I get asked about this alot. Lupus patients are prone to inflammation and infection. Many of us have kidney issues, bladder infections, uti’s, cystitis & other urinary tract issues.
Our rheumies check our urine every 3 months looking for proteins or red or white blood cells that can cause inflammation or indicate infection. So what does it mean if you have an elevation in proteins, blood cells or leukocyte esterase in your urine?
Could be anything from a simple UTI to kidney lupus involvement. Here’s the scoop from Johns Hopkins:
A complete urinalysis evaluates several different aspects of your urine through physical, chemical, and microscopic examination. In lupus treatment, a urinalysis is often used to monitor protein leakage and identify and assess urinary tract infections (UTIs). Most people with kidney lupus (lupus nephritis) will have an abnormal urinalysis.
Protein, urine casts (especially red blood cell casts), red blood cells, or white blood cells in the urine can indicate serious kidney involvement; leukocyte esterase or indicate a bladder infection.
The chemical examination measures several features of the urine. Most laboratories use chemical test strips (“dipsticks”) that change colors when dipped into the urine. Either the laboratory technician or an automated instrument will then read the reaction color for each test pad to determine the result for each test. The use of automated instruments helps to eliminate discrepancies that arise with human interpretation.
pH: Usually, the pH of urine is between 4.5 and 8.0. The kidneys regulate this acid-base chemistry by reabsorbing sodium and secreting hydrogen and ammonium ions. When the body retains excess sodium or acid, urine becomes more acidic (i.e., the pH is lower). Highly acidic urine can occur with uncontrolled diabetes, diarrhea, starvation, dehydration, and certain respiratory diseases. When your body retains excess base, your urine becomes more basic, or “alkaline” (i.e., the pH is higher). This can occur with urinary tract infections and certain kidney and lung conditions. Certain foods can also alter the pH of your urine. For example, eating excessive protein or cranberries can make your urine more acidic, whereas eating a low-carbohydrate or vegetarian diet can make your urine more basic. Sometimes people are asked by their doctors to regulate the pH of their urine through diet in order to manage certain diseases or medications. For example, kidney stones can occur if urine pH is too high or too low.
Protein: Excessive protein in the urine (proteinuria) is a sign of kidney involvement in lupus. Usually, your kidneys prevent protein from passing from your blood into your urine: loops of capillaries (glomeruli) that filter blood allow small particles to pass into the urine while retaining larger particles, such as protein, and kidney tubules reabsorb the smaller proteins that were able to escape. Large amounts of protein in the urine suggest that these glomeruli and tubules are inflamed or damaged in some way.
If there is a large amount of protein in the urine, your doctor may request that you give a 24-hour urine sample or obtain a random protein to creatinine ratio. These two tests are used to monitor lupus affecting the kidneys (lupus nephritis).
Glucose: Your urine should not contain glucose. If it does, your doctor will order further bloodwork and urine tests to determine the cause. Glucose in the urine is called glucosuria; it can occur in people with diabetes that is not properly regulated with insulin, in people with kidney problems that affect the absorption of glucose, in pregnant women, and in people with liver abnormalities or hormonal disorders.
Ketones: Ketones in the urine (ketonuria) indicate that your body is metabolizing its fat reserves instead of carbohydrates to obtain energy. This can occur in people on low-carbohydrate diets, people who are malnourished, or people who have a problem properly metabolizing carbohydrates (e.g., people with diabetes). It can also occur with excessive exercise, loss of carbohydrates due to vomiting, or exposure to cold. In people with diabetes, ketonuria may indicate insufficient management with insulin.
Blood: The chemical examination of urine also measures the amount of red blood cells in the urine sample. The presence of red blood cells in the urine is known as hematuria, and the presence of hemoglobin (from red blood cells) is known as hemoglobinuria. Usually people have very small amounts of red blood cells in their urine, but even a minute increase can indicate a problem, such as a disease of the kidney or urinary tract, trauma, medications, smoking, or intense exercise (e.g., running a marathon). When the chemical test for blood in the urine is negative but the microscopic assessment shows the presence of red blood cells, the laboratory will usually check for the presence of vitamin C, which can interfere with test results. [It is important to also note that contamination of the urine sample with menstrual blood or hemorrhoids cannot be distinguished from the presence of red blood cells in the sample. Therefore, it is very important to tell your physician if you are menstruating or are experiencing any other condition that could contaminate your urine sample. It is also very important that you speak to your lab technician about proper aseptic technique when giving a urine sample.]
Leukocyte Esterase: Leukocyte esterase is an enzyme present in your white blood cells. Therefore, the presence of this substance in the urine indicates the presence of white blood cells (leukocyturia). White blood cells in the urine may indicate inflammation of the kidneys or urinary tract due to bacterial infection. It is important to note, however, that contamination of the urine can also cause the presence of white blood cells in the urine, so remember to practice proper aseptic technique when giving the sample.
