Proteinuria- Pathologic

Tubular Proteinuria
Healthy individuals filter large amounts of proteins of lower molecular weight than
albumin (lysozyme, light chains of immunoglobulin, beta2 -microglobulin, insulin,
growth hormone
these are normally reabsorbed in the proximal tubule
Injury to the proximal tubules results in diminished reabsorptive capacity and the loss of
these low molecular weight proteins in the urine
such proteinuria rarely exceeds 1 g/24 hr
it is not associated with edema. Tubular proteinuria
may be seen in acquired and inherited disorders
may be associated with other defects of proximal tubular function, such as glucosuria,
phosphaturia, bicarbonate wasting, and aminoaciduria.
underlying disease is usually detected before the proteinuria.
In tubular proteinuria, the low molecular weight proteins migrate primarily in the alpha
and beta regions and little or no albumin is detected, whereas in glomerular proteinuria
the major protein is albumin.

Glomerular Proteinuria
increased permeability of the glomerular capillary wall.
amount of glomerular proteinuria may range from less than 1 to 30 g/24 hr.

selective (loss of plasma proteins of molecular weight up to and including albumin)

nonselective (loss of albumin and of larger molecular weight proteins such as IgG).

Most forms of glomerulonephritis are accompanied by nonselective proteinuria.

Selective proteinuria occurs primarily in minimal-change nephrosis

the finding of selective proteinuria in this disease increases the likelihood of
corticosteroid responsiveness

PROTEINURIA
proteinuria is not a renal function test
It accompanies renal damage.
Its severity does not correlate with the amount of damaged renal parenchyma
Proteinuria may be secondary to benign or extra-renal etiologies or even to contamination
of the specimen.

significance of small proteinuria.

The urine protein lower limit is 10 mg/100 ml (0.1 g/L).
values of up to 30 mg/100 ml are normal;
30-40 mg/100 ml may be abnormal.

total urinary protein output per 24 hours may be up to 100 mg/24 hours.

Values in milligrams per 24 hours may not be equal to values in milligrams per 100 ml
due to diluent water.

in diabetes mellitus, lesser degrees of albuminuria may suggest early renal damage

duration of proteinuria is even more important than quantity

Intrinsic renal disease is associated with persistent proteinuria,

the proteinuria seen with extrarenal types disappears if the primary disease is treated.

asymptomatic proteinuria =

repeat the test after 2 or 3 days (in clinically healthy persons)

orthostatic proteinuria is common
If proteinuria persists and orthostatic proteinuria is ruled out, the microscopy report
should be analyzed
prevent contamination of the urine specimen, in female patients.
The presence of hematuria or pyuria suggest diseases.

search for RBC or white blood cell (WBC) casts.

history may elicit previous proteinuria or hematuria, suggesting chronic

glomerulonephritis, or previous kidney infection or calculi,

Uremia due to chronic bilateral renal disease has associated hypertension.

anemia, normochromic or hypochromic and without reticulocytosis is found in severe

chronic diffuse renal disease.
note random specific gravities
normal (i.e.,>1.020= renal function is adequate.

If low, do creatinine clearance test,

If the creatinine clearance rate is abnormal and the BUN level is normal with no
hypertension or anemia present, the patient has severe diffuse bilateral renal abnormality
but not end-stage disease.