PROTEINURIA
DR.Mohammed almansour
MD,SBFM,ABFM
Assisstant professor
Family medicine
College of medicine,almajmaah university
outlines
Case scenario
 Definition
 Pathophysiology
 Causes
 Clinical presentation
 Workup
 Management
 conclusion
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case
fatimah is 8 Years old Female presented to ER
with:
 Fever , sore throat x 4 days
 Puffiness around eyes and swelling of
feet x 2 days
 Reduced urine output x 2 days
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How to approach this case?
History:
◦ H/o similar symptoms at 8 months of age and
treated with Prednisolone.
◦ H/o multiple relapses – responding to steroids
Problems list
Acute:??URTI
 Acute on top of chronic:
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◦ Puffiness,swelling(edema),low urine output
??? RENAL DISEASE
What could be wrong with her kidneys?
Examination
What do you expect to find?
 HR = 97
RR = 28
BP = 98/62
 Temp = 37
 Periorbital and pedal edema
 HEENT : normal
 No other significant findings
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Clinical presentation
Work up
Is there some thing to do
at bedside?
Urine dipstick
For her was 3+
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negative <15 mg/dl,
trace 15-30 mg/dl,
1+ 30-100 mg/dl,
2+ 100-300 mg/dl,
3+ 300-1000 mg/dl,
4+ >1000 mg/dl
Na = 132 K = 4.2 Cl = 100
HCO3=23
 BUN = 38
Creat = 0.7
 Protein = 5.3(6-8) Albumin = 1.6 (3.6–5)
 HB = 13
WBC = 18.6
Plt = 450
 UA = Protein-500mg/dl SG-1.015, Urine
protein/creat = 14.4 (<0.1)
 Cholesterol = 206
 Blood Cultures = Negative
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SO !!!!!!!!!!!!!!!!
what is the abnormality in her urine?
PROTEINURIA
what is it?
LET US SEE
Definition
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Normal urine protein excretion is up to
150 mg/d (4 mg/m2/hr). Therefore, the
detection of abnormal quantities or types
of protein in the urine is considered an
early sign of significant renal or systemic
disease

Significant proteinuria can be defined:
◦ Qualitative: 1+ on dipstick examination of 2 out of 3
random urine specimens collected one week apart if
urine sp <= 1015 or 2+ in similarly collected urine if
USG >1015
◦ Semiquantitative: urine Pr/Cr ratio > 0.2 on early
morning specimen ( r = 0.97 with 24 hs collection) in
older children, >0.5 in infants. > 3 at any age is
suspicious of nephrotic range.
◦ Quantitative: Normal: <4 mg/m2/hour in 12-24 hrs
collection, Abnormal: 4-40 mg/m2/hour, Nephrotic
range >40 mg/meter/hour
pathophysiology
pathophysiology
The presence of abnormal amounts or types of
protein in the urine reflects the following:
 Overproduction of plasma proteins that are
capable of passing through the normal glomerular
basement membrane (GBM), as they enter the
tubular fluid in amounts that exceed the capacity
of the normal proximal tubule to reabsorb them
 A defective glomerular barrier that allows
abnormal amounts of proteins of intermediate
molecular weight to enter the Bowman space .
 Systemic diseases that result in an inability of
the kidneys to normally reabsorb the proteins
through the renal tubules
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causes
Is it due to a pre-renal, renal or postrenal cause?
 Pre-renal: protein loss in urine without renal
disease
 a. Tubular overload proteinuria
 i. Occurs when elevated levels of small MW
proteins (< 68K daltons) pass through the
normal glomerulus and appear in urine.
Excessive amounts of the same protein are
found in blood and urine.
 ii.e.g: hemoglobinemia (from intravascular
hemolysis),
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b. Functional proteinuria: transient
alteration in glomerular function.
Sometimes transient proteinuria (usually
albumin) is noted in association with
hypertension, strenuous exercise,
extremes of heat or cold, venous
congestion, fever, or seizures.
 c. Determining if proteinuria is pre-renal:
evaluate for hyperproteinemia.
