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Proteinuria
Diagnosis/Definition
Greater than 150 mg of proteinuria per day.
Initial Diagnosis and Management
- Diagnosis is usually suspected on the basis of an abnormal dipstick urinalysis. The suspicion should be confirmed by a spot urine protein to creatinine ratio of greater than 0.15 (equivalent to or greater than 150 mg of urinary protein daily). Be sure to use correct units when calculating ratio.
- Proteinuria is a marker of intrinsic renal disease, and causes of this need to be assessed.
- Perform a history and physical examination to evaluate for evidence of a systemic disorder that may cause glomerulonephritis, i.e., signs/symptoms to suggest collagen vascular disease such as SLE, cancer, chronic infections, or diabetes.
- Evaluate for evidence of nephrotic syndrome: serum albumin (low), cholesterol (high), the presence of edema, and greater than 3 gm of proteinuria daily.
- Obtain BUN, serum creatinine, electrolytes, and blood glucose.
- Obtain a microscopic urinalysis for hematuria, casts, or sterile pyuria.
- If suspicion for intrinsic renal disease is low, evaluate for orthostatic proteinuria by doing a split 24 hour collection (12 hours lying down and 12 hours upright). Nephrology will help with this if you are suspicious.
Ongoing Management and Objectives - If BUN/creatinine and microscopic urinalysis are normal, the patient has no evidence of a systemic disease and the degree of proteinuria is less than 1.5 gm per day, then the patient can be followed with every three to six month serial evaluations to assure stability and degree of progression.
- If the patient has orthostatic proteinuria, no further evaluation is required.
Indications for Specialty Care Referral
Nephrotic syndrome.
Non-nephrotic proteinuria with elevated BUN/creatinine or abnormal UA with greater than 2 red cells per high power field, or greater that 4 white cells per high power field in a non-contaminated urine specimen, or cellular casts.
Consider referral if a patient has persistently greater than 500mg proteinuria/day.
Evidence of systemic disease, e.g., SLE.
Criteria for Return to Primary Care
This will need to be determined on a case-by-case basis after discussion with the primary care provider and the nephrologist.
