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Evaluation of Proteinuria

Craig Dobson, MD CPT, MC, USAR NCC Pediatrics. Evaluation of Proteinuria. Some degree is always present. Tamm-Horstfeld Proteins are actually secreted by tubules themselves. Urine dipstick is extremely sensitive Normal 24hr Protein output < 200mg/dL for adults. < 20mg/kg/day for children

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Evaluation of Proteinuria

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  1. Craig Dobson, MD CPT, MC, USAR NCC Pediatrics Evaluation of Proteinuria

  2. Some degree is always present. Tamm-Horstfeld Proteins are actually secreted by tubules themselves. Urine dipstick is extremely sensitive Normal 24hr Protein output < 200mg/dL for adults. < 20mg/kg/day for children Spot protein detection must always be interpreted in the context of concentration of urine. 1+ Protein (10mg/dL) @ SG 1.030 is not concerning. 1+ Protein @ SG 1.010 may be important. Other renal signs, especially edema, should lead you to believe the result more. What is proteinuria, baby?

  3. False Postives for UA Protein • pH > 8 • Hematuria • Leukouria (incl. UTI) • Fever • Not really a false positive. • Causes leaky basement membrane. • Chlorhexidine wash to clean perineum. • Vaginal/seminal secretions • Menstrual blood • Exercise • Concentration

  4. How do we achieve a better estimation of quantity of proteinuria? • Spot Urine Protein/Creatinine Ratio • Normal <0.3 for children over age two. • Normal <0.5 under age two. • Well validated/nearly equivalent to 24hr Urine. • 24hr Urine Collection • Very difficult in children. • Usually performed incorrectly. • Many peds nephrologists only use Prot/Cr.

  5. Orthostatic Proteinuria Extremely common. Incidence 7-12% of adults. Pathogenesis Now proven to be laxity of support to kidney allows kidney to fall slightly when standing. Kinking of renal vein occurs. Back pressure causes minor spillage of protein. Absolutely a benign condition! No renal impairment/failure associated with it. Causes of Proteinuria

  6. Glomerular Glomerulonephritis Refers to any inflammation of glomerulus. Should have glomerular hematuria (RBC casts, abnormal shaped RBCs in urine) Minimal change disease IgA nephropathy Also should have RBCs. Tubular Acute Tubular Necrosis Fanconi’s Sx. Lowe’s Syndrome Cystinuria High Plasma Proteins Myoglobinuria/Hemoglobinuria Leukemia Urinary Tract Tumor Inflammation Other causes of Proteinuria

  7. Evaluation of Isolated Proteinuria • First r/o orthostatic proteinuria • First morning void after lying recumbant for at least 6hrs. (Also rules out exercise as a factor.) • Urine Protein/Creatinine ratio • If >0.2, proceed to further work-up • Referral to Nephro if >0.2 • Labs • BUN, Cr, C3, ASO, ANA • Consider Hep B/C, HIV • Imaging • Consider renal U/S.

  8. Refers to the degree of proteinuria, not a disease by itself. Prot/Cr ratio 0.5-2.5 is significant proteinuria. >=2.5 is nephrotic range. Equivalent to 2.5g/day in adult. May be caused by any of the causes of proteinuria including nephritis. Most common cause is minimal change disease. Treatment is trial of steroids Renal biopsy for failure to respond to steroids. Nephrotic syndrome

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