Nephrotic syndrome

Initial work-up

Quick tip: spot urine protein:creatinine ratio (uPCR) has replaced 24 hour urine collection as first line for quantifying proteinuria.

Quick tip: albuminuria refers to albumin loss in the urine and proteinuria refers to all protein losses in the urine - so proteinuria includes albumin losses, but albuminuria does not include all potential urine protein losses in conditions such as myeloma.

Nephrotic syndrome consists of the triad of

Peripheral oedema
Low serum albumin (<30 g/L)
High urinary protein loss (urine PCR >300mg/mmol or urine ACR >250 mg/mmol)

Nephrotic syndrome is an umbrella term for multiple conditions that lead to a leaky glomerular basement membrane. These conditions can often only be differentiated by renal biopsy but initial management of all patients with nephrotic syndrome is similar.

Patients typically present with new onset peripheral oedema. Commonly associated, though not diagnostic, features include;

Foamy urine
Fluid-related weight gain
New or worsening hypertension
Hypercholesterolaemia
Ascites and/or pleural effusions

Key initial investigations;

Serum albumin <30g/L AND
Urinary protein:creatinine ratio (uPCR) >300mg/mmol

Occasionally the cause of peripheral oedema is misdiagnosed as heart failure if the serum albumin is not dramatically reduced, so all patients with “?new heart failure” should have a urine dip and urine PCR if serum albumin is low.

Clearly many hospitalised patients with a severe inflammatory response (for example due to sepsis) or decompensated liver cirrhosis will have low serum albumin and peripheral oedema, hence getting the urinalysis and urine PCR is key to diagnosis.

Notes on uPCR;

Has replaced 24 hour urine collection as first line to quantify proteinuria
uPCR of >300mg/mmol is roughly equivalent to 3g of protein loss per day
Equivalent urine albumin:creatinine ratio is roughly >250mg/mmol (urine ACR is an acceptable alternative test to uPCR)

The most common mistake made is requesting the wrong test, such as ‘urine protein’ alone rather than protein:creatinine ratio.

Making the diagnosis based on the classic triad is sufficient to refer the patient to nephrology to consider further management including biopsy, but see the ‘additional work-up’ section for interest.

Additional work-up

Quick tip; nephrotic patients are highly salt avid so may require multiple diuretics to block different portions of the nephron, in order to achieve negative fluid balance and blood pressure control.

Refer to renal if you suspect a new nephrotic syndrome and they will usually arrange urgent review to consider renal biopsy. Primary causes include minimal change disease, membranous nephropathy and focal segmental glomerulosclerosis. These are more likely if the patient does not have diabetes and has a negative myeloma screen.

If the patient has long standing diabetes (especially with diabetic complications) and has had a gradual increase in proteinuria, then this typical history is sufficient to be confident their nephrotic syndrome is secondary to diabetic nephropathy. This allows renal biopsy to be avoided in most cases, however the patient should still be referred through to renal for outpatient input.

Sometimes nephrotic syndrome is caused by secondary causes such as amyloidosis, infections, cancers and medications.

Disease on biopsy	Association
Diabetes	N/A
Amyloidosis	Primary amyloidosis or secondary to chronic inflammatory response eg. rheumatoid arthritis, bronchiectasis
Minimal change disease	Hodgkin lymphoma, NSAIDs, lithium
Membranous nephropathy	Malignancies, SLE and other autoimmune disorders, hepatitis B and C, NSAIDs, penicillamine, infection
Focal segmental glomerulosclerosis (FSGS)	Obesity, hypertension, sickle cell disease, HIV, hepatitis C, heroin, pamidronate
Membranoproliferative glomerulonephritis	Plasma cell dyscrasias, autoimmune disease, hepatitis B and C, essential cryoglobulinaemia

What additional blood tests might be helpful?

Cholesterol – raised in nephrotic syndrome, additional support for diagnosis
Blood sugar and HbA1c; steroid treatment risks causing hyperglycaemia
Serum immunoglobulins, serum electrophoresis, serum free light chains
Routine auto-antibodies, particularly ANA and double-stranded DNA
Hepatitis B & C, HIV
Anti-streptolysin O titre (ASOT)
Complement C3 and C4
B-HCG in women of child-bearing potential
Anti-PLA2R; a specialist test that is specific for membranous nephropathy

Treatment

Quick tip; risk of VTE in nephrotic patients is at least 10 times higher than in the general population. Fifty percent of VTE in patients with nephrotic syndrome occurs prior to diagnosis, so consider urine dip in patients presenting with unprovoked VTE.

