Guidance of:
Dr Veerabhadrappa C
Professor, Department of Practice of Medicine
Government Homoeopathic Medical College & Hospital, Bengaluru, 560079