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Proteinuria Workup

  • Author: Edgar V Lerma, MD, FACP, FASN, FAHA, FASH, FNLA, FNKF; Chief Editor: Vecihi Batuman, MD, FACP, FASN  more...
Updated: Dec 10, 2015

Approach Considerations

Evaluation of proteinuria normally is conducted on an outpatient basis, unless the patient develops a complication of severe nephrotic syndrome. All patients with evidence of glomerular disease or any reduction in renal function should be referred to a nephrologist.

Laboratory studies

To determine whether patients have transient proteinuria, perform the following:

  • Urinalysis and microscopic examination on at least three separate occasions
  • Albumin-to-creatinine or protein-to-creatinine ratio in random urine sample[19, 20]
  • Urinalysis on early morning sample, before the patients is involved in physical activity

To determine whether patients have orthostatic proteinuria, perform the following:

  • Urine microscopy
  • Split urine collection - Daytime (7 am to 11 pm) and overnight (11 pm to 7 am)

To determine whether proteinuria may be glomerular in origin, perform the following:

  • Urine microscopy – To search for dysmorphic red blood cells and casts
  • Urine collection (24 h) for quantification of albumin (or protein) excretion and creatinine clearance – Especially if the patient is muscular or cachectic; spot protein/creatinine ratio can be used for subsequent assessments
  • Serum creatinine, albumin, cholesterol (see HDL cholesterol and LDL cholesterol), and blood glucose determinations
  • Autoantibody determinations - If indicated, including antistreptolysin O titers, antinuclear antibodies (ANAs), anti-DNA antibodies, complement levels, and cryoglobulins
  • Hepatitis B, hepatitis C, and HIV serologies - If indicated
  • Urine and plasma protein electrophoresis - If indicated
  • Anti–glomerular basement membrane (anti-GBM) antibodies and antineutrophil cytoplasmic antibodies (ANCA) – If there is a suspicion of pulmonary renal syndrome.

Imaging studies

Imaging studies in proteinuria can include the following:

  • Renal ultrasonography – If glomerular disease is being considered
  • Chest radiography or computed tomography – If indicated

Detection of Microalbuminuria

Microalbuminuria is referred to as excretion of 30-300 mg of albumin daily or 20-200 µg of albumin per minute. These amounts are too small to be detected; by routine dipstick screening methods, .

To date, numerous assays have been developed to detect this range of albumin concentrations in the urine. However, most of these assays are limited by intraindividual variations among patients with regard to factors such as physical activity level, acute illnesses or fevers, menstruation, pregnancy, vaginal discharge, diet, blood pressure, volume status, degree of glycemic control, and urine collection method (eg, 24 h, overnight or timed, short-term). On average, albumin excretion is 25% higher during the day than overnight, with a day-to-day variation of 40%.

Therefore, it is recommended that a diagnosis of albuminuria be made only after at least three of the patient’s urine samples over a 6-month period demonstrate albumin concentrations that fall within the above-mentioned range.


Renal Biopsy

Renal biopsy should be considered in adult patients with persistent proteinuria, because the diagnostic and prognostic information yielded is likely to guide the choice of specific therapy.

In children, most cases of nephrotic syndrome are due to steroid-sensitive minimal-change disease. The clinician may reasonably assume this to be the diagnosis and give a trial of therapy, reserving biopsy for unresponsive cases.

In adult patients who have isolated proteinuria of less than 1 g/day and no other indicators of renal disease, the renal prognosis is good and the need for specific treatment is unlikely. Most nephrologists would treat these patients with nonspecific measures (as detailed in the next section) and would proceed to biopsy only if the degree of proteinuria increases or if the patient undergoes progressive renal decline.

Contributor Information and Disclosures

Edgar V Lerma, MD, FACP, FASN, FAHA, FASH, FNLA, FNKF Clinical Professor of Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine; Research Director, Internal Medicine Training Program, Advocate Christ Medical Center; Consulting Staff, Associates in Nephrology, SC

Edgar V Lerma, MD, FACP, FASN, FAHA, FASH, FNLA, FNKF is a member of the following medical societies: American Heart Association, American Medical Association, American Society of Hypertension, American Society of Nephrology, Chicago Medical Society, Illinois State Medical Society, National Kidney Foundation, Society of General Internal Medicine

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Otsuka, Mallinckrodt, ZS Pharma<br/>Author for: UpToDate, ACP Smart Medicine.


Tejas Desai, MD Staff Nephrologist, WG (Bill) Hefner VA Medical Center

Tejas Desai, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology

Disclosure: Nothing to disclose.

Pankaj Jawa, MD Assistant Professor of Medicine, Division of Nephrology and Hypertension, The Brody School of Medicine at East Carolina University

Pankaj Jawa, MD is a member of the following medical societies: American Society of Hypertension, American Society of Nephrology, American Society of Transplantation, National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Renal Section, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology

Disclosure: Nothing to disclose.


George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Kevin McLaughlin, MBChB, PhD, MSc Associate Professor, Assistant Dean, Department of Medicine, University of Calgary Faculty of Medicine, Calgary Health Region

Kevin McLaughlin, MBChB, PhD, MSc is a member of the following medical societies: American Society of Nephrology, American Society of Transplantation, and College of Physicians and Surgeons of Alberta

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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