VTE and anticoagulation

Nephrotic patients are at very high risk of VTE, partly due to loss of antithrombin III in the urine
Clinical findings suggesting DVT, PE or renal vein thrombosis (eg. flank pain, enlarged kidney on ultrasound) need to be investigated urgently. Risk of intra-arterial thrombosis is also increased.
Common practice in the UK is to give treatment dose low molecular weight heparin if serum albumin <20g/L to all patients with nephrotic syndrome without contraindication, though no cut-off value is supported by good evidence.

Note that nephrotic patients are also at high risk of infection, in part due to loss of immunoglobulins and complement components in the urine.

How to help prepare patient for renal biopsy ahead of renal admission?

Coagulation screen, group and save
Ultrasound abdomen; ensure patient has two kidneys of good size (would likely not do biopsy if single kidney). Also helpful to rule out liver cirrhosis as cause peripheral oedema (though clearly this will not cause heavy proteinuria)
Treat hypertension. Diuretics are first line, and multiple diuretics to block different portions of the nephron may be required as the patients are highly salt avid. Higher doses of loop diuretics are needed in hypoalbuminaemia. Next line agents include ACE inhibitors (depending on renal function), amlodipine and doxazosin. Systolic blood pressure generally needs to be below 160mmHg systolic for renal biopsy, as high blood pressure increases bleeding risk (the major complication)
Plan suspension of anticoagulation around timing of biopsy

Discharge checklist

Salt and fluid restriction advice?
ACE inhibitor required (often used for its anti-proteinuric effects even if no hypertension?)
Immunosuppression weaning plan in place?
Follow-up booked?
Need a statin?
On bone and stomach protection if on steroids?
Anticoagulation plan?
Handed over to GP that pneumococcal and flu vaccine recommended?

References;

Diagnosis and management of nephrotic syndrome in adults. Kodner C. Am Fam Physician. 2016;93(6):479-485
Nephrotic syndrome redux. Glassock R, Fervenza FC, Hebert L and Cameron JS. Nephrology Dialysis Transplantation. 2015;30(1):12-17
High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome: results from a large retrospective cohort study. Mahmoodi BK et al. Circulation. 2008;117(2):224-30

Referral indications

These indications are broadly accepted nationally and in keeping with NICE guidance, but do check local referral guidelines in case they differ.

Immediate admission from primary care via local general medical take or to renal ward;

Stage 3 AKI where the cause is unclear, there are complications (hyperkalaemia, acidosis, oligo-anuria or fluid overload, discussed in more detail later) or where patients with suspected pre-renal AKI are not responding to treatment as expected
Hyperkalaemia ≥6.5 mmol/L
Hypertensive emergency = BP >180/>120 with evidence of papilloedema or life-threatening symptoms (new onset confusion, chest pain, AKI, or heart failure)
Suspected systemic vasculitis with renal involvement

Urgent outpatient review;

Nephrotic syndrome
Unexplained recent AKI Stage 1 or 2

Routine outpatient review;

eGFR <30ml/min/1.73m2 (i.e reaching CKD G4)
uACR >70mg/mmol unless known to be caused by diabetes and already appropriately treated
uACR >30mg/mmol, together with asymptomatic non-visible haematuria, after exclusion of UTI
If over course of one year
- Sustained >25% fall in eGFR and change in CKD category, or
- Sustained decrease in eGFR by >15ml/min/1.73m2
Suspected renal artery stenosis; >30% rise in serum creatinine (or >25% fall in eGFR) upon initiation or up-titration of ACEi or ARB (or Entresto) after exclusion of alternative causes (eg. hypovolaemia), resistant hypertension, or pulmonary oedema in absence severe heart disease
Known or suspected rare or genetic causes of CKD (eg. ADPKD)
Suspected complication of CKD not meeting other criteria; renal anaemia, CKD mineral bone disease, metabolic acidosis, hyperkalaemia
Poorly controlled hypertension despite use of 4 antihypertensive drugs at therapeutic doses, or hypertension in those aged <40 without obvious cause (though this service may be run by endocrinology/ cardiology depending upon local preferences)

Urology referral;