Nitrite: Bacteria can convert nitrate to nitrite; therefore, the presence of nitrite in the urine usually indicates a bacterial infection (i.e., a urinary tract infection). However, not all bacteria can convert nitrate to nitrite, so it is possible to have a urinary tract infection while also having a negative nitrite test.
Bilirubin: Bilirubin is made by the liver from old red blood cells; it is then processed by the intestine and excreted from the body. Therefore, healthy individuals do not have bilirubin in their urine. The presence of bilirubin in the urine indicates that the liver is allowing the substance to leak back into the blood. This can be an early indication of liver disease, even when other symptoms, such as jaundice, are not present.
The microscopic examination uses a microscope to identify and count cells, crystals, bacteria, mucous, and other substances that may be present in the urine. The amount of a substance present is reported one of two ways: as a count with the microscope strength used to view the substance [“per low power field” (LPF) or “per high power field” (HPF)], or as an approximate amount (“rare,” “few,” “moderate,” or “many”).
Red Blood Cells: The microscopic examination looks at how many red blood cells are present per HPF. As discussed above, the presence of red blood cells in the urine can indicate a problem, such as a disease of the kidney or urinary tract, trauma, medications, smoking, or intense exercise (e.g., running a marathon). However, contamination of the urine sample with menstrual blood or hemorrhoids cannot be distinguished from the presence of red blood cells in the sample. Therefore, it is very important to tell your physician if you are menstruating or are experiencing any other condition that could contamination your urine sample. It is also very important that you speak to your lab technician about proper aseptic technique when giving a urine sample.
White Blood Cells: A high number of white blood cells in the urine indicates inflammation of the kidneys or urinary tract. Like the test for red blood cells, this test can be misread if the sample is contaminated; in this instance, contamination can occur from vaginal secretions, which are high in white blood cells. Therefore it is important that you speak to your lab technician about proper aseptic technique before giving a urine sample.
Epithelial Cells: The tissue that lines the surfaces of cavities and structures in your body is called epithelial tissue. In healthy individuals, epithelial cells from the bladder and external urethra are normally present in the urine in small amounts. However, the amount of epithelial cells in the urine increases when someone has a urinary tract infection or some other cause of inflammation. Your doctor will evaluate the source of the problem by evaluating the type of epithelial cells that are present. For example, the presence of renal tubular epithelial cells (from your kidneys) may indicate kidney involvement. The presence of squamous epithelial cells may indicate contamination of the urine specimen.
Casts: Casts are formed in the tubules of they kidney when the tubules secrete a protein called Tamm-Horsfall protein. The origin of the casts causes them to take on a tubular or hotdog-like shape. These casts are known as hyaline casts and can be present in normal adults on the order of 0-5 per LPF. Strenuous exercise can cause more hyaline casts to be present. However, casts made from red or white blood cells indicate problems in the kidney. Red blood cells that stick together and form red blood cell casts usually indicate problems with the glomeruli, tiny ball-shaped structures in your kidneys that help filter blood and prevent the loss of valuable substances, such as blood cells and proteins. White blood cells casts indicate inflammation in the kidney. Cellular casts that remain in the nephron of your kidney for a long time before they are flushed out become granular casts and eventually waxy casts.
Bacteria: Bacteria in your urine can suggest infection, especially if you have other suggestive symptoms. If your doctor suspects that you may have a urinary tract infection, she/he will most likely order a culture or count of the bacteria. However, bacteria on the skin can also contaminate the urine sample and skew the results, so it is very important that you understand proper aseptic technique when giving a urine sample.
Crystals: Crystals can be present in the urine of healthy individuals; these crystals form when the pH, solute concentration, and temperature of your urine are within a specific range. If these crystals are made of substances that are supposed to be in urine, such as calcium oxalate or phosphate, then they are considered to be normal. Crystals made of substances that are not usually present in urine, such as cystine, tyrosine, or leucine (amino acids), are uncommon and usually indicate liver disease or some other abnormal process.
Urticarial vasculitis is a form of vasculitis that affects the skin, causing wheals or hives and/or red patches due to swelling of the small blood vessels.
What causes Urticarial Vasculitis?
The cause of most cases of urticarial vasculitis is unknown. It may be associated with a number of diseases, especially systemic lupus erythematosus, rheumatoid arthritis and Sjögren’s syndrome. Some cancers, including leukemias, colon and pancreatic, and infections like Hepatitis B and C can cause this form of vasculitis. So can some drugs, including antibiotics, ACE inhibitors used for treating high blood pressure, and certain diuretics.
How common is it?
Urticarial vasculitis is uncommon. There are no well researched estimates of how frequent it is.
The most common symptoms are hives that cause itching, pain and a burning feeling. Skin patches often are red-rimmed with white centers, and unlike common hives may have petechia, or bleeding under the skin. The patches can be present for days and result in skin discoloration as they heal. Some patients may also have fevers, joint and abdominal pain, shortness of breath and swollen lymph glands. Sometimes urticarial vasculitis even causes injury to vital organs including the gut, lungs and kidneys.
