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What further testing should be done if one has moderate blood and protein in urine? have AL Amyloidosis

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Doctor my husband had a heart cauth where he was diagnoised
with dilated cardiomypathy but 12 months later it was
changed to restrictive caused by AL amyloidosis. IF you were
instructed by the primary that he had moderate blood and
high protein in his urine what futher testing would you have
completed my husband and would that further testing of lead
you to restrictive sooner? i do understand its not the
responsability of a cardiologist to perform a urinalysis.
Thank you, XXXXXXX

Posted Mon, 23 Apr 2012 in Hypertension and Heart Disease
Answered by Dr. Avinash Ignatius 19 hours later

Thanks for the query.

AL Amyloidosis is a disorder of deposition of abnormal proteins in the tissues of various organs. Isolated cardiac involvement is rare.

A persistent high levels of protein and blood in urine would require further assessment with a kidney biopsy - which could confirm a diagnosis of AL Amyloidosis. However many common conditions like high blood pressure and diabetes themselves can be responsible for high protein in the urine (That I'm not sure your husband had?).

Hence he would need a physical examination, blood pressure check, complete renal function test and so on. A kidney biopsy may be planned at a later stage in consultation with a nephrologist and that will help confirm the diagnosis. In addition he would also need to be assessed for multiple myeloma.

The feature of restrictive cardiomyopathy are a diagnosis arrived at on echocardiography. In the initial stages, the early features of cardiac dysfunction are non specific and true restrictive cardiomyopathy develops over time as the diseases progresses. This might explain the change in diagnosis over time.

Hope this answers your query. Should you have any additional concerns with my recommendations, I will be available for follow ups.


Above answer was peer-reviewed by
Follow-up: What further testing should be done if one has moderate blood and protein in urine? have AL Amyloidosis 12 days later

Follow up query:

My husband was border line "pre-diabetes" and his blood pressure has always been below normal ranges. My husband has also been a very good weight and good muscle tone. Please note its just not the protein but moderate blood.

Only additional testing was CMP testing and except for the glucose the other results were in normal ranges. Please note my husband was diagnosed borderline pre-diabetes, Please note the urinalysis was never ever repeated even though we were in and out of his office many many times over the next year and a half.

It was and it is confirmed amyloid. But the sequence that diagnosed him 1 1/2 after the first urinalysis was a urinalysis, a 24 hour urine test, and then the kidney biopsy. He was tested for multiple myeloma and it was negative.

The feature of restrictive cardiomyopathy did show up on the echo by the 2nd cardiologist in 12/09 (we went for
a 2nd opinion). The 1st cardiologist did two echos (11/08 and 02/09) and nothing was noted OR it was missed.

Doctor 2 questions:
1) if a specialist was advised of the high protein and the blood in the urinalysis, in your medical opinion, wouldn't of one of the 14 specialist we went to trying to obtain a diagnose come up with the dianoise of Amyloid sooner. (I feel the cardiologist would of). I don't mean to be smirk, please don't take it that way, but when I finally know about the
blood and the protein I did Google it and Amyloid did come up.

2)Doctor why would a Primary think the CMP results identified diabetes as the issue for the urinalysis results. Personally I think the primary never saw the urinalysis results because from my reading it does seem the stand of care would, at the very least, to repeat the test the urinalysis. From my research 3+ protein and blood wouldn't
have been normal results for borderline prediabetes.
Answered by Dr. Avinash Ignatius 3 hours later

Thanks for writing again.

Both the points raised by you are valid, and it is likely that a kidney biopsy might have helped in Amyloidosis being diagnosed earlier.

Unfortunately in today's world of hi-tech investigations, urinalysis reports are rarely given due importance and leads to delay in diagnosis.

However, what exactly was the line of thought of the specialists at that time, I can't answer for them.

I would suggest you to consult your Nephrologist for further investigations and line of treatment accordingly.

Hope, this answers your query.

Wish you good health.

Above answer was peer-reviewed by
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