CKD or AKI with renal outflow obstruction should be referred to urological services, unless urgent medical intervention is required (eg. for treatment of hyperkalaemia)
Visible haematuria in absence of UTI (NICE)
- Two week wait if aged >45
- ‘Urgent’ if aged <45
Non-visible haematuria on two occasions in absence of UTI (must be at least one plus, not ‘trace’, on the urine dip)
- Two week wait if >60 AND have either high serum WCC OR dysuria
- Otherwise British Association of Urological Surgeons recommend non-urgent Urology referral (NB. local protocols vary significantly, if in doubt contact your local Urology team for a copy of their referral criteria).
- Refer to renal with asymptomatic microscopic haematuria if uACR>30mg/mmol, occurs alongside proteinuria (to any degree), hypertensive or inherited cause suspected
Note recurrent UTIs without CKD should be referred to Urology, not renal
Patients with an angiomyolipoma (AML) on imaging should be referred to Urology in line with local guidelines, but if multiple AMLs present then also nephrology to consider a diagnosis of tuberous sclerosis.
Incidental renal cysts on imaging should be referred to Urology if there is concern about malignancy (see final reference for link to Bosniak classification of renal cysts). However, if the appearance is of simple cysts in the context of a family history of cystic kidney disease, or if imaging suggests polycystic kidney disease, then patient should be referred to nephrology.

References

https://www.nice.org.uk/guidance/cg182/chapter/1-Recommendations#referral-criteria

https://www.baus.org.uk/_userfiles/pages/files/Publications/BAUS%20Cancer%20Guidelines%20Summary.pdf

https://www.cua.org/themes/web/assets/files/cua_guideline_on_the_management_of_cystic_renal_lesions.pdf

Pregnancy and the kidney

We have subdivided this module about pregnancy and the kidney into 4 subheadings;

AKI
CKD
Transplant
Medications

AKI

Quick tip; in pregnancy it is normal for the creatinine to fall (from a mean of 60 μmol/L to a mean of 47 μmol/L). Therefore you need to be more alert to detect AKI, as a 50% increase in creatinine may still be in the ‘normal range’.

Quick tip; although fertility is often reduced in advanced CKD or dialysis, women of a childbearing age should be proactively counselled regarding contraception

All the usual causes of AKI are possible in pregnancy e.g. sepsis, hypovolemia, heart failure, acute interstitial nephritis (see AKI section) but there are a few pregnancy-specific causes of AKI to also consider.

1st trimester:

Severe hyperemesis gravidarum (morning sickness)
Septic abortion

2nd and 3rd trimesters (or postnatally):

Pre-eclampsia / HELLP syndrome (haemolysis, elevated liver enzymes and low platelets)
TTP/ HUS / undifferentiated thrombotic microangiopathy
Acute fatty liver of pregnancy
Pyelonephritis or puerperal sepsis
Amniotic fluid embolism
Massive haemorrhage and acute cortical necrosis

In most cases the investigations and treatment is the same as in AKI outside pregnancy. Key tips include:

Acute glomerulonephritis can present during pregnancy (e.g. lupus nephritis). In AKI always perform urine dipstick and send urine for spot protein:creatinine ratio. Consider an autoimmune screen.
Oliguria can be seen with preeclampsia but IV fluid is generally avoided due to the risk of iatrogenic pulmonary oedema
Clinically differentiating TTP, aHUS and severe preeclampsia with HELLP syndrome is very challenging - to get started request an urgent ADAMTS-13 through local renal or haematology services to investigate for TTP

If concerned about potential aHUS contact the on-call national centre in Newcastle: www.atypicalhus.co.uk/contact-us/

It is normal to see dilation of the renal collecting system on ultrasound in late pregnancy, often more apparent on the right. Post-renal AKI is rare in pregnancy, though can be caused by uterine compression of the ureters or ureteric injury during C-section

CKD

Women with CKD often have pre-existing hypertension and are on antihypertensives. Upon becoming pregnant target blood pressure <135/<85mmHg.
Women with CKD require enhanced monitoring and joint care between nephrology and obstetrics; most regions have a specialty clinic serving this purpose.
Blood pressure often falls in early pregnancy. Appropriate antihypertensive treatment (see medication section) should be continued unless consistently <110/<70, or there is symptomatic hypotension.
Low-dose aspirin (75-150mg) indicated from 12 weeks to reduce the risk of pre-eclampsia.
Pre-eclampsia is usually diagnosed when proteinuria and hypertension develop in late pregnancy. It is more common in women with CKD and harder to diagnose e.g. if proteinuria or hypertension are already present

Transplant

Whilst it is possible for women to become pregnant with either advanced CKD or who are dialysis-dependent, it is especially important to consider and appropriately counsel women of child bearing age regarding potential return of fertility in the post-transplant period.
Ideally pregnancy should be avoided in the first twelve months post-transplantation to allow for a period of stability in the new graft.
In women planning pregnancy post-transplantation, azathioprine is the antimetabolite of choice.

