The document discusses proteinuria as an early indicator of renal disease, highlighting its association with renal impairment, hypertension, and cardiovascular disease. It outlines the evaluation process, including causes, assessment of renal function, and quantification of proteinuria, emphasizing the importance of additional investigations and follow-up. Key points include identifying persistent proteinuria through dipstick tests and managing any associated hypertension with ACE inhibitors or ARBs.

1. Proteinuria
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Ivy Hospital Sector 71 Mohali
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495

2. Proteinuria – early indicator of renal disease
 Increases the risk of renal impairment,
hypertension & cardiovascular disease.
 Proteinuria of 1+ or more persisting on 2
subsequent dipstick tests at weekly intervals –
requires further investigations.
 Causes of transient proteinuria to be excluded.

3. CAUSES
 Transient proteinuria
 UTI
 Fever
 Heavy exercise
 Pregnency
 Orthostatic proteinuria - not found in early morning
sample, uncommon over age of 30 yrs
 Vaginal mucus

4. Persistant proteinuria
 Primary renal disease
 Glomerular – GN
 Tubular
 Secondary renal disease
 DM
 CTD
 Vasculitis
 Amyloidosis
 Myeloma
 CCF
 Hypertension

5. Evaluation
 History
 Symptoms of renal failure
 CTD – arthralgia, mouth ulcers, rashes.
 Past h/o DM, HTN, CCF, CTD
 H/O drugs ass. with proteinuria – NSAIDs,
captopril, penicillamine
 Family h/o PCKD, reflux nephropathy, CTD.

6. Examination
 Look for signs of Nephrotic syndrome
 Signs of multisystem dis – rashes, splinter
haemorrhage, bruits.
 B.P
 Urine dipstick test to check for microscopic
haematuria – if + go for urine microscopy.
 Rule out Diabetes and UTI

7. Quantification of proteinuria
 24 hr urinary collection
 Spot morning protein/creatinine ratio – simpler & as
accurate.
 24 hr urinary protein excretion (mg/24hrs) can be
approximated as (mg/l protein) / ( mmol/l creatinine)
× 10 or (mg/l creatinine ) × 100.
 More than 150 mg in 24 hr or protein to creatinine
ratio of 15 mg/mmol or 150 mg/mg is abnormal
 Nephrotic range - >3.5 g/24 hr or a ratio > 3500 -
check for serum albumin and cholesterol.

8. Assessment of renal function
 Check serum creatinine, urea, electrolytes.
 Creatinine clearance gives more accurate
picture of renal function than creatinine alone,
can be calculated by Cockcroft- Gault formula.
 Best to estimate GFR by MDRD formula
 GFR or creatinine clearance > 90ml/min can
be considered normal. Lower values may be
normal in old age and in people with low
muscle mass.

9.  Significant proteinuria > 100 mg/mmol
although values > 50 may be significant if
other features of renal disease are present like
 Impaired renal function
 Coexistant microscopic haematuria
 Hypertension
 Features underlying systemic disease.

10. Further investigations
 Renal tract USG
 Immunology
 Serum and urine protein electrophoresis
 ANA
 ANCA
 Complements
 Hepatitis B & C serology

11. Follow-up
 Review after six months and then annualy to
reassess quantity of proteinuria, renal function
and blood pressure.
 Any hypertension if present – to be treated
aggressively with an ACE inhibitor or ARB.