Skip to Main Content

++

Clinical Summary

++

Healthy children normally have protein in their urine, at a rate of protein excretion <4 mg/m2/h or <100 mg/m2/d throughout childhood. The upper limit of normal protein excretion is up to 150 mg/d. Albumin, relatively small in molecular size, tends to be the dominant constituent, and Tamm-Horsfall protein, a mucoprotein produced in the distal tubule, makes up the remainder.

++

Proteinuria in children can be transient, orthostatic, or pathologic. Transient proteinuria (often associated with fever, stress, dehydration, or exercise) does not indicate underlying renal disease. Orthostatic proteinuria (elevated protein excretion when the subject is upright but normal protein excretion during recumbency) occurs most commonly in school-aged children and rarely exceeds 1 g/m/d. These patients do not have hematuria and have normal values of creatinine clearance and C3 complement. Pathologic proteinuria is likely if proteinuria is associated with hematuria and/or the first morning urine Pr/Cr ratio is >0.2 in older children. Nephrotic-range proteinuria is levels >40 mg/m/h in 24 hours.

++

Emergency Department Treatment and Disposition

++

Take a complete history and physical examination including blood pressure in a patient with proteinuria. In general, urinalysis showing mild proteinuria (trace to 1+) is not reliable during acute illness (unless there are other symptoms and signs pointing to renal disease). Discharge patients with mild proteinuria who have normal blood pressure and urine output and no evidence of kidney disease. For patients with moderate to severe proteinuria (3+ or 4+), obtain serum albumin, creatinine, cholesterol, electrolytes, serum C3/C4 complement, antinuclear antibody, serologies for hepatitis B and C, and human immunodeficiency virus as clinically indicated. Use renal ultrasound to exclude underlying renal disease. Consult pediatric nephrology for further evaluation if any of the studies are abnormal. Hospitalize patients with severe nephrosis, especially the first episode.

++

Pearls

++

  1. Not all proteinuria is pathologic.

  2. Exclude hematuria when evaluating patients with proteinuria in the emergency department (ED).

  3. Proteinuria is not an uncommon finding in children and may indicate a completely benign condition or be the first clue to a significant renal parenchymal disease (eg, nephrotic syndrome or glomerulonephritis).

  4. Heavy proteinuria (3+ or 4+ on dipstick) is typically seen in nephrotic syndrome; mild proteinuria (trace to 1+) is typically seen with fever or dehydration.

++
Figure 16.1 ▪ Nephrotic Syndrome (NS) Presenting with Edema and Proteinuria.
Graphic Jump LocationGraphic Jump Location

(A, B) An 18-month-old child presented with periorbital and facial edema (A) and edema of the feet (B). Urinalysis showed 4 + proteinuria associated with hypoproteinemia. He was clinically diagnosed as Minimal change NS. (Reproduced with permission from Shah BR, Laude T: Atlas of Pediatric Clinical Diagnosis. WB Saunders, Philadelphia, 2000, p. 468.)

++
Figure 16.2 ▪ Nephrotic Syndrome (NS) Presenting with Edema and Proteinuria.
Graphic Jump ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessPediatrics Full Site: One-Year Subscription

Connect to the full suite of AccessPediatrics content and resources including 20+ textbooks such as Rudolph’s Pediatrics and The Pediatric Practice series, high-quality procedural videos, images, and animations, interactive board review, an integrated pediatric drug database, and more.

$595 USD
Buy Now

Pay Per View: Timed Access to all of AccessPediatrics

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.