Medications

Quick tip; Prednisolone, azathioprine, hydroxychloroquine, ciclosporin and tacrolimus are safe in pregnancy.

Women with kidney disease are likely to be on medications which require review before pregnancy, but they may inadvertently become pregnant while on them. Below advice from Wiles et al, BMC nephrology 2019.

Labetalol, nifedipine and methyldopa are safe in pregnancy and are commonly used to control BP in pregnancy.
ACE-inhibitors are fetotoxic but can be used with caution into the first trimester. Therefore, some women are advised to stay on ACEi until they become pregnant, and the risk is weighed against the strength of indication for ACEi and the likelihood of confirming pregnancy within the first trimester. Once pregnant, women should switch to one of the pregnancy-safe antihypertensive options above. It is recommended that angiotension 2 receptor blockers are stopped pre-pregnancy.
Aspirin and low molecular weight heparin are safe in pregnancy.
Prednisolone, azathioprine and hydroxychloroquine are safe in pregnancy. Ciciclosporin and tacrolimus are safe but dose requirements will change, and levels should be checked more frequently during pregnancy and post-partum.
MMF, methotrexate and cyclophosphamide are teratogenic.
Women can breastfeed whilst taking prednisolone, hydroxychloroquine, azathioprine, ciclosporin, tacrolimus, enalapril, captopril, amlodipine, nifedipine, labetalol, atenolol and low molecular weight heparin.

References

Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L, Mohamed G, Mukherjee D, Nelson-Piercy C, Webster P, Whybrow R. Clinical practice guideline on pregnancy and renal disease. BMC nephrology. 2019 Dec 1;20(1):401.
Harel Z, McArthur E, Hladunewich M, Dirk JS, Wald R, Garg AX, Ray JG. Serum creatinine levels before, during, and after pregnancy. Jama. 2019 Jan 15;321(2):205-7.
Vijayan M, Avendano M, Chinchilla KA, Jim B. Acute kidney injury in pregnancy. Current opinion in critical care. 2019 Dec 1;25(6):580-90.
https://www.nice.org.uk/guidance/ng133
Steddon S, Chesser A, Cunningham J, Ashman N. Oxford handbook of nephrology and hypertension. Oxford University Press; 2014.

The contents of these pages were created with great care. For the accuracy, completeness and timeliness of content, we can not take any responsibility. As a service provider we are responsible according §7 1 TMG for own contents on these pages under the general laws. According to §8 to 10 TMG we are not obligated as a service provider to monitor transmitted or stored information, or to investigate circumstances that indicate illegal activity. Obligations to remove or block the use of information under the general laws remain unaffected. However, a relevant liability is only possible from the date of knowledge of a specific infringement. Upon notification of such violations, we will remove the content immediately.

Privacy Policy of Buku Haematology

This Application collects some Personal Data from its Users.

This document can be printed for reference by using the print command in the settings of any browser.

Owner and Data Controller

Buku Haematology - Newcastle - United Kingdom

Owner contact email: bukuhaem@gmail.com

Types of Data collected

Buku Haematology (The Owner) records no personally identifiable data. The following usage data are collected by default by the host of our App, AppYourself GmbH. This data is then managed as per their privacy policy below.

System Version
Smartphone model
Hardware ID (https://help.pushwoosh.com/hc/en-us/articles/360000365023-What-is-a-HWID-)
Opening of each module together with the time of the action
Date of register

Data will only be shared by AppYourself in accordance with their Privacy Policy.

Buku Haematology (owned by Buku Tech Ltd) retain none of this data. We can see our user traffic, country of access and modules accessed. Unique identifiers are generated for each user by the AppYourself system to show the number of times the App is accessed and which modules are viewed by individuals. No further information about the individual is given.

AppYourself privacy policy

We (Buku Haematology) have removed those elements that we have chosen not to include in the App (such as Facebook integration for example). Please contact privacy@appyourself.net if you have any questions about personal data storage.

Among the types of Personal Data that this Application collects, by itself or through third parties, there are: Cookies; Usage Data; various types of Data; unique device identifiers for advertising (Google Advertiser ID or IDFA, for example); Storage permission; geographic position.

