Protein in the Urine? What's the Big Deal!

Should you be worried about it, and does it need to be treated?

2611_Blood_Flow_in_the_Nephron.jpg
The Nephron, which includes the Glomerulus, or the kidney's filter. By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

To most of us, protein is something that you get from your diet, and it is generally good for you. So why is it a problem when your doctor tells you that you have "protein in the urine"? Well, protein in the urine, or "proteinuria", as it is referred to medically means the presence of abnormally high amount of protein in the urine. A normal person's urine, when tested with a dipstick should not show presence of any protein.

However, when you do, it could be a sign of of Chronic Kidney Disease (CKD). As I keep stressing, patients with CKD often do not have any symptoms and the only way to diagnose it is through blood and urine tests, or imaging.

ABNORMALLY HIGH LEVEL OF PROTEIN IN THE URINE COULD INDICATE KIDNEY DISEASE

So as I explained above, proteinuria could indicate CKD. Where does protein in the urine come from? Well, protein is there in the blood. It exists as different types (albumin, globulin, etc). Your muscles are primarily made of protein. The antibodies that circulate in your system fighting infection are protein. Hence protein is essential and you normally shouldn't be peeing it out in to the urine. 

HOW THEN DOES PROTEIN LEAK OUT IN TO THE URINE? 

Take a look at the accompanying picture. The kidney's filter, called the glomerulus is usually very selective. It lets the bad toxins out in to the urine.

But it holds back the good stuff (protein, blood cells, etc). However, damage to the kidneys filter (commonly from diseases like diabetes or hypertension) can make it lose this selectivity (think a sieve whose holes become too large, although it is more complicated than that) making protein escape.

Other factors that can cause this is damage to the kidney's drainage system (see the tubules in the accompanying picture) or in rarer cases, excess amount of protein in the blood where it just overflows in to the urine.

PROTEIN IN THE URINE IS NOT JUST AN EFFECT OF CKD, IT COULD BE A CAUSE TOO

Now we know that proteinuria indicates damage to the kidney's filter, and hence CKD. But if protein in the urine is just another downstream effect of kidney disease, then why do we nephrologists make so much fuss about treating it?  

Well, herein lies a key concept that I am going to talk about. Which is that protein is not just another consequence of CKD, it actually directly makes kidney disease worse. Which leads to further kidney damage; and which leads to even more protein in the urine! So it might start off as an effect, but it soon becomes (part of) the cause as well. I guess you are getting my point. Protein is not just a sign of the problem, it is the problem!

Let us look at the evidence to support the above conclusion.

A lot of research has been done on this, and today, minimizing proteinuria is a valid "target" for retarding the progression of CKD.

A key factor in the progression of kidney disease (regardless of the cause) is elevated pressure inside the kidney's filter, the glomerulus. This is called intraglomerular hypertension. This leads to elevated filtration rate, or GFR, in the initial stages of kidney disease. Over the short term, this might help the kidney numbers "look pretty". In the long run, it is actually maladaptive and GFR drops, and is the reason for scar tissue formation is many kinds of CKD, eg. diabetic kidney disease.

Protein in the urine makes intraglomerular hypertension worse. And so we have medical evidence that indicates that untreated proteinuria significantly increases the chances of your kidney disease progressing to failure (when dialysis or transplantation become necessary). The level of protein in the urine is directly proportional to the risk of your kidney disease getting worse. Similarly, multiple medical studies have proved that worsening of kidney disease can be prevented if proteinuria is treated using specific drugs like ACE inhibitors or ARBs. Interestingly, the protective effect that comes with these medications is independent of the control in blood pressure induced by the drugs! A greater reduction translates in to more kidney protection, and a more favorable outcome for your kidneys.

IS LOW PROTEIN DIET THE ANSWER

I have talked about the role of moderate protein diet in preventing CKD progression and in other forums as well. Even though it makes intuitive sense, and even though excess protein in the urine is directly associated with hyperfiltration, at this time the effect of protein restriction (especially when it is done in combination with ACE inhibitors or ARBs) on renal function is uncertain. For now, lets just suffice it to say that a moderate protein diet with about 0.8 grams per kilo body weight of protein per day, might be beneficial but going on a low protein diet may not be of benefit. 

Click here to read more about treating proteinuria

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