Prof. dr hab. Anna Wasilewska
“Bubbies appearing on the surface
of the urine indicate renal disease
and a prolonged illness”
Glomerular
Tubular
Overload
Benign
Size of protein
Shape of protein
Charge of protein
Renal hemodynamics
Definitions
Physiology
Physiological proteinuria
Classification of proteinuria
Urine dipstick
Investigation of proteinuria
Proteinuria
› Urine protein excretion > 150mg/day
Microalbuminuria
› Urine [albumin] > 30mg/day but not
detectable by urine dipstick
Nephrotic syndrome
› Urine protein excretion > 3.5g/day (with
hypoalbuminaemia, oedema and
hyperlipidaemia)
Protein filtration through the glomerulus is
dependent on the protein size, shape
and electrical charge
Protein charge
› At physiological pH, most proteins are
negatively charged
› Since the basement membranes are also
negatively charged, most proteins are
retained
Protein size
› Proteins greater than 40kDa are almost
completely retained
› Thus, only small proteins, e.g. retinol-binding
protein, ß2 microglobulin, passes into the
ultrafiltrate
However, most of the filtered proteins are
reabsorbed by the proximal tubules.
Consequently, very little plasma protein
appears in the urine
Normally < 150mg/24hours
In some non-pathological situations, a higher than normal urine protein level is found:
› A concentrated spot urine
› Exercise
› Orthostatic proteinuria
› Contamination e.g. from vagina
Tubular proteinuria
› Tubular dysfunction
› Overflow proteinuria
Glomerular proteinuria
› Selective proteinuria
› Non-selective proteinuria
› microalbuminuria
This occurs when glomerular function is
intact, but protein is lost to the urine
either because of:
› Tubular dysfunction
› Overflow
Tubular dysfunction
› The tubules are damaged and cannot
function properly
› Therefore, the small MW proteins that are
normally filtered are not reabsorbed by the
tubules
› The small MW proteins include: retinol-
binding protein, ß2 microglobulin, lysozyme,
light chains, haemoglobin, myoglobin
Tubular dysfunction
› Pyelonephritis
› Acute tubular necrosis
› Papillary necrosis e.g. analgesic
nephropathy
› Heavy metal poisoning
› SLE
› Fanconi’s syndrome
Overflow proteinuria
› Occurs when the concentration of one of
the small MW proteins is so high that the
filtered load exceeds the tubular
reabsorptive capacity
› Thus, the excess filtered load appears in the
urine
Overflow proteinuria
› Bence Jones proteinuria
› Myoglobinuria
› Haemoglobinuria
When there is glomerular dysfunction,
proteins > 40kDa can escape into the
urine
The most common form of proteinuria
Selective proteinuria
Non-selective proteinuria
Microalbuminuria
Selective proteinuria
› If only intermediate-sized (< 100kDa) proteins
(albumin, transferrin), leaks through the
glomerulus, this is termed selective
proteinuria
Non-selective proteinuria
› When a range of different sized proteins leak
through including larger proteins (IgG), this is
termed non-selective proteinuria
Selectivity
The measurement of the selectivity of
proteinuria used to be popular, however,
this has been replaced by renal biopsy
and electron microscopy
Causes› Glomerulonephritis
› Diabetes mellitus
› Multiple myeloma
› Amyloidosis
› SLE
› Pre-eclampsia
› Penicillamine, gold
Microalbuminuria
› Urine albumin concentrations which are
greater than normal but not detectable by
urine dipstick
Normal urine protein: 150mg/day
About 15-20 mg of the normal urine
protein is albumin
Urine dipsticks detects urine albumin
>300mg/day
Therefore, microalbuminuria is defined
as:
Urine albumin excretion 30-300mg/day
Or
Urine albumin excretion rate 20-
200ug/min.
Microalbuminuria is not detectable by
dipsticks
Therefore, a 24hr or 12 hr urine collection
is required
Clinical significance:
› Correlates with mortality in diabetics and
hypertensives
› Predicts the development of nephropathy in
Type 1 and Type 2 diabetes
Treatment:
› Good BP control, especially by ACE-inhibitors
And
› Good diabetic control
› Postpones the development of diabetic
nephropathy
Shaking
Boiling
Salicylosulphonic acid
Reagent strip
Protein dipstick grading
DesignationApprox. amount
Concentration[6] Daily[7]
Trace 5–20 mg/dL
1+ 30 mg/dL Less than 0.5 g/day
2+ 100 mg/dL 0.5–1 g/day
3+ 300 mg/dL 1–2 g/day
4+ More than 300 mg/dL More than 2 g/day
Commonly used for screening of
proteinuria
Is a plastic strip impregnated with a pH
indicator which changes colour in the
presence of proteins, due to a pH
change
The intensity of the colour correlates with
the concentration of protein in the urine
Mainly detects albumin, and therefore
glomerular proteinuria
Sensitivity: 0.1g/l
False positives:
› When urine is alkaline (some UTI)
› The urine is pigmented (haematuria)
› The urine is concentrated
› Drug / chemical interference (chlorhexidine)
› Contamination with vaginal secretions
› Addition of egg white
False negatives:
› The protein is not albumin
› The urine is dilute
› Incidental finding
› Evidence of renal disease
› Evidence of systemic illness
› Family history of renal disease
› Medications being taken
Renal function
Urine dipstick
› Determine the amount of protein detected
If renal function is normal
and
If protein is trace or 1+
and
There is no significant clinical history
then
Repeat testing
When urine dipstick is repeated, ask the
patient to:
› Refrain from exercise for few hours
› Collect early morning urine to exclude
orthostatic proteinuria
If the findings are negative upon repeat
testing, then the initial positive result may
be due to a transient proteinuria (e.g.
fever, exercise)
Or
A false positive
Further investigation is needed if:
› Still positive upon repeat testing
› Positive clinical history
› Abnormal renal function
› Initial urine protein is > 1+
Underlying disease process
Amount of protein excreted
24 hour urine protein excretion
Creatinine and creatinine clearance
Urine microscopy
Other relevant tests dependent on the
provisional diagnosis
Gives a more accurate assessment of
the severity of the proteinuria
> 150mg/24 hour = proteinuria
> 3.5 g/24 hour (with associated
features) = nephrotic syndrome
For estimation of 24hr urine albumin if
suspect microalbuminuria
And estimation of GFR
Assesses severity of renal dysfunction
To look for casts, white cells and red cells
May be a clue to the diagnosis of
glomerulonephritis, pyelonephritis,
tubular damage
Renal ultrasound if suspect renal disease
Renal biopsy if suspect glomerular disease
Plasma and urine electrophoresis if suspect multiple myeloma with Bence Jones proteinuria
Urine for myoglobin / haemoglobin
HbA1c to assess diabetic control