Complete details on each type of Personal Data collected are provided in the dedicated sections of this privacy policy or by specific explanation texts displayed prior to the Data collection.

Personal Data may be freely provided by the User, or, in case of Usage Data, collected automatically when using this Application.

Unless specified otherwise, all Data requested by this Application is mandatory and failure to provide this Data may make it impossible for this Application to provide its services. In cases where this Application specifically states that some Data is not mandatory, Users are free not to communicate this Data without consequences to the availability or the functioning of the Service.

Any use of Cookies – or of other tracking tools – by this Application or by the owners of third-party services used by this Application serves the purpose of providing the Service required by the User, in addition to any other purposes described in the present document and in the Cookie Policy, if available.

Mode and place of processing the Data

Methods of processing

In some cases, the Data may be accessible to certain types of persons in charge, involved with the operation of this Application (administration, sales, marketing, legal, system administration) or external parties (such as third-party technical service providers, mail carriers, hosting providers, IT companies, communications agencies) appointed, if necessary, as Data Processors by the Owner. The updated list of these parties may be requested from the Owner at any time.

Legal basis of processing

The Owner may process Personal Data relating to Users if one of the following applies:

Users have given their consent for one or more specific purposes. Note: Under some legislations the Owner may be allowed to process Personal Data until the User objects to such processing (“opt-out”), without having to rely on consent or any other of the following legal bases. This, however, does not apply, whenever the processing of Personal Data is subject to European data protection law;
provision of Data is necessary for the performance of an agreement with the User and/or for any pre-contractual obligations thereof;
processing is necessary for compliance with a legal obligation to which the Owner is subject;
processing is related to a task that is carried out in the public interest or in the exercise of official authority vested in the Owner;
processing is necessary for the purposes of the legitimate interests pursued by the Owner or by a third party.

In any case, the Owner will gladly help to clarify the specific legal basis that applies to the processing, and in particular whether the provision of Personal Data is a statutory or contractual requirement, or a requirement necessary to enter into a contract.

Retention time

Personal Data shall be processed and stored for as long as required by the purpose they have been collected for.

The Owner records no personal data, and therefore usage data is the only data retained, and this is retained by AppYourself.

Once the retention period expires, Personal Data shall be deleted. Therefore, the right to access, the right to erasure, the right to rectification and the right to data portability cannot be enforced after expiration of the retention period.

The purposes of processing

The Data concerning the User is collected for the following purposes: Analytics, Hosting and backend infrastructure, Data transfer outside the EU, Device permissions for Personal Data access, Displaying content from external platforms, Infrastructure monitoring, Registration and authentication, and Location-based interactions.

For specific information about the Personal Data used for each purpose, the User may refer to the section “Detailed information on the processing of Personal Data”.

Detailed information on the processing of Personal Data

Key facts about data control by AppYourself;

The servers used by AppYourself are located in Europe (and thus protected by GDPR) and the US.
The data is hosted on AWS infrastructure, but AWS does not store any user-related data. User-related data is stored by AppYourself in Google Firebase. The storage is located in USA.
Although the Google Firebase server (based in the US) is not secured by GDPR they operate under the EU-US privacy shield. For more information about cloud-sided encryption see; https://firebase.google.com/support/privacy#data_encryption. Google Firebase is also compliant with ISO27001. For more information see; https://firebase.google.com/support/privacy#firebase_is_certified_under_major_privacy_and_security_standards
User data is stored for up to 90 days after App subscription is terminated. Furthermore, users have the right to delete their profile at any time. By doing so, their account is irretrievably deleted.
In case of a data breach by AppYourself, this can be reported via https://iapp.org/resources/article/how-to-notify-your-dpa-of-a-data-breach/

Personal Data is collected for the following purposes and using the following services:

Analytics

The services contained in this section enable the Owner to monitor and analyze web traffic and can be used to keep track of User behavior.

Google Analytics for Firebase (Google LLC)

Google Analytics for Firebase or Firebase Analytics is an analytics service provided by Google LLC.

In order to understand Google's use of Data, consult Google's partner policy.

Firebase Analytics may share Data with other tools provided by Firebase, such as Crash Reporting, Authentication, Remote Config or Notifications. The User may check this privacy policy to find a detailed explanation about the other tools used by the Owner.

This Application uses identifiers for mobile devices and technologies similar to cookies to run the Firebase Analytics service.

Users may opt-out of certain Firebase features through applicable device settings, such as the device advertising settings for mobile phones or by following the instructions in other Firebase related sections of this privacy policy, if available.

