Proteinuria

APPROACH TO
PROTEINURIA WITH OR
WITHOUT HEMATURIA
-Dr. Anamika Singh
Pg student
Introduction
Urine analysisis an important investigation
to diagnose kidney diseases.
Proteinuria is one of the earliest & most important

finding of urine examination
Proteinuriacan be transient benign renal causes

due to persistent due to or
organic renal causes.
DEFINITION
• Healthy individuals can excrete less than 150mg /d of total protein
and less than 30mg/d of total alb min
• Proteinuria –Urinary protein excretion > 150mg/ day
• Albuminuria- Urinary albumin excr tion > 30mg/day
• Hematuria -
HISTORY
•Proteinuria is usually detected during a routine screen in

asymptomatic patients
•Symptoms with duration (history of recent fever with sore throat, periorbital
puffiness progressing to anasarca,frothy urine , high coloured urine, oliguria,
nausea,vomiting ,abdominal pain,joint pain etc)
• Past history-Diabetes, hypertension, renal disease,systemic illnesses
• Drug history-NSAIDS, Cyclosporin,exposure to heavy metals
• Family history of renal disease
PHYSICAL EXAMINATION
• Blood pressure, body weight
• Edema – particularly facial(around eyes), pedal edema, ascites
• Fundoscopic examination
Investigations
• Baseline investigations –
1. Complete blood count
2. Renal function test
3. Urine dipstick
4. Urine routine examination
5. 24 hour urinary protein
6.Spot urine ACR, PCR(albumin / protein to creatinine ratio)
Other tests
1. Fasting lipid profile

2. Hba1c
4. ANA
5. Serum C3/C4
6. Hepatitis B/C
7. Renal biopsy
COMPOSITION OF NORMAL URINARY
PROTEIN (150 mg/day)
• Tamm-horsfall protein(Maximum) (40%)
• Albumin (20%)
• Immunoglobulins
• Hormones, Enzymes
• Mucopolysaccharides
Urine dipstick
• Primarily detect albuminuria
• less sensitive for other forms of
proteinuria (low molecular weight
proteins, Bence Jones protein,
gamma globulins.
 Urine dipstick
□ Negative
□ Trace — between 15 and 30 mg/dL
□ 1+ — between 30 and 100 mg/dL
□ 4+ — >1000 mg/dL
Grading based on 24 hour proteinuria
< 150mg/24 hours- Normal
150-500 mg/24 hours-Functional(<1mg/24 hr)
>500mg/24 hours- Significant
>3.5gm/24 hours-Nephrotic ra n ge
>4gm/24 hours- Massive

Grading based on 24 hour albuminuria
<30mg/24 hours- Normal
30-300 mg/24 hours- Microalbuminuria
>300 mg/24 hours-Albuminuria
>2200 mg/24 hours- Nephrotic range

Grading based on Spot urinary ACR
<30mg/gram- Normal
30-300 mg/gram - Microalbuminuria
>300 mg/gram- Albuminuria
>2200 mg/gram- Nephrotic range

Diagnostic Evaluation of Proteinuria
1. When proteinuria is found on a dipstick urinalysis, the urinary
sediment should be examined microscopically
MICROSCOPIC FINDING PATHOLOGIC PROCESS

Fatty casts, free fat or oval fat bodies Nephrotic range
proteinuria (> 3.5 g
per 24 hours)
Leukocytes, leukocyte casts Urinary tract

with bacteria infection
Leukocytes, leukocyte casts Renal interstitial

without bacteria disease
Normal-shaped Suggestive of lower urinary

erythrocytes lesio
tract
n
Dysmorphic Suggestive of upper urinary
erythrocytes tract
lesio
n
Erythrocyte casts Glomerular
disease
Waxy, granular or cellular Advanced chronic renal
casts disease
Eosinophiluri Suggestive of drug-induced

a* acute
interstitial
nephritis
Hyaline No renal disease; present with

casts dehydration and with diuretic
therapy
* A Wright’s stain of the urine specimen is necessary to detect

eosinophiluria
CLASSIFICATION OF PROTEINURIA
• Functional
• Glomerular
• Tubular
• Overflow
FUNCTIONAL PROTEINURIA
U
• Benign form of proteinuria

• Protein excretion is less than 500mg/day(may rise upto 1g/d)
• Includes 2 types
1.Transient proteinuria
2.Orthostatic proteinuria
Transient proteinuria
• If dipstick analysis shows 0 to +2 proteinuria, but subsequent
dipstick tests are negative
• Potential triggers are acute illness,exercise, fever,heart failure
and UTI.
• After potential trigger has be e n treated or resolved, repeat
urine test is normal

