Initial Management of Proteinuria

Assessment and Evaluation

The Kidney International guideline recommends that all patients with proteinuria should be assessed for risk of progression by evaluating proteinuria level, blood pressure, and eGFR at diagnosis and during follow-up 1, 3
Quantify proteinuria using spot urine protein-to-creatinine ratio when dipstick shows ≥1+ protein (roughly correlates to 30 mg/dL or protein-to-creatinine ratio ≥1300 mg/g), as suggested by Clinical Infectious Diseases 4, 5
Renal ultrasound may provide information on kidney size, presence of stones, and extrarenal/intrarenal lesions in patients with evidence of chronic kidney disease, according to Clinical Infectious Diseases 4, 5
Additional evaluations to identify the cause of proteinuria include serological tests for hepatitis B and C, complement levels, antinuclear antibody testing, cryoglobulin levels, quantitative immunoglobulin testing, and serum/urine protein electrophoresis, as recommended by Clinical Infectious Diseases 5

For proteinuria >1 g/day, the American Journal of Kidney Diseases recommends starting long-term ACE inhibitor or ARB treatment with uptitration depending on blood pressure, with a target blood pressure <125/75 mmHg 1, 2, 6
For proteinuria >1 g/day, the Kidney International guideline suggests titrating ACE inhibitor or ARB upward as far as tolerated to achieve proteinuria <1 g/day 1, 2
For proteinuria between 0.5-1 g/day, consider ACE inhibitor or ARB treatment, with a target blood pressure <130/80 mmHg, as recommended by Kidney International 1, 2, 6

In HIV-infected patients, annual screening for proteinuria is recommended for high-risk groups, including African Americans, patients with diabetes, patients with hypertension, patients with hepatitis C coinfection, and patients with HIV RNA levels ≥14,000 copies/mL or CD4+ counts <200 cells/mL, according to Clinical Infectious Diseases 4, 5
Small kidneys (<9 cm in length) on ultrasound may indicate advanced and irreversible kidney disease, as suggested by Clinical Infectious Diseases 5