Personal Data processed: Cookies; unique device identifiers for advertising (Google Advertiser ID or IDFA, for example); Usage Data.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Data transfer outside the EU

Any data collected by AppYourself is transferred in keeping with these statements.

The Google Firebase services used to store and transfer data provide HTTPS encryption during information transit. Data encryption is also provided for cloud data storage. See https://firebase.google.com/support/privacy#data_encryption for more information.

Data transfer from the EU and/or Switzerland to the U.S based on Privacy Shield (this Application)

If this is the legal basis, the transfer of Personal Data from the EU or Switzerland to the US is carried out according to the EU - U.S. and Swiss - U.S. Privacy Shield.

In particular, Personal Data is transferred to services that self-certify under the Privacy Shield framework and therefore guarantee an adequate level of protection of such transferred Data. All services are listed within the relevant section of this document and those that adhere to Privacy Shield can be singled out by checking their privacy policy and possibly also by specifically checking for Privacy Shield adherence in the official Privacy Shield List. Privacy Shield also specifically guarantees rights to Users which can be found in its most current form on the website run by the US Department of Commerce.

Personal Data may be transferred from within the EU or Switzerland to the U.S. to services that are not, or not anymore, part of Privacy Shield, only based on other valid legal grounds. Users can ask the Owner to learn about such legal grounds.

Personal Data processed: various types of Data.

Data transfer to countries that guarantee European standards (this Application)

If this is the legal basis, the transfer of Personal Data from the EU to third countries is carried out according to an adequacy decision of the European Commission.

The European Commission adopts adequacy decisions for specific countries whenever it considers that country to possess and provide Personal Data protection standards comparable to those set forth by EU data protection legislation. Users can find an updated list of all adequacy decisions issued on the European Commission's website.

Personal Data processed: various types of Data.

Device permissions for Personal Data access

This Application requests certain permissions from Users that allow it to access the User's device Data as described below.

Device permissions for Personal Data access (this Application)

This Application requests certain permissions from Users that allow it to access the User's device Data as summarized here and described within this document.

Personal Data processed: Storage permission.

Hosting and backend infrastructure

This type of service has the purpose of hosting Data and files that enable this Application to run and be distributed as well as to provide a ready-made infrastructure to run specific features or parts of this Application. Some of these services work through geographically distributed servers, making it difficult to determine the actual location where the Personal Data are stored.

Firebase Cloud Functions (Google LLC)

Firebase Cloud Functions is a hosting and backend service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Firebase Cloud Firestore (Google LLC)

Firebase Cloud Firestore is a hosting and backend service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Firebase Realtime Database (Google LLC)

Firebase Realtime Database is a hosting and backend service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Firebase Cloud Storage (Google LLC)

Firebase Cloud Storage is a hosting service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Interoute (Interoute Communications Limited.)

Interoute is a hosting service provided by Interoute Communications Limited.

Personal Data processed: various types of Data as specified in the privacy policy of the service.

Place of processing: United Kingdom – Privacy Policy.

Infrastructure monitoring

This type of service allows this Application to monitor the use and behavior of its components so its performance, operation, maintenance and troubleshooting can be improved.

Which Personal Data are processed depends on the characteristics and mode of implementation of these services, whose function is to filter the activities of this Application.

Sentry (Functional Software, Inc. )

Sentry is a monitoring service provided by Functional Software, Inc. .

Personal Data processed: various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy.

Managing contacts and sending messages

This type of service makes it possible to manage a database of email contacts, phone contacts or any other contact information to communicate with the User.

These services may also collect data concerning the date and time when the message was viewed by the User, as well as when the User interacted with it, such as by clicking on links included in the message.

Firebase Cloud Messaging (Google Inc.)

Firebase Cloud Messaging is a message sending service provided by Google, Inc. Firebase Cloud Messaging allows the Owner to send messages and notifications to Users across platforms such as Android, iOS, and the web. Messages can be sent to single devices, groups of devices, or specific topics or User segments.

Personal Data processed: various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Further information about Personal Data

Push notifications

This Application may send push notifications to the User.

Unique device identification

This Application may track Users by storing a unique identifier of their device, for analytics purposes or for storing Users' preferences.

The rights of Users

Users may exercise certain rights regarding their Data processed by AppYourself.

