2. Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai.
2
3. DEFINITION
*Increased excretion of protein in urine.
*Normal protein excretion : 80 – 150mg daily
* increased excretion of protein in urine raise the
suspicion of renal disease.
Proteinuria can be due to
1. Primary renal disorders
a.Renovascular
b.Glomerular
c.Tubulointerstitial
2. Overflow of abnormal proteins
-- multiple myeloma
3.Secondary to non renal disorders
-- amyloidosis
4.Physiological conditions
-- strenuous exercise
3
Dept of Urology, GRH and KMC,
Chennai.
4. Urine protein composition
30% albumin
30% globulin
40% tissue proteins
(Tamm horsfall protein)
4
Dept of Urology, GRH and KMC,
Chennai.
6. TUBULAR PROTEINURIA:
* failure to reabsorb normally filtered
protein of low molecular weight such as
immunoglobulin
* 24hrs urine protein < 2 - 3gm
protein are of LMW proteins rather than
albumin
* proximal tubular functional defect such as
glucosuria,aminaciduria,phosphaturia,and
uricosuria(fanconi’s syndrome)
6
Dept of Urology, GRH and KMC,
Chennai.
7. OVERFLOW PROTEINURIA:
*due to increased concentration of
abnormal immunoglobulin and other LMW
proteins
* increased serum level
|
increased glomerular filtration
|
exceeds tubular absorptive capacity
*common condition: in multiple myeloma --
Bence jones protein (immunoglobulin light chain)
7
Dept of Urology, GRH and KMC,
Chennai.
8. DETECTION
I.Qualitative tests:
1.Dipstick
2.3%sulfosalicylic acid
3.protein electophoresis
4.immunoassay of specific protein
II.Quantitative tests:
1.24hrs urine collection test – Most sensitive
2.protein creatinine ratio(PCR):
-better than 24hrs urine protein
-conc. of protein compared with creatinine in
spot urine collection
-PCR>45mg/mmol or alb:creatinine
>30mg/mmol indicates proteinuria
-PCR >100mg/mmol—high level of nephrotic
syndrome 8
Dept of Urology, GRH and KMC,
Chennai.
9. PROTEIN DIPSTICK
DIPSTICK GRADING
GRADE CONCENTRATION DAILY
trace 5- 20mg/dl ---
1+ 30mg/dl <0.5gm/day
2+ 100mg/dl 0.5-1gm/day
3+ 300mg/dl 1-2gm/day
4+ >2000mg/dl >2gm/day
*dipstick impregnated with tetrabromophenol blue
*colour changes in response to pH shift related
protein content of urine mainly albumin
*background of stick – yellow
*Various shades of green will develop- darker the
green greater the concentration of protein.
9
Dept of Urology, GRH and KMC,
Chennai.
10. 20--30mg/dl is the minimal conc. detected
False negative results:
1.Alkaline urine
2.Dilute urine
3.Primary protein is not albumin
10
Dept of Urology, GRH and KMC,
Chennai.
11. 3%SULFASALICYLIC ACID TEST
*Precipitation of primary protein with3%SSA
will detect proteins <15mg/dl
*More sensitive in detecting other proteins
as well as albumin
*pts with dipstick -ve,
SSA +ve then suspect
Multiple myeloma—Bence jones protein
11
Dept of Urology, GRH and KMC,
Chennai.
12. PROTEIN ELECTROPHORESIS:
*Differential qualitative assesment
*to differentiate albumin&globulin
*distinguish glomerular from tubular
proteinuria
Glomerular-albumin -70%of total protein
excreted
Tubular– immunoglobulin are major protein
excreted ,albumin – 10-20%
12
Dept of Urology, GRH and KMC,
Chennai.
15. INTERMITTENT:
*related to postural change
*upright posture
*normalises when the pts is recumbent
*orthostatic proteinuria-secondary to
-increased pressure on renal vein due
to standing
-resolve spontaneously
15
Dept of Urology, GRH and KMC,
Chennai.
16. PERSISTENT PROTEINURIA
*Further evaluation
*mostly glomerular etiology
*quantitative & qualitative analysis
*>2gm of protein/24hrs
*mostly HMW proteins like albumin
establishes the glomerular etiology
*glomerular proteinuria is the most
common cause for abnormal and persistent
proteinuria
16
Dept of Urology, GRH and KMC,
Chennai.
17. Proteinuria with hematuria +dysmorphic
Erythrocyte,erythrocytic casts --- suggest
Glomerulonephritis
Proteinuria without hematuria suggest:
-- DM
-- Amyloidosis
-- Arteriolar nephroscerosis
>300—2000mg/day+majority LMW globulin
17
Dept of Urology, GRH and KMC,
Chennai.
18. If total protein excretion is
300—2000mg/day and major components
are LMW globulin further evaluation with
Immunoelectrophoresis is indicated
18
Dept of Urology, GRH and KMC,
Chennai.
19. IMMUNELECTROPHORESIS
Normal protein – tubular proteinuria
Abnormal protein – overflow proteinuria
Bence jones – multiple myeloma
hemoglobin – hemoglobinuria
myoglobin -- myoglobinuria
19
Dept of Urology, GRH and KMC,
Chennai.
