Scleroderma and Microalbuminuria: the Connection and Next Steps

Scleroderma and Urinary Microalbumin

Hello, in April of this year, I went to the rheumatology and immunology department due to hand pain and found the following abnormalities: ANA 1:160 (AC-10) Nucleolar punctate, Anti-Scl-70 16 (-) reference value (120 au/ml), Anti-Sm 9 (-), Anti-SSB 6 (-), Anti-SSA 45 (-), Anti-RNP 75 (-), RF IgM 5, CK 69, IgG4.Sub 83, HLA-B27 (-), Anti-CCP <4.6, Th/To (+-), RP155 (+-), Ku (+-), Fib (+-).
I have only undergone blood tests and hand X-rays, and have not had any further examinations such as echocardiograms or pulmonary function tests, nor have any medications been prescribed.
The doctor initially indicated that I could go home without needing to return for follow-up, and only after my request did they suggest returning in three months for blood tests, without mentioning any other examinations or confirming whether I have scleroderma or applying for major illness benefits.
I have diabetes but have not been on medication, with my HbA1c consistently below 6.5.
My blood pressure has been maintained below 133/100 for a long time, but in mid-June, I experienced a kidney infection.
The infection levels are now controlled within standard values, but microalbuminuria remains high: 112/3/8 Protein Negative, MicroALB(U) 48.3, Creatinine (urine) (semi-quantitative) 100, microalbumin/creatinine ratio (semi-quantitative) Normal (<30) 112/6/7 Protein Negative, Creatinine(U) 46.8, MicroALB(U) 76.6.
On 112/6/11, I went to the emergency department: Protein 1+ (30), MALB(U) (semi-quantitative) 150 mg/l, Blood 2+ UACR (semi-quantitative) 2+ (>=300), WBC esterase 3+.
On 112/6/28, one week after discharge, during a follow-up visit: T-protein (u) 41.9 mg/dl, Alb/cre ratio 782.8 mg/g (the doctor mentioned I was previously around 163), Malb(u) 296.7 mg/l, Creatinine(u) 37.9 mg/dl, Tp(u)/cre ratio 1105.5, Blood trace, UACR (semi-quantitative) 2+ (>=300), Protein 1+ (30).
The nephrologist said to observe for another month, and if the levels remain this high, a biopsy will be needed.
I am very worried that my scleroderma might be affecting my kidneys.
If it is affected, what are the survival chances? Additionally, I would like to ask if, based on the rheumatologist's assessment, I should seek another physician.

Sumi, 30~39 year old female. Ask Date: 2023/06/28

Dr. Gao Jiankai reply Internal Medicine

Hello, thank you for your inquiry.
The results from your rheumatology examination are mostly negative, with some results falling into a gray area, making it indeed difficult to draw conclusions based on the current test results.
The diagnosis of scleroderma can sometimes be confirmed solely based on skin manifestations, which is why the physician who examines you in person is very important.
Additionally, the renal manifestations of scleroderma often present as acute renal dysfunction and hypertension, rather than proteinuria, so I believe there may be another underlying cause.
Therefore, I recommend that you follow up with a nephrologist and not worry too much about survival issues.
As for seeking a second opinion from another rheumatologist, if you are already feeling anxious, I think it would be reasonable to do so.
The Allergy, Immunology, and Rheumatology Department at Changhua Hospital, Ministry of Health and Welfare, cares about you.

Reply Date: 2023/06/28

More Info

Scleroderma, also known as systemic sclerosis, is an autoimmune disease characterized by the hardening and tightening of the skin and connective tissues. It can affect various organs, including the kidneys, leading to complications such as scleroderma renal crisis. The connection between scleroderma and microalbuminuria is significant, as the presence of microalbuminuria can indicate early kidney damage, which is crucial for monitoring the progression of the disease.

In your case, the presence of microalbuminuria, which is a sign of kidney involvement, raises concerns, especially given your history of diabetes and hypertension. Microalbuminuria is defined as a urinary albumin excretion rate of 30-300 mg per day, and it is often an early indicator of kidney disease. The fact that your microalbumin levels have been elevated, along with your other lab results, suggests that your kidneys may be under stress, potentially due to scleroderma.

The next steps in managing your condition should involve a comprehensive approach. Since your rheumatologist has not yet performed further tests such as echocardiograms or pulmonary function tests, it may be beneficial to discuss these options with your healthcare provider. These tests can help assess the extent of organ involvement and guide treatment decisions. Additionally, given your elevated microalbumin levels and the risk of kidney damage, it is essential to monitor your renal function closely.

If your microalbuminuria persists or worsens, a kidney biopsy may be necessary to determine the underlying cause of the kidney impairment. This procedure can provide valuable information about the type of kidney damage and help tailor your treatment plan. While the thought of a biopsy can be daunting, it is a common procedure that can yield critical insights into your health.

Regarding your concerns about the potential impact of scleroderma on your kidney function and overall prognosis, it is important to understand that early detection and management of kidney involvement can significantly improve outcomes. Regular follow-ups with a nephrologist (kidney specialist) are advisable, especially given your elevated microalbumin levels and history of kidney infection.

As for seeking a second opinion, it is always within your rights as a patient to consult another physician if you feel uncertain about your current treatment plan or diagnosis. A second opinion can provide reassurance or alternative perspectives on your condition and management options. It is crucial to have a healthcare team that you trust and feel comfortable with, especially when dealing with complex conditions like scleroderma.

In summary, the connection between scleroderma and microalbuminuria is significant, and your elevated levels warrant close monitoring and possibly further investigation. Engaging with a nephrologist and considering additional tests will be essential in managing your health effectively. Don't hesitate to seek a second opinion if you feel it is necessary, as your health and peace of mind are paramount.

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