Essential Medication Reconciliation: A Hidden Cause of Proteinuria

Introduction: Alpha-lipoic acid (ALA) is an organic compound which is becoming a popular dietary supplement in many chronic conditions. We review the case of an older male whose new proteinuria rapidly improved after discontinuation of ALA. Case Description: A 66-year-old male with medical history significant for prostate cancer post resection and prediabetes was referred to the nephrology clinic for worsened proteinuria. He had been on multiple supplements initiated by his primary care physician including nattokinase, chromium picolinate, and ALA. He had a normal physical exam and normal creatinine between 0.9-1 mg/dL. Further workup was negative for hepatitis, HIV, syphilis, autoimmune disease, primary membranous nephropathy, and monoclonal gammopathies. The patient was initiated on an angiotensin receptor blocker and advised to stop taking ALA. Within 1 month, his proteinuria reduced by approximately 55%, and within 8 months, he had complete resolution of proteinuria. Kidney biopsy was not pursued given absence of nephrotic syndrome and stable kidney function. Discussion: ALA is a supplement growing in popularity for its use in diabetes, multiple sclerosis, Alzheimer's, and schizophrenia to reduce neuropathic symptoms and improve weight loss, memory, and balance. ALA was thought to be the cause for this gentleman’s presentation since chromium has only been associated with acute tubular necrosis and chronic kidney disease, and nattokinase has not been reported to cause proteinuria. Despite therapeutic promise, emerging evidence implicates ALA supplementation with unwarranted proteinuria. NELL1+ membranous nephropathy has been observed within 2 to 12 months of starting ALA supplementation and remission is largely achieved within 1 year of supplementation cessation, suggesting the nephropathy’s reversibility. This case highlights the importance of a thorough medication reconciliation especially when approaching new proteinuria for which no other obvious risk factors are present.Discontinuation of ALA (star) improved urine albumin creatinine ratio (UACR) and urine protein creatinine ratio (UPCR).