In particular, Users have the right to do the following:

Withdraw their consent at any time. Users have the right to withdraw consent where they have previously given their consent to the processing of their Personal Data.
Object to processing of their Data. Users have the right to object to the processing of their Data if the processing is carried out on a legal basis other than consent. Further details are provided in the dedicated section below.
Access their Data. Users have the right to learn if Data is being processed by the Owner, obtain disclosure regarding certain aspects of the processing and obtain a copy of the Data undergoing processing.
Verify and seek rectification. Users have the right to verify the accuracy of their Data and ask for it to be updated or corrected.
Restrict the processing of their Data. Users have the right, under certain circumstances, to restrict the processing of their Data. In this case, the Owner will not process their Data for any purpose other than storing it.
Have their Personal Data deleted or otherwise removed. Users have the right, under certain circumstances, to obtain the erasure of their Data from the Owner.
Receive their Data and have it transferred to another controller. Users have the right to receive their Data in a structured, commonly used and machine readable format and, if technically feasible, to have it transmitted to another controller without any hindrance. This provision is applicable provided that the Data is processed by automated means and that the processing is based on the User's consent, on a contract which the User is part of or on pre-contractual obligations thereof.
Lodge a complaint. Users have the right to bring a claim before their competent data protection authority.

Cookie Policy

This Application uses Cookies and other Identifiers. To learn more, the User may consult the Cookie Policy.

Additional information about Data collection and processing

Legal action

The User's Personal Data may be used for legal purposes by the Owner in Court or in the stages leading to possible legal action arising from improper use of this Application or the related Services.

The User declares to be aware that the Owner may be required to reveal personal data upon request of public authorities.

Additional information about User's Personal Data

In addition to the information contained in this privacy policy, this Application may provide the User with additional and contextual information concerning particular Services or the collection and processing of Personal Data upon request.

System logs and maintenance

For operation and maintenance purposes, this Application and any third-party services may collect files that record interaction with this Application (System logs) use other Personal Data (such as the IP Address) for this purpose.

Information not contained in this policy

More details concerning the collection or processing of Personal Data may be requested from the Owner at any time. Please see the contact information at the beginning of this document.

How “Do Not Track” requests are handled

This Application does not support “Do Not Track” requests.

To determine whether any of the third-party services it uses honor the “Do Not Track” requests, please read their privacy policies.

Changes to this privacy policy

The Owner reserves the right to make changes to this privacy policy at any time by notifying its Users on this page and possibly within this Application and/or - as far as technically and legally feasible - sending a notice to Users via any contact information available to the Owner. It is strongly recommended to check this page often, referring to the date of the last modification listed at the bottom.

Should the changes affect processing activities performed on the basis of the User’s consent, the Owner shall collect new consent from the User, where required.

Definitions and legal references

Personal Data (or Data)

Any information that directly, indirectly, or in connection with other information — including a personal identification number — allows for the identification or identifiability of a natural person.

Usage Data

Information collected automatically through this Application (or third-party services employed in this Application), which can include: the IP addresses or domain names of the computers utilized by the Users who use this Application, the URI addresses (Uniform Resource Identifier), the time of the request, the method utilized to submit the request to the server, the size of the file received in response, the numerical code indicating the status of the server's answer (successful outcome, error, etc.), the country of origin, the features of the browser and the operating system utilized by the User, the various time details per visit (e.g., the time spent on each page within the Application) and the details about the path followed within the Application with special reference to the sequence of pages visited, and other parameters about the device operating system and/or the User's IT environment.

User

The individual using this Application who, unless otherwise specified, coincides with the Data Subject.

Data Subject

The natural person to whom the Personal Data refers.

Data Processor (or Data Supervisor)

The natural or legal person, public authority, agency or other body which processes Personal Data on behalf of the Controller, as described in this privacy policy.

Data Controller (or Owner)

The natural or legal person, public authority, agency or other body which, alone or jointly with others, determines the purposes and means of the processing of Personal Data, including the security measures concerning the operation and use of this Application. The Data Controller, unless otherwise specified, is the Owner of this Application.

This Application

The means by which the Personal Data of the User is collected and processed.

Service

The service provided by this Application as described in the relative terms (if available) and on this site/application.

European Union (or EU)

Unless otherwise specified, all references made within this document to the European Union include all current member states to the European Union and the European Economic Area.

Cookies

Small sets of data stored in the User's device.

Legal information

This privacy statement has been prepared based on provisions of multiple legislations, including Art. 13/14 of Regulation (EU) 2016/679 (General Data Protection Regulation).

This privacy policy relates solely to this Application, if not stated otherwise within this document.

