Kidney damage is defined as structural or functional abnormalities of the
kidney, initially without decreased GFR, which over time can lead to decreased
GFR. As described earlier, markers of kidney damage include abnormalities in the
composition of the blood or urine or abnormalities in imaging tests. This
section will emphasize proteinuria as a marker of kidney damage because it has
been studied most thoroughly, including in NHANES III.
Proteinuria is an early and sensitive marker of kidney damage in many types
of chronic kidney disease. Albumin is the most abundant urine protein in most
types of chronic kidney disease. Low molecular weight (LMW) globulins are the
most abundant urine proteins in some types of chronic kidney disease. In this
and later guidelines, the term proteinuria(Proteinuria and Kidney Disease) includes albuminuria, increased
urinary excretion of other specific proteins, and increased excretion of total
urine protein. On the other hand, the term albuminuria has been used only when
referring to increased urinary albumin excretion. Older laboratory methods, such
as the urine dipstick or acid precipitation, detect most urine proteins.
Microalbuminuria refers to excretion of small but abnormal amounts of albumin,
which requires recently developed, more sensitive laboratory methods that are
now widely available.
Normal mean value for urine albumin excretion in adults is approximately 10
mg/d. Albumin excretion is increased by physiological variables, such as upright
posture, exercise, pregnancy, and fever. Normal mean value for urine total
protein is approximately 50 mg/d. Major constituents of normal urine protein are
albumin, LMW proteins filtered from the blood, and proteins derived from the
urinary tract.
In practice, it is difficult to collect a timed urine specimen. the urinary
excretion rate for albumin and total protein can be estimated from the ratio of
albumin or total protein to creatinine concentration in an untimed (“spot”)
urine specimen. Because protein excretion varies throughout the day, the normal
ratio varies throughout the day. The ratio in a first morning specimen
correlates most closely with overnight protein excretion rate, whereas the ratio
in mid-morning specimens correlates most closely with 24-hour protein excretion
rate. Creatinine excretion is higher in normal men than women,(How to Reduce High Creatinine Level in Blood ); therefore, the
values in the general population and cut-off values for abnormalities in urine
albumin-to-creatinine ratio are lower for men than women