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2. Renal proteinuria: protein loss in urine due
to renal disease
 a. Glomerular disease
Glomerular proteinuria results from a damaged
glomerulus that allows for leakage of plasma
proteins through the glomerulus. This form of
proteinuria is usually profound and consists
predominantly of albumin.e.g.
 nephrotic syndrome,
 nephritis,HUS,HS purpura……etc
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b. Tubular disease
Tubular proteinuria may occur due to tubular
dysfunction (tubules fail to reabsorb filtered
protein) or parenchymal inflammation.e.g
acute tubular nephrosis,
interstitial nephritis,
drugs
This form of proteinuria is usually mild.
c. Determining if proteinuria is renal: significant
proteinuria in association with an inactive urine
sediment is likely due to a renal cause.
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3. Post-renal proteinuria: protein added to
urine after it has been formed.
a. Lower urinary tract or genital disease
This may occur when inflammatory exudates
or blood proteins from the lower urinary or
genital tract mix with urine (usually due to
infection, hemorrhage, neoplasia, etc).
b. Determining if proteinuria is post-renal
Proteinuria in association with an active
urine sediment (pyuria, hematuria,
bacteriuria, crystalluria, etc.)
*Q: Is it possible to have both a renal and
post-renal cause of proteinuria?
 *A: Yes - in these cases, you may note an
active urine sediment, proteinuria,
hypoalbuminemia, and
hypercholesterolemia.
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Back to our case
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Is it pre- renal,renal or post renal cause?
history
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In most patients, proteinuria is asymptomatic .
So think of the pre-renal/renal /post renal approach
Are symptoms present that suggest nephrotic syndrome or
significant glomerular disease?
Have changes occurred in urine appearance (eg, red/smoky,
frothy)? Did this occur in relation to an upper respiratory
tract infection?
Is edema (eg, ankle, periorbital, labial, scrotal) present?
Has the patient ever been told his or her blood pressure is
elevated?
Has the patient ever been told his or her cholesterol is
elevated?
Is there family hx of renal diseases?
Drugs?
examination
General looking(e.g.obese child)
looking for edema (eg, ankle, leg, scrotal,
labial, pulmonary, periorbital), ascites, and
pleural effusions.
 Examine for signs of systemic disease (eg,
retinopathy, rash, joint swelling or deformity,
stigmata of chronic liver disease,
organomegaly, lymphadenopathy, cardiac
murmurs).
 Examine for such complications as venous
thrombosis or peritonitis.
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Back to our case
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What does fatimah have in hx and exam ?
Work up
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Initial investigations:
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Urine:
◦ Urine microscopy
◦ Urine collection (24 h) for quantification of
albumin (or protein) excretion and creatinine
clearance.
◦ Protein/creatinine ratio
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serum
◦ BUN, creatinine, total protein,albumin,
cholesterol,TG,ca, and blood glucose.
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Advance investigation:
◦ Depend on the cause you want to rule in or
out
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ASO titer, C3 complement, ANA, hepatitis B serology
Renal US,VCUG, renal scan
Renal biopsy
management
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Medical care can be considered as having 2
components :
◦ Nonspecific treatment that is applicable
irrespective of the underlying cause, assuming the
patient has no contraindications to the therapy
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Control BP(<125/75)
ACEI
Treat edema(cautious use of diuertic)
Diet: salt restriction
◦ Specific treatment that depends on the
underlying renal or nonrenal cause
Close the case
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Do we reach diagnosis of fatimah’s
disease?
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Does she need hospitalization?
NEPHROTIC SYNDROME
The nephrotic syndrome is a clinical complex
characterized by:
 proteinuria of >3.5 g per 1.73 m2 per 24 h (in
practice, >3.0 to 3.5 g per 24 h),
 hypoalbuminemia,
 edema,
 hyperlipidemia,
 lipiduria, and
 Hypercoagulability
In children the most common variety is MCNS with
a characteristic response to corticosteroid therapy
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conclusion
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Definition :>150 mg/d (4 mg/m2/hr) protein
in urine
proteinuria.
Causes:
◦ pre-renal(overload/functional) protein in
blood.
◦ Renal(Glomerular disease/ Tubular
disease).
INactive urine
sediment(INside the kidney)
◦ Post-renal(infection/haemorrhage/cancer)
active urine sediment
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Most of time asymptomatic but don’t
forget nephrotic syndrome
presentation:
◦ Edema
◦ Cholesterol
◦ S.albumin
Work up urine and blood
 Management:treat the cause
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THANK YOU