Proteinuria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Sapan Patel M.B.B.S; Ogheneochuko Ajari, MB.BS, MS [3]; Mahmoud Sakr, M.D. [4]

Synonyms and keywords: Elevated urinary protein levels; Elevated urine protein

Overview

Proteinuria (from protein and urine) means the presence of an excess of serum proteins in the urine. The protein in the urine often causes the urine to become foamy, although foamy urine may also be caused by bilirubin in the urine (bilirubinuria), retrograde ejaculation, pneumaturia (air bubbles in the urine) due to a fistula, or drugs such as pyridium.

Causes

Common Causes

• Glomerulonephritis
• IgA nephropathy
• Urinary tract infection

Causes by Organ System

Cardiovascular	Amyloidosis, benign orthostatic proteinuria, constrictive pericarditis, dehydration, eclampsia, hypertension, Nutcracker syndrome, preeclampsia, renal artery stenosis, renal vein thrombosis, shock , subacute bacterial endocarditis, tricuspid insufficiency
Chemical/Poisoning	Nitrosourea compounds, mercury, cadmium, trichloroethlene, bromobenzene , chloroform, aristolochic acids , paraquat, diquat, ethylene glycol
Dental	No underlying causes
Dermatologic	Scleroderma
Drug Side Effect	Aflibercept, anticonvulsants, bevacizumab, captopril, carmustine, caspofungin, cisplatin, deferasirox, gemcitabine, gold, heavy metal ingestion, heroin, lomustine, micafungin, mithramycin, NSAIDS, pazopanib, penicillamine, sulfasalazine
Ear Nose Throat	No underlying causes
Endocrine	Diabetes mellitus, hypothyroidism
Environmental	Allergens, irradiation
Gastroenterologic	Cirrhosis of liver, Wilson's disease, hemochromatosis
Genetic	Alport syndrome, Alström syndrome, aminoaciduria, amyloidosis, autosomal dominant conditions, autosomal recessive conditions, Balkan endemic nephropathy, connatal tulbulopathies, cystinosis, Dent disease, diabetes mellitus, Fabry's disease, familial mediterranean fever, galactosemia, genitourinary tuberculosis, glycogen storage disease type I, hepatorenal tyrosinemia, hereditary fructose intolerance, idiopathic multicentric osteolysis, Imerslund-gräsbeck syndrome, Lecithin cholesterol acyltransferase deficiency, Nail patella syndrome, adult polycystic kidney disease , recurrent hereditary polyserositis, Wilson's disease, X-linked hypophosphataemia
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	Epstein-barr virus, helminthic, hepatitis b, HIV, infectious mononucleosis, Legionella pneumophila, leprosy, malaria, poststreptococcal glomerulonephritis, Prostitis, acute Pyelonephritis, Subacute bacterial endocarditis, toxoplasmosis, bacterial urinary tract infections, Viral illness, yellow fever
Musculoskeletal/Orthopedic	rhabdomyolysis
Neurologic	No underlying causes
Nutritional/Metabolic	extreme obesity
Obstetric/Gynecologic	Eclampsia, preeclampsia
Oncologic	Renal neoplasm, multiple myeloma
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	stress
Pulmonary	No underlying causes
Renal/Electrolyte	Amyloidosis, Bence-jones proteinuria, crescentic glomerulonephritis, dehydration, Fanconi syndrome, fibrillary glomerulopathies, focal segmental glomerulosclerosis ), hyperoxaluria, hypertension-related kidney failure, hyperuricaemia, hypokalemic nephropathy, interstitial nephritis, medullary cystic kidney disease, myoglobinuria, nephritic syndrome, nephritis of pregnancy, nephrotic syndrome), Papillary necrosis, Polycystic kidney disease, adult (autosomal dominant), Poststreptococcal glomerulonephritis, Proliferative glomerulonephritis, Proximal renal tubular acidosis, acute Pyelonephritis, renal artery stenosis, renal metastases, renal neoplasm, renal tubular acidosis, renal vein thrombosis, rhabdomyolysis, toxic nephropathy, unilateral kidney, Urinary tract infection, X-linked hypophosphataemia
Rheumatology/Immunology/Allergy	Allergens, arteriolar nephrosclerosis, autoimmune conditions, Bence-jones proteinuria, Collagen vascular diseases, crescentic glomerulonephritis, Fanconi syndrome, fibrillary glomerulopathies, focal segmental glomerulosclerosis ), Henoch-schonlein syndrome, hepatitis b, IgA nephropathy (i.e., Berger's disease), IgM nephropathy, increased formation of polyclonal free light chains, interstitial nephritis, mixed cryoglobulinemia, multiple myeloma, Organ rejection- kidney transplant patients], Polyarteritis nodosa, recurrent hereditary polyserositis, rheumatoid disease, sarcoidosis, systemic lupus erythematosis, systemic sclerosis, Wegener's granulomatosis
Sexual	No underlying causes
Trauma	musculoskeletal trauma
Urologic	Retrograde ejaculation
Miscellaneous	No underlying causes

