Dr. NK Hase delivers a masterclass on proteinuria, exclusive in this weekly series for M3 India. In the final part, he discusses 4 cases, writing in detail on the evaluation, aetiology, and final diagnosis. If you have queries, send in your questions at the end of this article. Dr. NK Hase will address them in a separate article, once this series concludes.

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Case 1

A male, 23 years old, came in for evaluation of proteinuria. He was asymptomatic, BP: 110/70 mmHg, no oedema. Systemic examination is unremarkable.

Urine:

Protein- 2+, glucose- 1+, no RBC or WBC, cast crystals

• Urinary proteins- 2 g/day
• UPCR- 200 mg/g
• UACR- 400 mg/g
• S. creatinine- 1.3 mg/dL
• HbA1c- 4.8%
• Blood glucose- Fasting- 89 mg/dL
• USG abdomen- Normal size kidney with grade 1 echogenicity

What is the likely cause of proteinuria? What is the possible aetiology?

Young asymptomatic male with normal BP, dipstick proteinuria 2+, quantification: 2 g, bland urine. UPCR > UACR; a ratio less than 0.4 suggests tubular proteinuria. Glucosuria with normal sugar favours proximal tubular dysfunction.

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Case 2

A 10-year-old male child comes in with h/o haematuria, smoky urine, a h/o sore throat 2 days prior, and a h/o similar episode 6 months back with h/o mild oedema.

• BP- 140/100 mmHg
• Mild oedema

Systemic examination was unremarkable.

Urine:

• Colour- Brown
• Protein- 3+
• Glucose- Absent
• Blood+
• Dysmorphic RBCs.
• WBCs- 8-10/HPF
• Urine proteins- 2.5 g/day
• S.creatinine- 0.8 mg//dL
• BUN- 8 mg/dL
• C3- 100 mg/dL
• C4- 15 mg/dL
• ANA- Negative
• USG- Kidney, right: 11 cm and left:12 cm, PCS: Normal

What is the likely cause of proteinuria? What is the possible aetiology?

A child with abrupt onset of haematuria which is synpharyngitic; H/O similar episode in the past. Proteinuria with glomerular haematuria suggests glomerular proteinuria. Normal complement and synpharingitic illness suggests mostly IgA nephropathy.

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Case 3

A 50-year-old male was referred for evaluation of backache and anaemia.

Physical examination:

• No h/o DM, hypertension
• No h/o oedema
• H/o nocturia and polyuria
• BP- 130/80 mmHg
• Anaemia+
• Verteral tenderness+
• Systemic examination was unremarkable

Urine:

• Protein- Absent
• Glucose- Absent
• No RBC, WBC
• UACR- 20 mg/g
• UPCR- 3.0 g/g
• BUN- 20
• S. creatinine- 2 mg/dL
• S Na-130 mEq/l
• K- 5.00
• S. proteins- T: 8 g/dL
• Albumin- 2.5 g/dL
• S.ca- 11.0 mg/dL
• PO4- 2.5 mg/dL
• Alkaline phosphatase- 30 IU

What is the likely cause of proteinuria? What is the possible aetiology?

Urine dipstick negative with proteinuria, PCR>ACR high total proteins and globulins with hypercalcaemia suggest overflow proteinuria due to multiple myeloma. Evaluations required- serum protein electrophoresis, serum-free light chain assay, and immunofixation.

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Case 4

A 26-year-old male, asymptomatic, healthy, had a pre-employment check-up and was found to have proteinuria by dipstick 2+. He had no h/o diabetes mellitus, no h/o febrile illness. BP was 120/80 mmHg and BMI was 32. No oedema was detected.

Urine: Early morning urine

• Proteins- Absent
• No RBC, WBC or cast
• 24 hours urinary proteins- 1.5 g/day
• UPCR- 0.8 g/g
• BUN- 8
• S. creatinine- 0.8

What is the likely cause of proteinuria? What is the possible aetiology?

The young, asymptomatic, non-hypertensive, non-diabetic, overweight, found dipstick positive in pre-employment check done in the afternoon 24 hours urinary proteins are 1.5 g. Early morning sample is negative for proteins most likely due to orthostatic proteinuria. This need to be confirmed by split urine protein test

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In the next part, Dr. NK Hase will answer questions posted by you on proteinuria.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author Dr. NK Hase is a Director clinical Nephrology & Transplant working at Jupiter Hospital, Thane and former Professor & Head of Department of Nephrology Seth GS Medical College and KEM Hospital, Mumbai.