Latest update: May 17, 2018

Cookie Policy of Buku Haematology

Cookies and other Identifiers consist of portions of code placed on the User’s device that assist the Owner in providing the Service according to the purposes described.

Some of the purposes for which Identifiers are used may also require the User's consent. Whenever consent is given, it can be freely withdrawn at any time following the instructions provided in this document.

Activities strictly necessary for the operation of this Application and delivery of the Service

This Application uses Cookies or other Identifiers to carry out activities that are strictly necessary for the operation or delivery of the Service and, therefore, do not require Users to consent. Users can disable such Identifiers by modifying their browser or device settings as described in more detail within this document, but this may affect core operational functions or result in the unavailability of the Service.

Other activities

Experience enhancement

This Application uses Cookies or other Identifiers to provide a personalized user experience by improving the quality of preference management options, and by enabling interaction with external networks and platforms.

Measurement

This Application uses Cookies or other Identifiers to measure traffic and analyze User behavior with the goal of improving the Service.

Analytics

The services contained in this section enable the Owner to monitor and analyze web traffic and can be used to keep track of User behavior.

Google Analytics for Firebase (Google LLC)

Google Analytics for Firebase or Firebase Analytics is an analytics service provided by Google LLC.

In order to understand Google's use of Data, consult Google's partner policy.

This Application uses identifiers for mobile devices and technologies similar to cookies to run the Firebase Analytics service.

Personal Data processed: Cookies, unique device identifiers for advertising (Google Advertiser ID or IDFA, for example) and Usage Data.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

How to provide or withdraw consent

Users can provide or withdraw consent to the use of Cookies and other Identifiers by setting their preferences within the cookie notice or by updating such preferences via the relevant consent-preferences widget accordingly, if available.

Additionally, Users can manage preferences regarding Identifiers directly from within their own device settings and prevent – for example – the storing of third-party Identifiers. It is also possible, via relevant browser or device features, to delete previously stored Identifiers, including those used to remember the User’s initial consent. Users can, for example, find information about how to manage Identifiers in the most commonly used browsers at the following addresses: Google Chrome, Mozilla Firefox, Apple Safari and Microsoft Internet Explorer.

With regard to any Identifiers stored by third parties, Users can manage their preferences and withdraw their consent by clicking the related opt-out link (where provided), by using the means indicated in the third party's privacy policy, or by contacting the third party.

Notwithstanding the above, Users are hereby informed that they may follow the instructions provided by YourOnlineChoices (EU), the Network Advertising Initiative (US) and the Digital Advertising Alliance (US), DAAC (Canada), DDAI (Japan) or other similar services. Such initiatives allow Users to select their tracking preferences for most of the advertising tools. The Owner thus recommends that Users make use of these resources in addition to the information provided in this document.

Owner and Data Controller

Buku Haematology - Newcastle - United Kingdom

Owner contact email: bukuhaem@gmail.com

Since the storing of third-party Cookies and other Identifiers through the services used within this Application cannot be technically controlled by the Owner, any specific references to Identifiers stored by third parties are to be considered indicative. In order to obtain complete information, the User is kindly requested to consult the privacy policies of the respective third-party services listed in this document.

Given the objective complexity surrounding technologies related to Cookies and other Identifiers, Users are encouraged to contact the Owner should they wish to receive any further information on the use of such Identifiers by this Application.

Definitions and legal references

Personal Data (or Data)

Usage Data

User

The individual using this Application who, unless otherwise specified, coincides with the Data Subject.

Data Subject

The natural person to whom the Personal Data refers.

Data Processor (or Data Supervisor)

The natural or legal person, public authority, agency or other body which processes Personal Data on behalf of the Controller, as described in this privacy policy.

Data Controller (or Owner)

This Application

The means by which the Personal Data of the User is collected and processed.

Service

The service provided by this Application as described in the relative terms (if available) and on this site/application.

European Union (or EU)

Unless otherwise specified, all references made within this document to the European Union include all current member states to the European Union and the European Economic Area.

Cookie

Cookies are Identifiers consisting of small sets of data stored in the User's browser.

Identifier

Any technology - including Cookies - that allows for the storing of information, or the accessing of already-stored information, on the User’s device.

Legal information

This privacy statement has been prepared based on provisions of multiple legislations, including Art. 13/14 of Regulation (EU) 2016/679 (General Data Protection Regulation).

This privacy policy relates solely to this Application, if not stated otherwise within this document.

Buku Medicine

Nephrotic syndrome

Referral indications

Pregnancy and the kidney