genitourinary disorders
Proteinuria
Evaluation of Proteinuria
History of present illnessmay reveal symptoms of fluid overload or hypoalbuminemia, such as eye puffiness upon awakening and leg or abdominal swelling. Proteinuria itself may cause heavy foaming of the urine. However, patients with proteinuria and no obvious fluid overload may not report any symptoms. seeks symptoms suggesting cause, including red or brown urine (glomerulonephritis) or bone pain (myeloma). Patients are asked about existing conditions that can cause proteinuria, including recent serious illness (particularly with fever), intense physical activity, known renal disorders, Diabetes Mellitus (DM) , pregnancy, is of limited use, but vital signs should be reviewed for increased blood pressure (BP), suggesting glomerulonephritis. The examination should seek signs of peripheral edema and Ascites , reflective of fluid overload or low serum Urine dipstick primarily detectsalbumin. Precipitation techniques, such as heating and sulfosalicylic acid test strips, detect all proteins. Thus, isolated proteinuria detected incidentally is usually albuminuria. Dipstick testing is relatively insensitive for detection of microalbuminuria, so a positive urine dipstick test usually suggests overt proteinuria. Dipstick testing is also unlikely to detect excretion of smaller proteins characteristic of tubular and overflow proteinuria. Patients with a positive dipstick test (for protein or any other component) should have routine microscopic urinalysis. Abnormalities on urinalysis (eg, casts and dysmorphic red blood cells suggesting glomerulonephritis; glucose, ketones, or both suggesting diabetes) or disorders suggested by history and physical examination (eg, peripheral edema suggesting a glomerular disorder) require further work-up. nitrogen, creatinine, and glucose; determination of glomerular filtration rate (see Evaluating Kidney Function ); quantification of urinary protein (by 24-hour measurement or random urine protein/creatinine ratio); and evaluation of kidney size (by ultrasonography or CT). In most patients with glomerulopathy, proteinuria is in the nephrotic range ( Other testing is usually done to determine the cause of a glomerular disorder, including lipid profile, complement levels, cryoglobulins, hepatitis B and C serology, antinuclear antibody testing, urine and serum protein electrophoresis, HIV testing, and rapid plasma reagin testing for Syphilis . If these noninvasive tests are not diagnostic (as is often the case), Among patients aged<30 years, orthostatic proteinuria should be considered. Diagnosis requires 2 urine collections, one done from 7 AM to 11 PM (day sample) and the other from 11 PM to 7 AM (night sample). The diagnosis is confirmed if the urinary protein exceeds normal values in the day sample (or if urine protein/creatinine ratio is>0.3) and does not in the night sample. 