Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity. In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals. Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.
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In patients with kidney disease, the composition of urinary protein can provide a clue as to the etiology. In patients with renal glomerular pathology, the primary protein that is lost is albumin, whereas in patients with renal tubular pathology, the primary proteins lost are of lower molecular weight. Urine protein electrophoresis has been used to help with the diagnosis of kidney disease, but is costly and requires skilled interpretation. One study looked at the use of a urinary albumin to protein ratio (uAPR) as an easy and inexpensive way to distinguish between glomerular and tubular diseases. The uAPR was correlated to urine protein electrophoresis and immunofixation as well as histologic findings from renal biopsy. A uAPR cut-off of 0.4 had a sensitivity and specificity of 88 and 99%, respectively, for diagnosing primary tubulointerstitial diseases.
References: Urine Protein
Glucagon-like peptide 1 receptor agonists (GLP-1RA’s) are insulin sensitizing drugs initially developed for use as antiglycemic agents. Recently, they have been explored as a potential treatment for Non-Alcoholic Steatohepatitis (NASH). A recent multicenter, randomized control trial demonstrated statistically significant histologic resolution or improvement in patients with NASH treated with liraglutide vs. placebo for 48 weeks, without significant adverse events. Larger, international studies with subcutaneous semaglutide are ongoing. Currently, there are no formal recommendations from any major specialty societies on their use in NASH.
Complications of diabetes mellitus can be divided into two major categories: macrovascular complications such as heart attack, stroke and peripheral artery disease, and microvascular complications such as neuropathy, retinopathy and nephropathy. Around 50% of control subjects in the EMPA-REG trial had one or more of the microvascular complications of diabetes. In a post-hoc analysis, these subjects had greater risk of heart failure hospitalization, and this risk increased with severity of disease, suggesting a link between microvascular disease and heart failure.
References: Microvascular Disease