ORTHOSTATIC
PROTEINURIA
 This benign condition occurs in about 3 to 5 per ent of adolescents and
young adults which is characterized by increased protein excretion in
p
the upright position but normal protein excretion when the atient is
supine.
 To diagnose orthostatic proteinuria, split urine specimens are obtained
for comparison.
 The daytime specimen typically has an increased concentration of
protein, with the nighttime specimen having a normal concentration.
There should be no hematuria
Causes of proteinuria
Benign
1. Fever
2. Strenuous exercise
Due to increased renal blood
3. Acute illness flow
4. Emotional stress
5. Orthostatic
proteinuria
Pathological proteinuria
Glomerular – Due to increased capillary

permeability of glomerulus
Glomerulonephritis – Primary or secondary
 Tubular – Due to decreased tubular reabsorption of

filtered proteins Tubulo-interstitial diseases
 Overflow – Due to increased production of low molecular

weight proteins Monoclonal gammopathies,
Leukaemias, Lymphomas
GLOMERULAR PROTEINURIA
• Occurs due to effacement of epithelial foot process and disruption of glomerular
basement membrane
•Urinary protein electrophoresis shows l a rge albumin spike indicative of increased
permeability of albumin across damaged GBM
Presence of RBC cast/Dysmorphic RBCs
•Only proteinuria that can cause >2 g protein/24 hours with albumin:beta 2
macroglobulin ratio>1000:1
Glomerular proteinuria
Minimal change disease
Primar Idiopathic membranous
y
GN FSGS
Membranoproliferative
GN IgA nephropathy
Seconda
ry Diabetes
Connective tissue disorders –p Lu us
nephritis
Amyloidosi
s
Preeclamps
ia
Infection –
TUBULAR PROTEINURIA
• Occurs due to faulty reabsorption of normally filtered proteins by the proximal tubule
• Characterised by the presence of large amounts of small proteins in urine, with normal serum
protein.
• Rarely exceeds 1.5-2g/day

OVERFLOW PROTEINURIA
• Excessive production of an abnormal filterable plasma protein(monoclonal
gammapathies) that exceeds the tubular capacity for reabsorption
• Usually less than nephrotic range
• Examples:Multiple myeloma(Bence Jones protein),Myoglobinuria
in rhabdomyolysis and hemoglobinuria in hemolysis.

Pathological proteinuria
 Tubular
Hypertensive nephrosclerosis
Uric acid
nephropathy
Interstitial nephritis
Heavy metals
Sickle cell disease
Drugs(eg.NSAIDS,Cyclosporin,Con
trast)
Hypersensitive interstitial
nephritis
 Overflow
Thank you

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APPROACH TO

Proteinuria is one of the earliest & most important

Proteinuriacan be transient benign renal causes

• Proteinuria –Urinary protein excretion > 150mg/ day

• Albuminuria- Urinary albumin excr tion > 30mg/day

•Proteinuria is usually detected during a routine screen in

• Blood pressure, body weight

• Edema – particularly facial(around eyes), pedal edema, ascites

1. Fasting lipid profile

150-500 mg/24 hours-Functional(<1mg/24 hr)

>500mg/24 hours- Significant

>4gm/24 hours- Massive

30-300 mg/24 hours- Microalbuminuria

>300 mg/24 hours-Albuminuria

>2200 mg/24 hours- Nephrotic range

30-300 mg/gram - Microalbuminuria

>300 mg/gram- Albuminuria

>2200 mg/gram- Nephrotic range

MICROSCOPIC FINDING PATHOLOGIC PROCESS

Leukocytes, leukocyte casts Urinary tract

Leukocytes, leukocyte casts Renal interstitial

Normal-shaped Suggestive of lower urinary

Eosinophiluri Suggestive of drug-induced

Hyaline No renal disease; present with

* A Wright’s stain of the urine specimen is necessary to detect

• Benign form of proteinuria

dipstick tests are negative

• Potential triggers are acute illness,exercise, fever,heart failure

• After potential trigger has be e n treated or resolved, repeat

urine test is normal

Glomerular – Due to increased capillary

 Tubular – Due to decreased tubular reabsorption of

 Overflow – Due to increased production of low molecular

•Urinary protein electrophoresis shows l a rge albumin spike indicative of increased

permeability of albumin across damaged GBM

Presence of RBC cast/Dysmorphic RBCs

• Rarely exceeds 1.5-2g/day

• Excessive production of an abnormal filterable plasma protein(monoclonal

gammapathies) that exceeds the tubular capacity for reabsorption

• Usually less than nephrotic range

• Examples:Multiple myeloma(Bence Jones protein),Myoglobinuria

in rhabdomyolysis and hemoglobinuria in hemolysis.

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