Diagnosis is based on characteristic patches in the skin. Sometimes a biopsy is ordered to show inflammation in the skin and damage of small blood vessels with white blood cells. Since it’s often associated with a number of different diseases, it’s often necessary to do other tests and exams to rule out underlying conditions like lupus erythematosus or cancer. Tests of vital organs may also be indicated, especially when the blood levels of complement are low.
Treatment depends on the extent of symptoms and organ involvement. When levels of complement are normal and there is no internal organ involvement or underlying disease, the symptoms may improve on their own or with minimal treatment. In this case, antihistamines or nonsteroidal drugs such as ibuprofen or naproxen may be helpful. For more severe cases, other drugs which affect the immune system may be needed, such as corticosteroids (prednisone, others), hydroxychloroquine, colchicine, dapsone; and chemotherapies like azathioprine or cyclophosphamide. Treatment may be intermittent, although it is not uncommon for patients to need treatment for several years.
What are the complications?
The most common serious complications are skin pigmentation and, occasionally, skin ulcers, plus damage to organs such as the lungs, eyes and kidneys.
The natural history of urticarial vasculitis depends in part upon the blood complement levels. In cases where these are normal, the prognosis is generally good. In cases where the complements are low, the disease may be more severe. When urticarial vasculitis is related to a disease such as lupus or cancer, its prognosis is often governed by the prognosis of the underlying disease.
It Happens Like THIS:
What is a Hypersensitivity Reaction?
In our case, when we are exposed to Ultraviolet – Antibodies & Immune Complexes Are Triggered & Cause a Hypersensitivity Type 3 Reaction:
My Personal Experience With Urticarial Vasculitis
Those rashes up there are all mine. They all ITCHED horribly, a deep DEEP intractable painful burning type itch that could not be relieved. Like a friend said, like poison ivy times 100. On several occasions my arm tingled and I had some muscle weakness. I get mine with hard nodules under my skin- you can feel them, hard lumps right on the itch that hurt when you touch or press them.
Mine are always activated by UV exposure. I live in the desert where the summer months are killer-and I spend most of my time indoors to avoid lupus flare ups. But it always gets me! I have double blackout drapes on my windows and that makes me pretty safe indoors-but noone can stay indoors ALL the time!
I almost always flare with the urticaria combined with uveitis (inflammation in the iris of eye), nose sores & mouth sores and my malar rash becomes prominent. Sometimes I get low grade fevers and fatigue with the reaction.
My rashes respond pretty well to betamethazone steroid cream and usually 40mg of prednisone for a few days with an immediate taper down to 0. I take plaquenil and cellcept to control my lupus on a daily basis and it works well for me. I’m extremely lucky that my rashes usually start healing after 24 to 48 hours. Sometimes I end up with discolored skin (see above photo on left). Sometimes I end up with skin so hard on my face-it looks like I’m getting a chemical peel! The skin underneath is usually fine.
I’ve had rash reactions that don’t stop at lupus or urticaria- I’ve had autoimmune pemphigus rashes like this one on the back of my neck- and I get malar rashes like most lupus patients do! But I always recover! 😀
If you have any questions- feel free to ask! I’m happy to help!
Best to You! JJ
My Pemphigoid Rash
More Urticaria Vasculitis Info-explained by Dr Donald Thomas, author of “The Lupus Encyclopedia “. You can follow him on twitter at @lupuscyclopedia
Urticarial vasculitis is a less common form of vasculitis seen in people who have lupus. The areas of vasculitis look similar to hives (the medical term for hives is “urticaria”).
The skin lesions of urticarial vasculitis are typically slightly raised areas of skin that are tender to the touch. When they heal, they often leave pigment changes on the skin. Usually a skin biopsy is required to diagnose urticarial vasculitis accurately.
Doctors usually check SLE patients who develop vasculitis for substances in the blood called cryoglobulins. “Cryo-”comes from the Greek word for “cold,”while “globulins”refer to antibodies. These particular antibodies precipitate and clump together with cooler temperatures.
“Precipitation”is a scientific term meaning that a substance in a liquid solidifies; for example, if you warm up a pan of water and pour in a bunch of salt, the salt dissolves in the water. When the water then cools down in the refrigerator, salt begins precipitating out of the water as salt crystals on the edges of the pan. What happens in people who have cryoglobulinemia (cryoglobulins in their blood) is that the cryoglobulins can clump together and precipitate in parts of the body that are cooler than other parts.
This may occur in the cooler skin of the legs, causing bruised appearing areas and inflammation of the blood vessels (vasculitis). Doctors treat this condition with high doses of steroids along with immunosuppressants. Sometimes doctors have to use a special type of treatment called plasmapheresis, which removes the cryoglobulins from the blood.
Sometimes vasculitis of the skin can occur along with vasculitis in other organs of the body such as the kidneys.
Therefore, if you develop the symptoms of vasculitis, it is important to see your doctor immediately to make sure this is not the case.
Most of the time, cutaneous vasculitis occurs by itself, without involvement of internal organs, but it is important that your doctor checks you thoroughly, especially the first time it happens.