Causes in Alphabetical Order

• Acute pyelonephritis

• Aflibercept

• Allergens

• Alport syndrome

• Alström syndrome

• Aminoaciduria

• Amyloidosis

• Anticonvulsants

• Arteriolar nephrosclerosis

• aristolochic acids

• Autoimmune conditions

• Autosomal dominant conditions

• Autosomal dominant polycystic kidney disease

• Autosomal recessive conditions

• Bacteria and bacterial conditions

• Balkan endemic nephropathy

• Bence-jones proteinuria

• Benign orthostatic (postural) proteinuria

• Bevacizumab

• Bromobenzene

• cadmium
• Captopril

• Carmustine

• Caspofungin

• Chronic lymphocytic leukemia

• Chronic pyelonephritis

• Choloroform

• Circulatory failure

• Cirrhosis of liver

• Cisplatin

• Collagen vascular disease

• Congenital conditions

• Connatal tulbulopathies

• Constrictive pericarditis

• Crescentic glomerulonephritis

• Cystinosis

• Cystitis

• Cytomegalovirus

• Deferasirox

• Dehydration

• Dent disease

• Diabetes mellitus

• Diquat

• Ebola hemorrhagic fever

• Eclampsia

• Epstein-Barr virus

• Ethylene glycol

• Exercise-induced

• Fabry's disease

• Familial mediterranean fever

• Fanconi syndrome

• Fibrillary glomerulopathies

• Focal segmental glomerulosclerosis

• Galactosemia

• Gemcitabine

• Genitourinary tuberculosis

• Glycogen storage disease type I

• Gold

• Heavy metal ingestion

• Helminthic

• Hemoglobinuria

• Henoch-Schonlein syndrome

• Hepatitis B

• Hepatorenal tyrosinemia

• Hereditary fructose intolerance

• Heroin

• High blood pressure

• High fever

• HIV

• Hyperoxaluria

• Hypertension-related kidney failure

• Hyperuricaemia

• Hypokalemic nephropathy

• Hypothyroidism

• Idiopathic multicentric osteolysis

• IgA nephropathy (i.e., Berger's disease)

• IgM nephropathy

• Imerslund-Gräsbeck syndrome

• Increased formation of polyclonal free light chains

• Infectious Mononucleosis

• Interstitial nephritis

• Irradiation

• Lecithin cholesterol acyltransferase deficiency

• Legionella Pneumophila

• Leprosy

• Lomustine

• Malaria

• Malignancies (e.g., lymphoma, other cancers)

• Massive obesity

• Medullary cystic kidney disease

• Mercury
• Micafungin

• Mithramycin

• Mixed cryoglobulinemia

• Multiple myeloma

• Myoglobinuria

• Nail patella syndrome

• Nephritic syndrome

• Nephritis of pregnancy

• Nephrolithiasis

• Nephrotic syndromes

• Nitrosourea compounds

• NSAIDS

• Nutcracker syndrome of left renal vein

• Obstetric conditions

• Orthostatic proteinuria

• Papillary necrosis

• paraquat

• Pazopanib

• Penicillamine

• Polyarteritis nodosa

• Poststreptococcal glomerulonephritis

• Preeclampsia

• Proliferative glomerulonephritis

• Prostatitis

• Proximal renal tubular acidosis

• Recurrent hereditary polyserositis

• Renal artery stenosis

• Renal metastases

• Renal neoplasm

• Renal tubular acidosis

• Renal vein thrombosis

• Retrograde ejaculation

• Rhabdomyolysis

• Rheumatoid disease

• Sarcoidosis

• Shock

• Sickle cell disease

• Stress

• Subacute bacterial endocarditis

• Sulphasalazine

• Systemic lupus erythematosis

• Systemic sclerosis

• Toxic nephropathy

• Toxoplasmosis

• Transplant rejection

• Tricuspid insufficiency

• Tricholoroethelene

• Unilateral kidney

• Urinary tract infection

• Vasculitis

• Viral

• Waldenstrom's macroglobulinemia

• Wegener's granulomatosis

• Wilson's disease

• X-linked hypophosphataemia

• Yellow fever

Associated Conditions

Proteinuria may be a sign of renal (kidney) damage. Since serum proteins are readily reabsorbed from urine, the presence of excess protein indicates either an insufficiency of absorption or impaired filtration. Diabetics may suffer from damaged nephrons and develop proteinuria.

With severe proteinuria, general hypoproteinemia can develop which results in diminished oncotic pressure. Symptoms of diminished oncotic pressure may include ascites, edema, and hydrothorax.

Diagnosis

Laboratory Findings

Proteinuria is often diagnosed by a simple dipstick test although it is possible for the test to give a false negative even with nephrotic range proteinuria if the urine is dilute. False negatives may also occur if the protein in the urine is composed mainly globulins or Bence-Jones Proteins because the reagent on the test strips, Bromphenol blue, is highly specific for albumin. Traditionally dipstick protein tests would be quantified by measuring the total quantity of protein in a 24-hour urine collection test, and abnormal globulins by specific requests for Protein electrophoresis.

Alternatively the concentration of protein in the urine may be compared to the creatinine level in a spot urine sample. This is termed Protein/Creatinine Ratio (PCR). The 2005 UK Chronic Kidney Disease guidelines states that PCR is a better test than 24 hour urinary protein measurement. Proteinuria is defined as a Protein:creatinine ratio >45 mg/mmol (which is equivalent to Albumin:creatinine ratio of >30 mg/mmol) with very high levels of nephrotic syndrome being for PCR > 100 mg/mmol.

Reference Range
Physiologic protien elimination	<150mg protien/24 hours
Proteinuria	>150mg protein/24 hours
Microalbuminuria	<30mg albumin/24 hours

Treatment

Treating proteinuria mainly needs proper diagnosis of the cause. The most common cause is diabetic nephropathy; in this case, proper glycemic control may slow the progression. Medical management consists of angiotensin converting enzyme (ACE) inhibitors, which are typically first-line therapy for proteinuria. In patients whose proteinuria is not controlled with ACE inhibitors, the addition of an aldosterone antagonist (i.e., spironolactone) or angiotensin receptor blocker (ARB) may further reduce protein loss. Caution must be used if these agents are added to ACE inhibitor therapy due to the risk of hyperkalemia. Proteinuria secondary to autoimmune disease should be treated with steroids or steroid-sparing agent plus the use of ACE inhibitors.

Related Chapters

• Albuminuria
• Microalbuminuria
• List of terms associated with diabetes