COMPARISON OF SPOT URINARY PROTEIN CREATININE RATIO AND 24 HOUR URINARY PROTEIN EXCRETION IN CHILDREN PRESENTING WITH NEPHROTIC SYNDROME IN TERTIARY CARE HOSPITAL OF EASTERN NEPAL

Nephro�c syndrome is an important chronic disorder in children and it's one of the important diagnos�c criteria is presence of 2 heavy proteinuria (> 40 mg/m /hour)

Nephro c syndrome is an important chronic disorder in children and it's one of the important diagnos c criteria is presence of 2 heavy proteinuria (> 40 mg/m /hour). As 24-hour urinary protein es ma on is cumbersome, inconvenient, me consuming and expensive, a more convenient and accurate method of urinary protein es ma on is needed. 24-hour urinary protein es ma on and urine protein/ crea nine in a child with nephro c syndrome correlates well but there are very few studies done in Nepal to prove this correla on. Hence, this study is undertaken with objec ve of evalua ng usefulness of urine protein/crea nine (UP/UC) in random sample of urine as a rapid and reliable test for quan fica on of proteinuria and to know their correla on with 24hour urinary protein excre on.

Objec ves Primary Objec ve
To evaluate accuracy of urine protein crea nine ra o (UP/UC) in early morning sample in comparison with 24 hours urinary protein excre on in children of nephro c syndrome having normal Glomerular Filtra on Rate.
Secondary Objec ve 1. To evaluate usefulness of urine protein / crea nine ra o (UP/UC) in random sample of urine as rapid and reliable test for quan fica on of proteinuria. 2. To evaluate biochemical and other laboratory abnormali es in children with nephro c syndrome.

Methodology
This is a descrip ve cross-sec onal study conducted in pediatric unit, Nobel Medical College Teaching Hospital, Biratnagar for 12 months. In this study, 50 pa ents of both sexes, ranging from one to fi een years of age were studied. The modes of presenta on, laboratory inves ga on reports which included urine rou ne microscopy, 24-hour urine protein es ma on, urine protein / crea nine in random sample of urine were documented and data was analyzed by linear regression.

Result
Linear regression revealed that as med 24-hour urine protein in gm/24 hour increased, Random urine/protein crea nine ra o mg/mg also increased linearly with correla on coefficient of r = 0.56 which was highly significant (p < 0.001).

Conclusion
This study concludes that UP/UC ra o in a spot urine reflects the amount of protein in 24-hour urine collec on. UP/UC ra o > 2 in pa ents with normal renal func on represents nephro c range proteinuria. immunosuppressant therapy and protracted proteinuria. Assessment of urinary protein excre on is not only diagnos c but also has prognos c value in monitoring of nephro c syndrome. Tradi onally, urinary protein assessments has been done in 24 hours urine collec on specimens but this approach is me consuming, 3 cumbersome, and imprecise. More appropriate quan ta ve test for proteinuria is spot urine protein: crea nine ra o (UPr: UCr). This ra o is calculated by dividing the UPr (mg/dL) concentra on by the UCr (mg/dL) concentra on and is best performed on a first morning voided urine specimen to eliminate the possibility of orthosta c proteinuria. Ra os <0. 5  N e p h ro c ra n g e p ro t e i n u r i a > 4 0 m g / m / h o u r, Hypoalbuminemia <2.5 gm/dl and Generalized Edema were included in the study. Children in renal failure and in those where parents did not give consent were excluded from the study. Exclusion criteria was considered as a necessity for this study since the ra o of urine protein and crea nine in a random sample reflects the protein excre on only in presence of a stable glomerular filtra on rate. Clinical and laboratory parameters of the enrolled children were recorded in a structured proforma. Following clinical parameters were recorded: age, sex, age of onset of nephro c syndrome, dura on of disease, edema, anthropometry (height, weight, body mass index) blood pressure recordings, following laboratory parameters were recorded: Blood urea, serum crea nine, urine protein: urine crea nine ra o, 24-hour urine protein es ma on, serum albumin, serum cholesterol. All pa ents were asked to carefully collect a 24-hour urine protein sample and Foley's catheteriza on done for collec ng 24hour urine sample in a child below 3 years which was measured using Eshbach's Albuminometer. Also, a random urine sample was obtained, and urine protein/crea nine ra o was calculated. Urine protein was es mated by Pyrogallol Red-Molybdate method and crea nine was measured by Jaffe's reac on. The random urine, protein-crea nine ra o was calculated mg/mg.

RESULTS
In our study, most of the pa ent belonged to the age group 1-5 years and 6-10 years with total 23 in each age group followed by 4 pa ents above 10 years as shown in table below.
In the present study, 66% of pa ents presented as first a ack of nephro c syndrome and about 34% (24% as frequent relapse and 10% as infrequent relapse) of pa ents had one or more relapse at the me of admission as shown below in figure 1. In the present study, 92% of pa ent presented with swelling of limbs and 82% presented with puffiness of face followed by decreased urine output and abdominal distension. The least common manifesta on was genital oedema which was seen in only 28% of cases.
We found the mean hemoglobin of pa ent presented with nephro c syndrome to be 11.18gm/dl, mean serum albumin was 1.90gm/dl, mean blood urea was 29.76mg/dl, mean serum crea nine was 0.59mg/dl, mean serum cholesterol was 340.68mg/dl, mean urine protein/ crea nine was 7.97 and mean 24-hour urinary protein 2 excre on was 119.79mg/m /hr.
We found the correla on coefficient between Urine Protein: Crea nine Ra o and 24-Hour Urinary Protein Excre on 2 (mg/m /hr) to be 0.566 which was highly significant (p < 0.001).
In the linear regression equa on, Y = 2.903 + 0.046(X) is the random urine protein crea nine ra o and X is total protein (grams in 24 hours) and it revealed that as X increased Y also increased linearly. The correla on coefficient between these values was 0.56 and this was highly significant (p < 0.001).

Giri A et al
In the present study, hypertension was noted in 8 cases (16%). As there were no other associated features like hematuria or renal insufficiency to suggest significant glomerular lesion, these children were not inves gated further and they responded to steroid therapy.
In a review of ISKDS study by Struss J.et al. 9, hypertension was found to be present in 20.7% of cases with minimal change nephro c syndrome.  Wahbeh AM et al.

CONCLUSION
We conclude that random urine protein-crea nine ra o is highly reliable and rapid test for quan fica on of proteinuria in children. It reflects the amount of protein in a 24-hour collec on and UP/UC ra o > 2 in pa ents with normal renal func on represents nephro c range proteinuria.

RECOMMENDATIONS
Spot urine examina on for proteinuria and urine protein /crea nine ra o should be considered as a first line inves ga on for diagnosis and treatment outcome of nephro c syndrome in children as it is more acceptable and is less me consuming and for older children. This study showed good accuracy and correla on between 24-hour urinary protein es ma on and urine protein/crea nine ra o. Therefore, the urine protein/crea nine ra o will be of great value in early diagnosis of nephro c syndrome in children thereby helping in early ini a on of treatment and preven ng from future complica ons.

LIMITATIONS OF THE STUDY
This is a hospital-based study so the actual clinical presenta on and the biochemical parameter of pa ent with nephro c syndrome in the community level cannot be determined.