Chyluria Associated with Nephrotic-Range Proteinuria: Pathophysiology, Clinical Picture and Therapeutic Options

Graziani, G.; Cucchiari, David; Verdesca, Simona; Balzarini, Luca; Montanelli, Alessandro; Ponticelli, Claudio

doi:10.1159/000329154

Cited by 37 publications

(41 citation statements)

References 32 publications

(20 reference statements)

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“…3,10 Other invasive treatments include laser cauterization, povidone-iodine or silver nitrate sclerotherapy, laparoscopic renal pedicle lymphatic disconnection or even autotransplantation. 7,[15][16][17][18][19][20][21] As in other previously reported cases, 6,[22][23][24] the present patient had observed by herself improvement of milky urine soon after fed on low fat meal. In patients with chyluria the urine turns cloudy and milky within 1 h and 4 h after a fatty meal.…”

Section: Discussionsupporting

confidence: 88%

“…However, lipiduria is not expected to make the urine cloudy or milky or with clots. 3,7 On the other hand, chyluria does not exhibit oval fat bodies or fatty casts. 8 Triglycerides are the main components in chyluria whose composition is similar to the intestinal chyle, 6,9 and the charge of excreted fat may reach 20% of the ingested fat.…”

Section: Discussionmentioning

confidence: 99%

“…7 In order to find the site and the etiology of the lymph urinary fistula, lymphography or lymphoscintigraphy 3,14 and abdominal ultrasonography, computer tomography and magnetic resonance could be performed as noninvasive methods, 3,7,10 while cystoscopy followed by ureteroscopy and pyeloscopy as invasive methods. 3,7,10 In the present case, the lymphoscintigraphy only confirmed leakage of lymph into urinary tract. Only by ureteroscopy and pyeloscopy was possible to find the unspecific caliceal lesions whose cauterizations resulted in temporary improvement of the chyluria.…”

Section: Discussionmentioning

confidence: 99%

“…6 In other previously reported cases, the patients remain for several months in remission. 6,7,23 Some authors have pointed out that in spite of the recognized benefits of this diet, surprisingly, it has not been extensively employed. 7 In this case, the patient experienced a dramatic improvement of her urine appearance after her adaptation with low-fat/high-protein diet with EFA source without MCT.…”

Section: Discussionmentioning

confidence: 99%

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Good response of low-fat/high-protein diet in a patient with chyluria

et al. 2013

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Chyluria is an inappropriate urinary excretion of chyle that turns the urine milky. A nutritional approach based on low-fat/high-protein content diet associated or not with medium-chain triglyceride (MCT) showed to be an efficient conservative treatment to improve the milky urine appearance in a patient with chyluria. Case report: A 30-year-old female patient was admitted with chyluria of unknown etiology. An ureteropyeloscopy revealed a single lesion in each kidney, both with linear aspect and measuring 5 mm in extension. These lesions were located close to the renal papillae and were leaking a cloudy and milky fluid. Both lesions were laser cauterized followed by improvement of the milky urine. However, the chyluria relapsed after few months and a low-fat/high-protein content diet with 10 g of soybean oil to meet the requirements essential fatty acids (EFA) and with MCT from coconut oil as alternative to prepare foods was started. Few weeks later the patient returned reporting consistent improvement of the milky urine appearance related with the use of the diet. However since the diet was tasteless and time consuming to prepare, she reported low compliance to diet with MCT and the milky urine relapsed. The MCT was discontinued and the diet with EFA source was maintained with better compliance. Since then the chyluria remains in remission. In conclusion, the dramatic improvement of the milky urine with low-fat/high-protein diet with EFA source observed in our patient demonstrates that this nutritional approach is efficient with fast results to treat chyluria during long term.

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Good response of low-fat/high-protein diet in a patient with chyluria

et al. 2013

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“…Diet of medium-chain triglycerides is the major conservative treatment. 4 Intrarenal silver nitrate instillation, laparascopic pedicle mobilization, and surgical treatment are proposed invasive procedures.3,4 However, the high rate of spontaneous remission suggest conservative treatment in most cases.In our case, military training was suggested to be the cause of the chyluria. Cystourethroscopy affords the direct observation of chylus reflux and confirmation of the disease.…”

mentioning

confidence: 99%

Chyluria

Wang

2014

Nephrology

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A 22-year-old healthy soldier, born and living in Taiwan, presented with passage of milky white urine of 2 months duration. He had weight loss of 11 kg within one month. The urine appeared milky and turbid with its turbidity increasing obviously after a meal. His serum triglyceride levels were 55 mg/dL and total protein levels were 6.2 g/dL. Urine analysis demonstrated proteinuria (5.3 g per day), triglyceriduria (226 mg/dL), and chylomicronuria. All these findings indicated the presence of chyluria.Enzyme-linked immunosorbent assay for circulating Wuchereria bancrofti antigens was negative. The computed tomography of the abdomen revealed normal kidneys and urinary tract. No other infections or tumours were found. The lymphoscintigraphy and retrograde pyelogram disclosed no remarkable extravasation around the pelvicalyceal system. He underwent a flexible cystourethroscopy that showed efflux of milky urine (Fig. 1, right side) from the right ureteral orifice and clear urine ( Fig. 1, left side) from the left side. The protein concentrations of urine sample obtained from the right side and the left side ureter were 1086 mg/dL and 15 mg/dL, respectively. He was given a diet of medium chain triglycerides and attained spontaneous remission 3 months later.Chyluria is not uncommon in Asia, especially in Japan, India, Hong Kong, and Taiwan.1,2 It is characterized by the passage of chyle in urine, and develops as a result of communication between obstructed lymphatic vessels and the urinary tract. 3 The clinical symptoms include passage of milky urine, weight loss, and unilateral flank pain.Diagnosis of chyluria is based on the presence of chyle in urine. Lympho-renal fistula can be localized by flexible cystoscopy, computed tomography, or lymphangiography. 1Most reported cases are secondary to parasitic infections, in particular, Wuchereria bancrofti or Brugia malayi infection. 2,3Other causes include tuberculosis, pregnancy, neoplasms, trauma, surgery and congenital diseases. 1-3Anthelmintic drugs are effective for parasite-induced chyuria. Diet of medium-chain triglycerides is the major conservative treatment. 4 Intrarenal silver nitrate instillation, laparascopic pedicle mobilization, and surgical treatment are proposed invasive procedures.3,4 However, the high rate of spontaneous remission suggest conservative treatment in most cases.In our case, military training was suggested to be the cause of the chyluria. Cystourethroscopy affords the direct observation of chylus reflux and confirmation of the disease. This patient was treated by limiting fat intake and had a good response. We posited the possibility of chyluria after vigorous exercise, such as military training. Conservative treatment can be used for early and mild chyluria.

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