Orthostatic (postural) proteinuria
- Michael J Somers, MD
Michael J Somers, MD
- Associate Professor of Pediatrics
- Harvard Medical School
Orthostatic (also referred to as postural) proteinuria is characterized by an elevated protein excretion while in the upright position and normal protein excretion in a supine or recumbent position. It is the most frequent cause of isolated proteinuria in children, especially adolescents.
The prevalence, pathogenesis, diagnosis, and prognosis of orthostatic proteinuria will be reviewed here. The evaluation of proteinuria in children is discussed separately. (See "Evaluation of proteinuria in children".)
Normal protein excretion — The following are definitions for normal protein excretion in children and adults:
●Children – Urinary protein excretion in the normal child is less than 100 mg/m2 per day (<4 mg/m2 per hour) or a total of 150 mg per day. (See "Evaluation of proteinuria in children", section on 'Normal protein excretion'.)
●Adults – Urinary protein excretion in the normal adult is less than 50 mg per eight-hour duration or a total of 150 mg per day. (See "Assessment of urinary protein excretion and evaluation of isolated non-nephrotic proteinuria in adults", section on 'Amounts of proteinuria'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Hogg RJ, Portman RJ, Milliner D, et al. Evaluation and management of proteinuria and nephrotic syndrome in children: recommendations from a pediatric nephrology panel established at the National Kidney Foundation conference on proteinuria, albuminuria, risk, assessment, detection, and elimination (PARADE). Pediatrics 2000; 105:1242.
- Devarajan P. Mechanisms of orthostatic proteinuria: lessons from a transplant donor. J Am Soc Nephrol 1993; 4:36.
- Dodge WF, West EF, Smith EH, Bruce Harvey 3rd . Proteinuria and hematuria in schoolchildren: epidemiology and early natural history. J Pediatr 1976; 88:327.
- Sebestyen JF, Alon US. The teenager with asymptomatic proteinuria: think orthostatic first. Clin Pediatr (Phila) 2011; 50:179.
- Mahurkar SD, Dunea G, Pillay VK, et al. Relationship of posture and age to urinary protein excretion. Br Med J 1975; 1:712.
- Miltényi M. Urinary protein excretion in healthy children. Clin Nephrol 1979; 12:216.
- Robinson RR. Isolated proteinuria in asymptomatic patients. Kidney Int 1980; 18:395.
- Park YH, Choi JY, Chung HS, et al. Hematuria and proteinuria in a mass school urine screening test. Pediatr Nephrol 2005; 20:1126.
- Brandt JR, Jacobs A, Raissy HH, et al. Orthostatic proteinuria and the spectrum of diurnal variability of urinary protein excretion in healthy children. Pediatr Nephrol 2010; 25:1131.
- Alon US, Simon S, Hampl S, Hornberger L. Prevalence of proteinuria and its relationship to body mass in adolescents. J Am Soc Nephrol 2007; 18:338A.
- Sinniah R, Law CH, Pwee HS. Glomerular lesions in patients with asymptomatic persistent andorthostatic proteinuria discovered on routine medical examination. Clin Nephrol 1977; 7:1.
- ROBINSON RR, GLOVER SN, PHILLIPPI PJ, et al. Fixed and reproducible orthostatic proteinuria. I. Light microscopic studies of the kidney. Am J Pathol 1961; 39:291.
- Ha TS, Lee EJ. ACE inhibition can improve orthostatic proteinuria associated with nutcracker syndrome. Pediatr Nephrol 2006; 21:1765.
- Vehaskari VM. Mechanism of orthostatic proteinuria. Pediatr Nephrol 1990; 4:328.
- Cho BS, Suh JS, Hahn WH, et al. Multidetector computed tomography findings and correlations with proteinuria in nutcracker syndrome. Pediatr Nephrol 2010; 25:469.
- Ragazzi M, Milani G, Edefonti A, et al. Left renal vein entrapment: a frequent feature in children with postural proteinuria. Pediatr Nephrol 2008; 23:1837.
- Shintaku N, Takahashi Y, Akaishi K, et al. Entrapment of left renal vein in children with orthostatic proteinuria. Pediatr Nephrol 1990; 4:324.
- Park SJ, Lim JW, Cho BS, et al. Nutcracker syndrome in children with orthostatic proteinuria: diagnosis on the basis of Doppler sonography. J Ultrasound Med 2002; 21:39.
- Milani G, Bianchetti MG, Bozzani S, et al. Body mass index modulates postural proteinuria. Int Urol Nephrol 2010; 42:513.
- Poortmans JR. Postexercise proteinuria in humans. Facts and mechanisms. JAMA 1985; 253:236.
- Houser M. Assessment of proteinuria using random urine samples. J Pediatr 1984; 104:845.
- Heathcote KL, Wilson MP, Quest DW, Wilson TW. Prevalence and duration of exercise induced albuminuria in healthy people. Clin Invest Med 2009; 32:E261.
- Springberg PD, Garrett LE Jr, Thompson AL Jr, et al. Fixed and reproducible orthostatic proteinuria: results of a 20-year follow-up study. Ann Intern Med 1982; 97:516.
- Rytand DA, Spreiter S. Prognosis in postural (orthostatic) proteinuria: forty to fifty-year follow-up of six patients after diagnosis by Thomas Addis. N Engl J Med 1981; 305:618.
- Normal protein excretion
- Normal variant
- Subtle glomerular abnormality
- Exaggerated hemodynamic response to the upright position
- Left renal vein entrapment
- CLINICAL PRESENTATION
- Urine protein-to-creatinine ratio
- 24-hour urine collection
- Urinary dipstick
- Effect of strenuous exercise on the diagnostic evaluation
- DIFFERENTIAL DIAGNOSIS
- MANAGEMENT AND FOLLOW-UP CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS