Article ID: WMC003814 ISSN 2046-1690

Proteinuria in Pregnancy: A Review of the Literature

Corresponding Author:
Mr. Anthony Kodzo - Grey Venyo,
Urologist, Urology Department. North Manchester General Hospital - United Kingdom

Submitting Author:
Mr. Anthony Kodzo - Grey Venyo,
Urologist, Urology Department. North Manchester General Hospital - United Kingdom

Article ID: WMC003814

Article Type: Review articles
Submitted on:09-Nov-2012, 10:44:04 PM GMT Published on: 11-Nov-2012, 12:47:00 AM GMT
Article URL: http://www.webmedcentral.com/article_view/3814
Subject Categories:OBSTETRICS AND GYNAECOLOGY
Keywords:Proteinuria; Pregnancy; Blood vessel; Endothelial-damage;
Exaggerated-maternal-inflammatory-response; Preeclampsia.
How to cite the article:Sheikh F, Venyo A . Proteinuria in Pregnancy: A Review of the Literature .
WebmedCentral OBSTETRICS AND GYNAECOLOGY 2012;3(11):WMC003814
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution
License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Source(s) of Funding:
None

Competing Interests:
None

WebmedCentral > Review articles Page 1 of 12

WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
Proteinuria in Pregnancy: A Review of the Literature
Author(s): Sheikh F, Venyo A
Abstract
Background: Proteinuria can be encountered in
pregnant and non-pregnant patients, and is a worrying
feature for clinicians and pregnant ladies as it is
related to preeclampsia.
Aim: Literature review on proteinuria in pregnancy.
Materials and methods: Using several search
engines, information was gathered from 68 references
as the foundation for the review.
Results: Proteinuria is a consequence of two
mechanisms, the abnormal trans-glomerular passage
of proteins due to increased permeability of the
glomerular capillary wall and the impaired
re-absorption by the epithelial cells of the proximal
tubules. It is most commonly associated with urinary
tract infections in pregnancy or longstanding renal
disease, but is related to pre-eclampsia after 20 weeks
gestation in the presence of hypertension. Blood
vessel endothelial cell damage plus an exaggerated
maternal inflammatory response leads to increased
vascular permeability, vasoconstriction, reduced
placental blood flow and clotting abnormalities.
Studies imply that the correlation between dipstick
urinalysis and 24 hour protein estimation is weak and
NICE recommend that with significant proteinuria,
automated dipstick readers be used to improve the
rate of false positive and false negatives and a dipstick
finding of proteinuria should be confirmed by 24 hours
urine collection/protein creatinine ratio. In pregnant
ladies with renal disease the main aim is to have
delivery at term but patients with preeclampsia quite
often develop progressive disease which ends up in
the need for iatrogenic delivery. In situations when it is
difficult to distinguish preeclampsia from pre-existing
renal disease, it is pertinent to assume a working
diagnosis of preeclampsia because of its potential for
rapid development of serious maternal and foetal
complications. Proteinuria (or hypertension) which
persists longer than 3 months post-delivery should be
followed up closely.
Conclusions: The gestational age at which
proteinuria is first documented is important in
establishing the likelihood of preeclampsia versus
other renal disease. Proteinuria prior to or early in
pregnancy suggests pre-existing renal disease. In late
pregnancy, the presence of hypertension or aspects of
WebmedCentral > Review articles
severe preeclampsia also helps to distinguish
preeclampsia from underlying renal disease. Renal
biopsy is best left until the post-partum period unless
unexplained rapidly progressive loss of renal function
is occurring.
Introduction
Proteinuria is defined as the presence of urinary
protein in amounts exceeding 0.3 g in a 24 hour urine
collection or in concentrations more than 1g per litre
(1+ on urine dipstick). When protein excretion exceeds
these levels in a pregnant women it is considered
abnormal and a sign of preeclampsia after 20 weeks
gestation. However, before pregnancy or before 20
weeks gestation, proteinuria is considered a sign of
existing underlying renal disease. Proteinuria in
pregnancy is a clinical entity which is of interest to the
obstetrician, nephrologist, urologist, general physician
as well as the patient’s general practitioner. More
importantly, it is worrying for the pregnant patient and
her family. In view of this, it is pertinent to understand
the pathophysiology, differential diagnosis,
investigation and management of proteinuria in
pregnancy. In order to understand the aforementioned
aspects, there is a need to review the literature
relating to proteinuria in pregnancy.
Materials and Methods
The following literature search engines were used
searching for proteinuria in pregnancy: Google,
Google Scholar, Educus, Up to date and Pub Med. All
together, information gathered from 68 references
used as foundation for the literature review. Some of
these papers have been case reports and others were
reviews and case studies. Thirteen papers were found
to have extensively reviewed proteinuria in pregnancy
and these in addition to documentation of proteinuria
in two books were thoroughly scrutinized in order to
document / summarise the presentation, investigation
and management as well as conclusions relating to
proteinuria in pregnancy.
Literature Review
Pathophysiology of proteinuria
Page 2 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
It has been suggested that proteinuria is a
consequence of two mechanisms. [1] It can be due to
the abnormal transglomerular passage of proteins due
to increased permeability of the glomerular capillary
wall and the impaired reabsorption by the epithelial
cells of the proximal tubuli. In glomerular disease,
more damage to the glomerular capillary wall means
the glomerular barrier is more likely to be permeated
by high-molecular-weight proteins, to which the barrier
is normally impermeable. [1] The increased
concentration of these proteins in the tubular lumen
leads to the saturation of the reabsorptive mechanism
by the tubular cells and damages them. This in turn
promotes the urinary excretion of all proteins, including
low-molecular-weight proteins, which are reabsorbed
in normal physiologic conditions. [1]
Recent clinical studies [1] showed that in patients with
glomerular diseases the urinary excretion of some
HMW proteins [immunoglobulins G and M (IgG and
IgM)] and of some low molecular weight (LMW)
proteins, 1-microglobulin, 2-microglobulin, correlates
with the severity of the histologic lesions, and may
predict, better than the quantity of proteinuria, the
natural course, the outcome, and the response to
treatment. It is suggested that some patients have
already, at the time of clinical presentation, a structural
damage of the glomerular capillary wall (injury of
podocytes) and of the tubulointerstitium, the severity
and scarce reversibility of which are reliably indicated
by an elevated urinary excretion of high mplecular
weight (HMW) and low molecular weight (LMW
proteins). [1]
The kidney in pregnancy
There are striking functional alterations of the urinary
tract both anatomical and physiological during
pregnancy. The gravid kidney enlarges its length by
approximately 1 cm whilst the calyces, renal pelvices
and ureters all dilate markedly through both humoral
and obstructive causes. [2] Marked alterations in renal
haemodynamics also occur as the estimated
glomerular filtration rate (eGFR) and effective renal
plasma flow (ERPF) increase by approximately 50%.
Creatinine clearance significantly increases by 4
weeks gestation, peaks at 9–11 weeks gestation and
then is sustained until the 36th week of gestation. In the
last four weeks of pregnancy creatinine clearance
reduces by 15–20%. [3]
In pregnancy the renal haemodynamic changes mean
that greater quantities of colloids and solute pass by
the glomerular barrier. There are also changes in
glomerular permeability and altered tubular
reabsorption of filtered proteins that may result in
increased excretion of protein. It is normal in
WebmedCentral > Review articles
pregnancy after 20 weeks gestation for total protein
excretion to reach 0.3g over 24 hours and for urinary
albumin excretion to reach 0.2g over 24 hours. [4] It
has been suggested that the threshold for normal total
protein excretion be lowered to 0.2g over 24 hours. [5]
Differential diagnosis: preeclampsia
Proteinuria in pregnancy has been linked to urinary
tract infections and chronic renal disease, but most
importantly, to preeclampsia. [6]
Preeclampsia is a multisystem disease that manifests
as hypertension and proteinuria in pregnancy. It is
peculiar to pregnancy, of placental origin and is only
cured by delivery. Preeclampsia affects nulliparous
women and is less common in multiparous women
unless additional risk factors are present. [7]
Regarding pathophysiology, blood vessel endothelial
cell damage plus an exaggerated maternal
inflammatory response leads to:
1. Increase vascular permeability causing oedema and
proteinuria
2. Vasoconstriction causing hypertension, eclampsia
(reduced cerebral perfusion) and liver damage
3. Reduced placental blood flow causing intrauterine
growth restriction
4. Clotting abnormality. [6]
Risk factors include nulliparity, family/previous history,
older maternal age, obesity, macrovascular diseases
(chronic hypertension, chronic renal disease, sickle
cell disease, diabetes and autoimmune diseases such
as antiphospholipid syndrome) and pregnancies with a
large placenta (twin and molar pregnancy). [7]
Symptoms include headache, visual disturbance,
vomiting, drowsiness, epigastric pain/tenderness and
oedema.
Investigations
To confirm the diagnosis of preeclampsia, if urinalysis
is positive for proteinuria, infection is excluded by urine
cultures and the protein is quantified by either 24 hour
urine collection or protein creatinine ratio on a single
sample. More than 30mg/n-mol on protein creatinine
ratio or > 0.3g/24 hour on urine collection represents
significant proteinuria. [8] Blood pressure and urine is
checked at every antenatal appointment.
Investigations in preeclampsia also include monitoring
blood tests, ultrasounds, umbilical artery Doppler
scans and cardiotocography. [6]
Despite the prognostic role of proteinuria, it remains a
poorly assessed clinical sign in pregnancy. Although
proteinuria is best measured by biochemical assay of
a 24 hour urine sample, this is impractical and
Page 3 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
semi-quantitative dipstick urinalysis is more common
as it is easy, quick and cheap. [8] Clinically, urinalysis
is performed in an unsupervised manner by many
healthcare professionals including untrained doctors,
nurses and students. Many clinicians think that 1+
proteinuria on dipstick corresponds to 300 mg/24
hours total protein excretion. This assumption is
flawed in that 1+ corresponds to a protein
concentration of 30 mg/dl. [8] This idea has led to a
dependence on the dipstick for both clinical decision
making and research definitions of preeclampsia. [8]
Several studies have investigated the relationship
between dipstick urinalysis on random voided urine
samples and a subsequently collected 24-hour urine
sample.
1. Kuo and associates [5] found a poor correlation with
1+ dipstick proteinuria and subsequent 24-hour protein
estimation. They reported a false positive rate of 18%
and a false negative rate of 40%
2. Meyer and associates [9] in a retrospective study
found that in 300 samples of urine from hypertensive
pregnant women, 66% of the women had false
negative dipstick urinalysis (if significant proteinuria is
defined as more than or equal to 300 mg/24 hours).
They reported a false positive rate of 26% at the 1+
level
3. Brown and associates [10]produced false negative
results of 8–18% and a very high false positive rate of
67% with 1+ scores. To explain the persistent false
positive rate of 1 in 4, they suggested that the dipstick
is too sensitive at the 1+ threshold and that it is useful
for the management of preeclampsia as it will
minimise the false negative results (missed proteinuria)
but the test will be incorrect at least half of the time
4. Waugh and associates [11] found a high false
negative rate where up to 65% of women with <1+
proteinuria on dipstick analysis had significant
proteinuria.
The studies imply that the correlation between dipstick
urinalysis and 24 hour protein estimation is weak.
False positive results may result in over investigation
and intervention but a more serious issue is when a
false negative result may place a woman and her
pregnancy at risk. Reasons for the poor correlation
include observer error, the characteristics of the
dipstick tests, the units of protein estimation, the
differing nature of the urine specimens involved, as
well as possible variation in the “gold standard” assay
employed in the laboratory setting. [8]
The National Institute for Clinical Excellence (NICE)
[12] recommend that with significant proteinuria (? 2+
proteinuria on dipstick), automated dipstick readers be
WebmedCentral > Review articles
used to improve the rate of false positive and false
negatives and a dipstick finding of proteinuria should
be confirmed by 24 hours urine collection/protein
creatinine ratio. Also, further research is needed to
determine the optimal frequency and timing of blood
pressure measurements and the role of screening of
proteinuria in preeclampsia management.
Management
Where proteinuria is present with infection, the
infection is treated needless to say. The degrees of
preeclampsia are described as follows: [13]
1. Mild – proteinuria and hypertension <170/110
mmHg
2. Moderate – proteinuria and hypertension ?170/110
mmHg
3. Severe – proteinuria and hypertension <32 weeks
gestation or with maternal complications (see below)
The complications of preeclampsia can be split into
maternal and fetal complications13:
● Maternal
❍ Eclampsia
❍ Cerebrovascular accident (CVA)
❍ Haemolysis, elevated liver enzymes and low
platelet count (HELLP syndrome)
❍ Disseminated intravascular coagulation (DIC)
❍ Liver failure
❍ Renal failure
❍ Pulmonary oedema
❍ Fetal
■ Intrauterine growth restriction
■ Preterm birth
■ Placental abruption
■ Hypoxia
Patients are investigated with a blood pressure >
140/90 mmHg but are admitted if evidence of
significant proteinuria regardless of hypertension or
moderate/severe preeclampsia (see above). Those
without significant proteinuria on 24 hours collection
can be discharged. Those with 1+ proteinuria only
have their proteinuria quantified and are reviewed as
outpatients. [13]
Antihypertensives are given if blood pressures in
pregnancy reach 170/110 mmHg or above. Oral
nifedipine is used for initial control with intravenous
labetalol as a second line in severe hypertension.
Methyldopa is best used as a maintenance drug. For
eclampsia, magnesium sulphate is used. However,
preeclampsia and eclampsia is indefinitely cured by
delivery alone. For mild preeclampsia, monitoring is
best as long as there is no fetal compromise. Induction
of labour at term is best. For moderate or severe
Page 4 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
preeclampsia, delivery is required after 34 weeks
gestation. Before 24 weeks, monitoring at a specialist
unit is advised. [13]
Discussion
Viswanathan and Upadhyay [14] as well as Montanes
Bermudes and associates [15] stated that the average
daily urinary protein excretion in adults is 80 mg per
day urinary protein excretion is considered to be
normal when the excretion rate is less than 150 mg
per day. They also stated that albumin represents 15%
of the daily urinary protein excretion in healthy
individuals, with other plasma proteins (for example,
immunoglobulins, beta-2-microglobulin and
Tamm-Horsfall protein constituting the remaining 85%
and that proteinuria varies in amount (from
microalbuminuria to nephritic range proteinuria), and
could be transient or persistent.
Some authors [16] [17] stated that the diagnosis of
chronic renal disease is made when there is urinary
excretion of abnormal quantities of protein for three
months or longer. Other authors [18] [19] [20] [21]
stated that the presence of proteinuria is an
independent factor for end-stage renal disease and
death within the general population, and also in
patients with chronic kidney disease.
A number of authors iterated that pharmacologic
reduction of proteinuria is utilised as a surrogate
marker in the management of acute glomerulonephritis
and chronic renal disease and this is associated with
improved renal outcomes. [22] [23] [24] [25] [26] [27]
Various types of proteinuria have been described
including: microalbuminuria; overt albuminuria;
nephritic rsnge proteinuria; glomerular proteinuria;
tubular proteinuria; overflow proteinuria.
Microalbuminuria which is associated with increased
risk of progressive kidney disease and future
cardiovascular events in many populations.
Microalbuminuria is defined as urine albumin of 20 to
200 mg per gram of creatinine in men; and 30 to 300
mg per gram of creatinine in women. [28]
In overt albuminuria, urine albumin is greater than 300
mg per day. [28] In overt proteinuria urine total protein
is equal to or greater than 300 mg per day. [28] In a
number of renal diseases, larger amounts of
proteinuria are associated with worse renal survival.
In nephrotic range proteinuria, urine total protein is
equal to or greater than 3.5 grams per day and serum
albumin is less than 3.0 grams per deci-litre. The
presence of nephritic range-range proteinuria with
WebmedCentral > Review articles
oedema, hypoalbuminuria, and hyperlipidemia
constitutes nephritic syndrome. [28]
In glomerular proteinuria there is passage of protein
from glomerular capillary blood (mainly albumin) into
the urine and the urine albumin is between 1 gram and
20 grams per day. [28]
In tubular proteinuria there is passage of low
molecular weight proteins (e.g., retinol-binding protein,
alpha-2-microglobulin, beta-2-microglobulin) into the
urine and the urine total protein is less than 2 grams
per day. [28]
In overflow proteinuria there is overproduction of small
proteins (for example, myoglobin, light chains) which
leads to increased glomerular filtration and
appearance in the urine and in overflow proteinuria the
urine total protein is up to 20 grams per day. [28]
Proteinuria can be tested by means of qualitatitive
testing, semi-quantitative testing and quantitative
testing.
In qualitative testing proteinuria is routinely detected
by means of multiagent urinary dipstick testing. The
presence of urinary albumin is detected by means of a
colorimetric reaction with the dipstick-impregnated
reagent. It has been stated that dipstick testing has
limited sensitivity for nonalbumin protein, and it is
hence often falsely negative in the presence of
predominantly tubular or overflow proteinuria. [28]
Siedner and associates [29] as well as White and
associates [30] stated that the sensitivity of the urinary
dipstick for albumin ranges from 83% to 98% with a
specificity of 59% to 86%. They also stated that this
reaction depends upon the concentration of albumin,
in such a way that testing of large-volume, dilute urine
would underestimate the degree of albuminuria and
similarly, testing of highly concentrated urine may
overestimate the degree of albuminuria. Sperati and
Fine [28] false-positive results may be obtained with
markedly alkaline PH (greater than 8.0) and whilst
qualitative dipstick testing is rapid, easy to perform,
and commonplace, the false-negative and
false-positive rates limit the utility of qualitative testing
of urine for proteinuria. Sperati and Fine [28] also
stated that quantification of extent of proteinuria using
dipstick testing is as follows:
● Negative – 0 mg per decilitre
● Trace – 15 to 30 mg per decilitre
● 1+ - 30 to 100 mg per decilitre
● 2+ - 100 to 300 mg per decilitre
● 3+ - 300 to 1000 mg per decilitre
● 4+ - greater than 1000 mg per decilitre.
Sperati and Fine [28] iterated that in previously
Page 5 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
sulfosalicylic acid (SSA) was added to urine
specimens in order to precipitate all protein, for the
detection of non-albumin proteins. They stated that the
resultant turbidity is graded upon a scale of 0 to 4+
and even though SSA testing is still used,
semiquantitative and quantitative testing methods
have largely replaced it.
It has been stated that dipsticks that have been
subsequently developed are capable of reporting
albumin-to-creatinine ratios in the micro-albumin range,
as well as total protein-to-creatinine ratios and
standardization of the protein measurement to the
quantity of creatinine in the urine does help avoid
errors introduced by dilute or concentrated urine
samples. Comper and Osicka [31] stated that
measurement of total protein allows the detection of
tubular and overflow proteinuria and the reported
sensitivity of these semi-quantitative dipsticks is 80%
to 97% with a specificity of 33% to 80%.
Sperati and Fine stated that quantitative measurement
of urinary protein is the definitive for detecting
protenuria and for this purpose twenty-four-hour urine
collections have been utilised, although these
collections are prone to under-collection and
over-collection. [28]. They also stated that in addition
24-hour urine collections are cumbersome for, and
unpopular with patients and that reporting the 24-hour
urine standardized to the 24-hour urine creatinine
(grams of protein / grams creatinine) helps in adjusting
for variations in the duration of collection. Sperati and
Fine [28] indicated that in men, an adequate collection
typically has 20 to 25 grams per kilogram and in
women 15 grams to 20 grams per kilogram body
weight.
Ginsberg and associates [32] suggested that the
expected grams of excreted creatinine can
alternatively be estimated by 140 minus age multiplied
by weight / 5000 [(140-age) X weight/5000], where
weight is in kilograms. This result is then multiplied by
0.85 in women. Sperati and Fine [28]stated that quite
commonly, a urine-protein-creatinine ratio on a spot
urine sample is being used to approximate the 24-hour
urine protein excretion.
Some authors [16] [32] iterated that a first morning
sample of urine most closely estimates 24-hour protein
excretion, even though a random sample is acceptable
if a first morning void is unavailable.
Papanna and associates [33] as well as Cote and
associates [34] suggested that in view of diurnal
variation, it would be best to collect spot urine samples
at the same time each day if it is being used to follow
up patients on long term basis. Furthermore the
WebmedCentral > Review articles
correlation of the spot sample with 24-hour excretion is
less robust with nephrotic-range proteinuria. They also
stated that the spot ratio might also be less accurate in
pregnant women with greater than 300 mg of
proteinuria.
Sperati and Fine [28] iterated that about 1 gram of
creatinine is excreted by people whose body surface
areas are 1.73 m^2 and as such a
protein-to-creatinine ratio of 1 gram protein per gram
of creatinine in an average-sized person approximates
1 gram of proteinuria in 24 hours. In view of this it is
pertinent to appreciate that a ratio of 2.5 grams protein
per gram of creatinine in a muscular person who
excretes 2 grams of creatinine in 24 hours may
actually represent nephrotic-range proteinuria of 5
grams per day. In the same token, an older, frail
woman might excrete less than 1 gram of creatinine
per day, and in a situation like this, the spot ratio
would tend to overestimate her proteinuria.
Microalbuminuria is on the whole measured on a spot
urine sample which is standardized to urine creatinine.
Roberts and associates [35] iterated that glomerular
filtration rate (GFR) and renal blood flow rise markedly
during pregnancy, resulting in a physiologic fall in
serum creatinine concentration and urinary protein
excretion increases substantially as a result of a
combination of increased glomerular filtration rate
(GFR) and increased permeability of the glomerular
basement membrane.
Eknoyan and associates [36] iterated that the spot
urine protein-to-creatinine ratio (PC ratio) has become
the preferred method for the quantification of
proteinuria in the non-pregnant population in view of
high accuracy, reproducibility, and convenience in
comparison with timed urine collection.
Robert and associates [37] as well as Neithanol and
associates [38] stated that majority of studies that
evaluated the urine protein-to-creatinine ratio (the PC
ratio) were highly correlated with the 24-hour urine
protein measurement as it is in non-pregnant adults.
Chen and associates [39] stated that routine
catheterization of the urinary bladder for the
measurement of urine protein-to-creatinine ratio (the
PC ratio) is not necessary, mid-stream clean-catch
samples are accurate in pregnant women.
More than a dozen studies attempted to validate the
urine PC ratio for the detection of abnormal proteinuria
in women with hypertensive pregnancy; in most of
these studies 24-hour urine collection was used as the
“gold standard” [38] [40] [41] [42] [43] [44] [45] [46] [47]
[48] [49] [50] [51] [52]. Two systematic reviews
evaluated the literature and arrived at similar
Page 6 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
conclusions as follows:
1. Côté and associates [34] iterated that the spot urine
ratio had a pooled sensitivity of 83.6 percent (95% CI
77.5-89.7) and specificity of 76.3 percent (95% CI
72.6%-80.0) using a cut-off of 30 mg protein per
m-mol creatinine (0.26 mg protein per mg creatinine)
to predict proteinuria greater than 300 mg per day by
24-hour urine collection. They concluded that a low
spot protein creatinine ratio is a reasonable “rule-out”
test for excluding proteinuria greater than 300 mg/day
in hypertensive pregnancy.
2. Papanna and associates [33] observed that a lower
cut-off-of 0.13 to 0.15 mg protein per mg creatinine
provides higher (0 to 99 percent) sensitivity, albeit with
more false-positive results (specificity 33 to 65
percent). They also observed that a higher cutoff of
0.6 to 0.7 mg protein / mg creatinine had a much
higher specificity (96 percent) for significant proteinuria
(greater than 300 mg in a 24-hour specimen), but at
the cost of lower sensitivity (85 to 87 percent0. They in
addition observed that midrange protein/creatinine
ratios (0.8 mg protein/mg creatinine) had poor
sensitivity and specificity.
Visintin and associates stated that deductions from the
above two analyses would indicate that a urine PC
ratio above 0.7 mg protein per mg creatinine strongly
predicts significant proteinuria while a urine PC ratio
less than 0.15 mg protein per mg creatinine can be
considered to be normal (predictive of less than 300
mg protein in a 24-hour collection), such that
confirmatory testing with 24-hour urine collection is
probably not necessary in these individuals. Women
with urine PC ratio results that range between 0.15
and 0.7 mg protein/mg creatinine should have a
24-hour urine collection to accurately quantify
proteinuria. In the event where a 24-hour urine
collection is not obtained, the guidelines define
proteinuria as random urine sample PC ratio greater
than 0.26 mg protein per mg creatinine (30 mg per
m-mol). [53]
Thadhani and associates [54] stated that the urine
albumin creatinine ratio (ACR), similar to the PC ratio,
is measured by means of “spot” urine specimen. ACR
which was initially developed fo the detection of
albuminuria in patients with diabetes mellitus, it has
now been recommended as the best initial screening
test for proteinuria in non-pregnant adults, in view of
its increased sensitivity as compared with the PC
ratio.
Kyle and associates [50] stated that ACR which can
be performed by means of an automated analyzer
allows immediate point-of-care testing that could be
WebmedCentral > Review articles
utilized in an antenatal clinic and like the PC ratio,
ACR (using the threshold of ? 8.0 mg /m-mol) is
strongly predictive of significant proteinuria in a
high-risk obstetric antenatal clinic. Nissell and
associates [55] as well as Gangeran and associates
[56] also said ACR is also predictive of significant
proteinuria in women with hypertensive pregnancies.
When a pregnant lady is found to have proteinuria it
would pertinent to all the differential diagnoses of
proteinuria in pregnancy and to determine whether or
not the pregnant lady has preeclampsia.
Thadani and associates stated that in patients with pre
existing established renal disease prior to conception
or in whom proteinuria is documented before the 20th
week of gestation, the diagnosis of pre-existing renal
disease can be readily made in view of the fact that
preeclampsia rarely occurs before that time. [54] They
also said that on the contrary the clear documentation
of new-onset proteinuria after 20 weeks of gestation,
especially when it is accompanied by new-onset
hypertension, would strongly suggest preeclampsia.
Nevertheless, at times de novo renal diseases (for
example, lupus nephritis) can occur during late
pregnancy as well. In cases when information on the
presence or absence of proteinuria (and hypertension)
in early pregnancy is lacking, differentiating underlying
renal disease from preeclampsia can be very difficult.
In view of this Thadani and associates [54] advised
that quantification of protein excretion in early
pregnancy in women at risk for underlying renal
disease (for example, women with chronic
hypertension, diabetes mellitus and systemic lupus
erythematosus).
Verlohren and associates [57] reported that a new
serum test for early diagnosis of preeclampsia has
been developed which involves the detection of
abnormal levels of placentally-derived angiogenic
factors, sFit1 (soluble fms-like tyrosine kinase-1) and
PIGF (placental growth factor). Some authors stated
that this new diagnostic test is available in Europe and
it is being evaluated by the FDA for use in the United
States of America. [58] [59] [60]
In pregnant ladies with renal disease the main aim is
to have delivery at term but patients with preeclampsia
quite often develop progressive disease which ends
up in the need for iatrogenic delivery. In situations
when it is difficult to distinguish preeclampsia from
pre-existing renal disease, it is pertinent to assume a
working diagnosis of preeclampsia because of its
potential for rapid development of serious maternal
and foetal complications. [54]
Chua and associates [60] iterated that some cases the
Page 7 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
differentiation between preeclampsia and kidney
disease can only be made retrospectively in view of
the fact that signs of preeclampsia generally resolve
within 12 weeks after delivery, on the other hand
proteinuria due to underlying renal disease does not.
They added that the resolution of proteinuria pursuant
to preeclampsia, especially when severe, nevertheless,
can sometimes take much longer. It has been stated
that in one cohort of study involving 205 women with
preeclampsia, fourteen percent had persistent
proteinuria at 12 weeks post delivery, which eventually
resolved by two years postpartum in all but 2 percent
of subjects. [54] [61] However, proteinuria (or
hypertension) which persists longer than 3 months
post delivery should be followed-up closely and this
should be evaluated further and appropriate referral to
enable detection and treatment of underlying kidney
disease or chronic hypertension. [54] [61]
It has been recommended that in situations when
preeclampia has developed in women with
pre-existing renal disease and / or hypertension, this
often occurs earlier in the pregnancy and may be
particularly severe. In such situations, significant
pointers to the diagnosis of superimposed
preeclampsia can be provided by systematic
manifestations of the disease, if present, such as
thrombocytopenia, an increase in levels of liver
enzymes, hemolysis, and / or evidence of fetal
compromise (inclusive of intra-uterine growth
restriction) [62]
Katz and associates [63] as well as Reece and
associates [64] stated the association of worsening
hypertension and proteinuria in a woman with renal
disease may represent exacerbation of the underlying
disease. They iterated that studies in women with
documented primary renal disease prior to the
pregnancy have revealed that the majority of women
with glomerular disease exhibit increasing proteinuria
during the course of their pregnancy and nephrotic
syndrome in the third trimester.
Fisher and associates [65] iterated that severe
preeclampsia is the most common cause of de novo
nephrotic syndrome in pregnancy. Yang and
associates [66] said that nephrotic syndrome in
pregnancy could also be caused by pre-existing
kidney disease during pregnancy (for example,
associated with invasive trophoblastic tumours). Once
heavy proteinuria is found the cause of the proteinuria
may be obtained from the history and clinical
examination. This is particularly pertinent in patients
who have systemic disease like diabetes mellitus,
systemic lupus erythematosis, HIV infection, or in
cases of intake of a commonly offending drug even
WebmedCentral > Review articles
though this is much less common in pregnant women.
(Non steroidal anti-inflammatory drugs, gold,
penicillamine) In order to confirm the diagnosis in such
cases renal biopsy is required. [54]
Strauch and Hayslett [67] stated that if de novo kidney
disease is suspected as the cause nephrotic
syndrome, a renal biopsy is an option to establish a
definitive diagnosis if the patient’s management would
be affected, nevertheless, this is rare. They also stated
that numerous analyses have concluded that the
presence of nephrotic syndrome due to renal disease,
in the absence of significant renal insufficiency and / or
significant hypertension, does not seem to affect the
natural course of renal disease or fetal survival.
Thadani and associates [54] as well as Collins and
associates [68] suggested that the management of
nephrotic syndrome in pregnancy should be based
upon expert opinion, in view of availability of very little
data to support evidence-based practice. They also
suggested that management should be aimed at
reduction of oedema to a level that shows comfort
during ambulation and the dietary intake of sodium
may be limited to 1.5 grams of sodium per day (about
60 mEq) to reduce new oedema formation provided
normal blood pressure is maintained. In addition they
suggested that bed rest is a safe and often effective
method to facilitate resolution of oedema. Other
recommendations made by Thadani and associates
[54] include: Generally, the use of diuretics should be
discouraged because of the theoretical risk that they
would impair the normal pregnancy-associated
expansion of plasma volume, possibly leading to
decrease in placental perfusion. Nevertheless, no
clear evidence exists of adverse foetal effects with
either thiazide diuretics or loop diuretics, and their use
is occasionally indicated for severe, intractable
oedema. In such cases, the therapy should be aimed
at reduction of excessive oedema at a slow rate of no
more than 1 to 2 pounds per day with a loop diuretic,
while a low sodium diet is maintained. In cases where
treatment on a chronic basis is needed, diuretic
therapy should be given on alternative-day schedule in
order to avoid a reduction of plasma volume and
electrolyte disturbances. They also recommended that
a written record of daily weights taken by the patient
should be kept and that diuretics should not be used in
preeclampsia because this condition is characterized
by a reduction in circulating plasma volume.
Conclusions
Proteinuria is a consequence of two mechanisms, the
abnormal transglomerular passage of proteins due to
Page 8 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
increased permeability of the glomerular capillary wall
and the impaired reabsorption by the epithelial cells of
the proximal tubuli. Proteinuria can be quantified in
many ways, through urine dipstick, 24 hours urine
collection and protein creatinine ratio. It is most
commonly associated with urine tract infection in
pregnancy or longstanding renal disease. However, it
is associated with preeclampsia after 20 weeks
gestation in the presence of hypertension too. It is
imperative that this proteinuria and hypertension be
investigated as preeclampsia can have serious
consequences for mother and pregnancy.
Recommendations included an emphasis on
improving diagnostic techniques to confirm proteinuria
above the level of 0.3g/24 hour on a simple dipstick
test meaning this would in turn remove the need for
patients to wait 48 hours to establish a diagnosis of
preeclampsia on 24 hour urine assay.
The gestational age at which proteinuria is first
documented is important in establishing the likelihood
of preeclampsia versus other renal disease.
Proteinuria, which has been documented prior to
pregnancy or in early pregnancy (before 20 weeks of
pregnancy), suggests pre-existing renal disease. In
late pregnancy the presence of hypertension or other
symptoms/signs of severe preeclampsia (for example,
thrombocytopenia, elevated liver transaminases), if
present, also helps to distinguish preeclampsia from
underlying renal disease.
Preeclampsia is the most common cause of
proteinuria in pregnancy and must be excluded in all
women with proteinuria first identified after 20 weeks
of gestation. If preeclampsia is excluded then the
presence of primary or secondary renal disease
should be considered. If renal biopsy is indicated for
diagnosis it is usually better to wait until the patient is
postpartum unless unexplained rapidly progressive
loss of renal function is occurring.
References
1. Giuseppe D'Amico and Claudio Bazzi.
Pathophysiology of proteinuria. Kidney International
2003; 63: 809 – 825
2. Lindheimer MD, Katz AI. The Kidney in pregnancy.
In: B.M. Brenner BM and Rector FC Jr. (eds) The
Kidney (3rd Ed). WB Saunders, Philidelphia; 1986;
1253–1295.
3. Davison JM. Renal function during normal
pregnancy and the effect of renal disease and
pre-eclampsia. In: Andreucci VE (ed). The kidney in
pregnancy. Martinus Nijhoff, Boston; 1986. 65 – 80.
4. Higby K, Suiter CR, Phelps JY, Siler-Khodr T,
WebmedCentral > Review articles
Langer O. Normal values of urinary albumin and total
protein excretion during pregnancy. Am. J Obstet
Gynaecol 1994; 171: 984–989.
5. Kuo VS, Koumanantakis G, Gallery EDM.
Proteinuria and its assessment in normal and
hypertensive pregnancy. Am. J Obstet Gynecol. 1992;
167: 723–728.
6. Redman CWG, Sacks GP and Sargent IL.
Preeclampsia: An excessive maternal inflammatory
response to pregnancy. Am. J. OG 1999; 180: 499
7. Duckitt K. Risk factors for pre-eclmapsia at
antenatal booking: systematic review of controlled
studies. BMJ 2005; 330: 565
8. Maybury H and Waugh J. Proteinuria in pregnancy
– just what is significant? Fetal and Maternal Medicine
Review 2004; 16(1): 71 – 95
9. Meyer NL, Mercer BM, Friedman SA, Sibai BM.
Urinary dipstick protein: a poor predictor of absent or
severe proteinuria. Am. J Obstet Gynecol. 1994; 170:
137 – 141
10. Brown MA, Buddle ML. Inadequacy of dipstick
proteinuria in hypertensive pregnancy. Aust NZ J
Obstet Gynaecol 1995; 35: 366 – 369.
11. Waugh JJS, Bell SC, Kilby MD, Shennan AH,
Halligan AWF. Effect of urine concentration and
biochemical assay on dipstick accuracy in
hypertensive pregnancy. Hypertens Pregnancy 2001;
20: 205 – 217
12. National Collaborating Centre for Women’s and
Children’s Health. Commissioned by the National
Institute for clinical excellence. Antenatal Care: routine
care for the healthy pregnant woman. RCOG Press
October 2008
13. Impey I and Child T. Obstetrics and Gynaecology.
Third Edition. Chichester, West Sussex: 2008
14. Viswanathan G, Upadhyay A. Assessment of
proteinuria. Adv Chronic Kidney Dis. 2011; 18: 243 –
248
15. Montanes Bermudez R, gracia Garcia S, Perez
Sunibas D, et al. Consensus documentations on
assessing proteinuria during the diagnosis and
follow-up of chronic kidney disease. Neurolgia 2011;
31: 331 – 345
16. National Kidney Foundation KDOQI clinical
practice guidelines for chronic kidney disease:
evaluation, classification, and stratification. Am J
Kidney Dis. 2002; 39(Suppl 1): S1-S266
17. Levey A S, de Jong P E, Coresh J, et al. The
definition, classification, and prognosis of chronic
disease: a KDIGO controversies report. Kidney Int
2011; 80: 17 – 28
18. Chronic Kidney Disease Prognosis Consortium;
Matsushita K, van der Velde M, Astor B C, et al.
Association of estimated glomerular filtration rate and
Page 9 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
albuminuria with all-cause and cardiovascular mortality
in general population cohorts: a collaborative
meta-analysis. Lancet 2010; 375: 2073 – 2081
19. Astor B C, Matsushita K, Gansebon R T, et al.
Lower estimated glomerular filtration rate and higher
albuminuria are associated with mortality and
end-stage renal disease: A collaborative meta-analysis
of kidney disease population cohorts. Kidney Int. 2011;
79: 1331 – 1340
20. van der velde M, Matsushita K, Coresh J, et al.
Lower estimated glomerular filtration rate and higher
albuminuria are associated with all0cause and
cardiovascular mortality: A collaborative meta-analysis
of high-risk population cohorts. Kidney Int. 2011; 79:
1341 –
21. Gansevoort R T, Matsushita K, van der velde M, et
al. Lower estimated GFR and higher albuminuria are
associated with adverse kidney outcomes. A
collaborative meta-analysis of general and high-risk
population cohorts. Kidney Int. 2011; 80: 93 – 104
22. Lewis E J, Hunsicker L G. Bain R P, et al. The
effect of angiotensin-converting-enzyme inhibition on
diabetic nephropathy. N Engl J Med. 1993; 329: 1456
– 1462
23. The GISEN Group: randomised placebo-controlled
trial of ramipil on decline in glomerular filtration rate
and risk of terminal renal failure in proteinuria,
non-diabetic nephropathy. Lancet. 1997; 349: 1857 –
1863
24. Brenner B M, Cooper M E, de Zeeuw D, et al.
Effects of losartan on renal and carcdiovascular
outcomes in patients with type 2 diabetes and
nephropathy. N Engl J Med. 2001; 345: 361 – 369
25. Lewis E J, Hunsicker L G, Clarke W R, et al.
Renoprotective effect of the angiotensin-receptor
antagonist irbesatan in patients with nephropathy due
to type 2 diabetes. N Engl J Med. 2001; 345: 851 –
860
26. Parving H H, Lehnert H, Brochner-Mortensen J, et
al. Irbesartan in Patients with Type 2 Diabetes and
Microalbuminuria Study Group: The effect of
Irbesartan on the development of diabetic nephropathy
in patients with type 2 diabetes. N Engl J Med. 2001;
345: 870 -878
27. Wright JT Jr, Bakris G, Greene T, et al. Effect of
blood pressure lowering and antihypertensive drug
class on progression of hypertensive kidney disease:
results from the AASK trial. JAMA. 2002; 288: 2421 –
2431
28. Sperati C J, Fine D M. Evaluation of proteinuria
Epocrates on line 20012 August 9th can be found at:
http://online.epocrates.com/u/2911875/Evaluation+of+
proteinuria
29. Siedner M J, Gelber A C, Rovin B H, et al.
WebmedCentral > Review articles
Diagnostic accuracy study of urine dipstick in relation
to 24-hour measurement as a screening tool for
proteinuria in lupus nephritis. J Rheumatol. 2008; 35:
84 – 90
30. White S L, Yu R, Craig J C, et al. Diagnostic
accuracy of urine dipstick for detection of albuminuria
in the general community. Am J Kidney Dis. 2011; 58:
19 – 26
31. Comper W D, Osicka T M. Detection of urinary
albumin. Adv Chronic Kidney Dis. 2005; 12: 170 – 176
32. Ginsberg J M, Chang B S, Matarese R A, et al.
Use of single voided urine samples to estimate
quantitative proteinuria. N Eng J Med. 1983; 309: 1543
– 1546
33. Papanna R, Mann L K, Kouldes R W, Giantz J C.
Protein/creatinine ratio in preeclampsia: a systematic
review. Obstet Gynecol. 2008; 112: 135 – 144
34. Côté A M, Brown M A, Lam E, et al. Diagnostic
accuracy of urinary spot protein:creatinine ratio for
proteinuria in hypertensive pregnant women:
systematic review. BMJ. 2008; 336: 1003 – 1006
35. Roberts M, Lindheimer M D, Dawson J M. Altered
glomerular permselectiSvity to neutral dextrans and
heteroporous membrane modelling in human
pregnancy. Am J Physiol 1996; 270: F 338
36. Eknoyan G, Hostetter T, Bakris G L, et al.
Proteinuria and other markers of chronic kidney
disease: a position statement of the national kidney
foundation (NKF) and the national institute of diabetic
and digestive and kidney diseases (NiDK). Am J
Kidney Dis. 2003; 42: 617
37. Robert M, Sepandj F, Liston R M, Dooley K G.
Random protein-creatinine ratio for the quantitation of
proteinuria in pregnancy. Obstet Gynecol. 1997; 90:
893
38. Neithardt A B, Dooley S L, Borensztajn J.
Prediction of 24-hour protein excretion in pregnancy
with a single voided urine protein-to-creatinine ratio.
Am J Obstet Gynecol 2002; 186 – 883
39. Chen B A, Parviainen K, Jeyabalan A. Correlation
of catheterized and clean catch urine
protein/creatinine ratios in preeclampsia evaluation.
Obstet Gynecol. 2008; 112: 606
40. Rodriguez-Thompson D, Lieberman E S. Use of a
random urinary protein-to-creatinine-ratio for the
diagnosis of significant proteinuria during pregnancy.
Am J Obstet Gynecol 2001; 185: 808
41. Young R A, Buchanan R J, Kinch R A. Use of the
protein/creatinine ratio of a single voided urine
specimen in the evaluation of suspected
pregnancy-induced hypertension. J Fam Pract 1996;
42: 385
42. Ramos J G, Martins-Costa S H, Mathias M M, et al.
Urinary protein/creatinine ratio in hypertensive
Page 10 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM
pregnant women. Hypertens pregnancy 1999; 18: 209
43. Saudan P J, Brown M A, Farrell T, Shaw L.
Improved methods of assessing proteinuria in
hypertensive pregnancy. Br J Obstet Gynaecol 1997;
104: 1159
44. Jaschevatzky O E, Rosenburg R P, Shalit A, et al.
Protein/creatinine ratio in random urine specimens for
quantitation of proteinuria in preeclampsia. Obstet
Gynecol 1990; 75: 604
45. Durmwald G, Mercer B. A prospective comparison
of total protein/creatinine ratio versus 24-hour urine
protein in women with suspected preeclampsia. Am J
Obstet Gynecol 2003; 189: 848
46. Ai R A, Baykal C, Karacay O, et al. Random urine
protein-creatinine ratio to predict proteinuria in
new-onset mild hypertension in late pregnancy. Obstet
Gynecol 2004; 104: 367
47. Wheeler T L 2nd, Blackhurst D W, Dellinger E H,
Ramsey P S. Usage of spot urine protein-creatinine
ratios in the evaluation of preeclampsia. Am J Obstet
Gynecol 2007; 196: 465 e1
48. Aggarwal N, Sun V, Soni S, et al. A prospective
comparison of random urine protein-creatinine ratio vs
24-hour urine protein in women with preeclampsia.
Medscape J med 2008. 10:98
49. Dwyer B K, Gorman M, Carroll I R, Druzin M.
Urinalysis vs urine-protein-creatinine ratio to predict
significant proteinuria in pregnancy. J Perinatol 2008;
28: 461
50. Kyle P M, Fielder J N, Puller B, et al. Comparison
of methods to identify significant proteinuria in
pregnancy in the outpatient setting. BJOG 2008; 115:
523
51. Leaflos-Miranda A, Márquez-Acosta J,
Romero-Arauz F, et al. Protein:creatinine in random
urine samples is a reliable marker of increased
24-hour protein excretion in hospitalized women with
hypertensive disorders of pregnancy. Clin Chem 2007;
53: 1623
52. Yamasmit W, Cnaithongwongwatthana S,
Charoenvidhya D, et al. Random urinary
protein-tocreatinine ratio for prediction of significant
proteinuria in women with preeclampsia. J Matern
Fetal Neonatal Med 2004; 16: 273
53. Visintin C, Mugglestone M A, Aimerie M Q, et al.
Management of hypertensive disorders during
pregnancy: summary of NICE guidance. BMJ 2010;
341: c2207
54. Thadhani R I, Glassock R J, Barss V A. Evaluation
of proteinuria in pregnancy. 2012;
UpToDate@www.uptodate.com
55. Nissell H, Trygg M, Back R. Urine
albumin/creatinine ratio for the assessment of
albuminuria in pregnancy hypertension. Acta Obstet
WebmedCentral > Review articles
Gynecol Scand 2006; 85: 1327
56. Gangeram R, Naicker M, Moodley J. Comparison
of pregnancy outcomes in women with hypertensive
disorders of pregnancy using 24-hour urinary
microalbumin to creatinine ratio. Int J Gynaecol Obstet
2009; 107: 19
57. Verlohren S, Galindo A,, Schlembach D, et al. An
Automated method for the determination of the
sFit-1/PIGF ratio in the assessment of preeclampsia.
Am J Obstet Gynecol 2010; 202: 161 e1
58. Sunderji S, Gaziano E, Wothe D, et al. Automated
assays for sVEGF R1 and PIGF as an aid in the
diagnosis of preterm preeclampsia: a prospective
clinical study. Am j Obstet Gynecol 2010; 202: 40 e1
59. Maynard S E, Karumanchi S A. Angiogenic factors
and preeclampsia. Semin Nephrol 2011; 31: 33
60. Chua S, Redman C W. Prognosis for
pre-eclampsia complicated by 5 g or more of
proteinuria in 24-hours. Eur J Obstet Gynecol Reprod
Biol. 1992; 43; 9
61. Berks D, Steegers E A, Molas M, Visser W.
Resolution of hypertension and proteinuria after
preeclampsia. Obstet Gynecol 2009; 114: 1307
62. ACOG Committee on Obstetric Practice. ACOG
practice bulletin. Diagnosis and management of
preeclampsia and eclampsia. Number 33, January
2002. American College of Obstetricians and
Gynecologists. Int J Gynecol Obstet 2002; 77: 67
63. Katz A I, Davison J M, Hayslett J P, et al.
Pregnancy in women with kidney disease. Kidney Int.
1980; 18: 192
64. Reece E A, Coustan D R, Hayslett J P, et al.
Diabetic nephropathy: pregnancy performance and
fetomaternal outcome. Am J Obstet Gynecol 1988;
159; 56
65. Fisher K A, Luger A, Spargo B H, Lindheimer M D.
Hypertension in pregnancy: clinical-pathological
correlations and remote prognosis. Medicine
(Baltimore) 1981; 60: 267
66. Yang J W, Choi S O, Kim B R, et al. Nephrotic
syndrome associated with invasive mole: a case report.
Nephrol Dial Transplant 2010; 25: 2023
67. Strauch B S, Hayslett J P. Kidney disease and
pregnancy. Br Med J 1974; 4: 578
68. Collins R, Yusuf S, peto R. Overview of
randomised trials of diuretics in pregnancy. Br Med J
(Clin Res Ed) 1986; 290: 17
Page 11 of 12
WMC003814 Downloaded from http://www.webmedcentral.com on 11-Nov-2012, 12:47:00 AM

Disclaimer
This article has been downloaded from WebmedCentral. With our unique author driven post publication peer
review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is
completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript
but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before
submitting any information that requires obtaining a consent or approval from a third party. Authors should also
ensure not to submit any information which they do not have the copyright of or of which they have transferred
the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to
the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor
replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the
WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm
that you may suffer or inflict on a third person by following the contents of this website.

WebmedCentral > Review articles Page 12 of 12