Comparison of 24-hour urinary protein and protein-to-creatinine ratio

in women with preeclampsia

Semra Kayatas
a
, Emre Erdogdu
a,
*, Erbil Cakar
a
, Vefa Ylmazer
a
, Sevcan Arzu Arnkan
a
,
Vedat Erkan Daycoglu
b
a
Zeynep Kamil Gynecologic and Pediatric Training and Research Hospital, Istanbul, Turkey
b
Special Ofce, Istanbul, Turkey
1. Introduction
Preeclampsia is determined by the presence of elevated blood
pressure and signicant proteinuria (300 mg per 24 h) after the
20th week of gestation [1]. Internationally, preeclampsia is a
signicant contributor to maternal and fetal mortality and it affects
2-8% of all pregnancies [2,3].
Proteinuria is an important sign of preeclampsia and the
diagnosis is questionable in its absence. A level of 300 mg or
more urine protein per 24-hour period is described as signicant
proteinuria, and urine collection over 24 hours is considered the
traditional comparator for quantication of proteinuria in
pregnancy. Waiting for 24-hour urine collection and results,
however, can delay the diagnosis of preeclampsia. Also, it may
not be possible to complete the urine collection when delivery
occurs, leading to undetermined proteinuria status and an
unsubstantiated diagnosis of preeclampsia [46]. Thus alterna-
tive methods including urinary dipsticks, urine collection over a
shorter period, the spot urine protein-to-creatinine (P/C) ratio
and spot albumin:creatinine ratio have been used to shorten the
time period to diagnose preeclampsia [7,8]. Since 1980 some
investigators have suggested the urinary spot P/C ratio for the
diagnosis of preeclampsia and other hypertensive conditions [9].
While some studies have demonstrated a good correlation
between urinary P/C ratio and 24-hour protein value [1012],
others did not show this correlation [1315]. Because of these
conincting results, spot P/C ratio has not been widely used in
obstetric practice.
In this study, we aimed to compare the spot urine P/C ratio and
24-hour urine protein excretion in pregnant women with
preeclampsia, and also to determine the best discriminator values
of the spot P/C ratios for 300 mg and 2000 mg per 24 h.
European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 368371
A R T I C L E I N F O
Article history:
Received 5 January 2013
Received in revised form 22 June 2013
Accepted 10 July 2013
Keywords:
Preeclampsia
Protein-to-creatinine ratio
Proteinuria
A B S T R A C T
Objective: To compare the spot urine protein-to-creatinine (P/C) ratio and 24-hour urine protein
excretion in pregnant women with preeclampsia and also to determine the best discriminator values of
the spot P/C ratios for 300 mg and 2000 mg protein per 24 h.
Study design: Prospective study of 200 pregnant women with newonset hypertension at or greater than
140/90 mmHg after 20 weeks of gestation. Women were instructed to collect urine during a 24-hour
period, and after the 24-hour urine sample collection was completed a mid-streamurine specimen was
obtained for P/C ratio determination. The correlation between 24-hour urine protein excretion and spot
urine P/C ratio was calculated. The receiver operating characteristic (ROC) curve was used to identify the
cut-off values of the spot P/C ratios for 300 mg and 2000 mg protein per 24 h. Areas under ROC curves
were calculated.
Results: There was a signicant correlation between 24-hour protein excretion and the urine P/C ratio
(r = 0.828, p < 0.0001). The cut-off P/C ratio for 300 mg per 24 h was 0.28: sensitivity and specicity were
60.4% and 77.9%, respectively. The positive predictive value (PPV) was 77.5% and negative predictive
value (NPV) was 60.9%. The cut-off P/C ratio for 2000 mg per 24 h was 0.77: sensitivity and specicity
were 96.8% and 98.6%, respectively. The PPV was 96.8% and NPV was 98.6%. Area under ROC curves for
24-hour urine total protein of 300-2000 mg/day and >2000 mg/day were 0.74 (95% CI 0.66-0.80) and
0.99 (95% CI 0.95-0.99), respectively.
Conclusions: Spot P/C ratio is a poor predictor of 24-hour proteinuria but can predict proteinuria
>2000 mg better than 300-2000 mg.
2013 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author. Tel.: +90 05053842092.
E-mail address: emreerd@yahoo.com (E. Erdogdu).
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and
Reproductive Biology
j ou r nal h o mepag e: w ww. el sevi er . co m / l ocat e/ ej og r b
0301-2115/$ see front matter 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejogrb.2013.07.024
2. Materials and methods
This prospective study included 200 pregnant women with
suspicion of preeclampsia who did not have known intrinsic renal
disease with proteinuria, chronic hypertension before pregnancy,
bacteriuria or diabetes. All patients had new onset hypertension at
or greater than 140/90 mmHg after 20 weeks of gestation. The
study was conducted at Zeynep Kamil Research Hospital, a tertiary
center, between September 2010 and June 2011. The local ethics
committee approved the study design and a total of 200
participants provided written informed consent. Twenty-four
hour urine was collected from outpatients or inpatients who
had suspicion of preeclampsia as clinically indicated. Written
instructions were given to patients for proper collection of a 24-
hour urine specimen, and 24-hour urine creatinine excretion was
used to assess the adequacy of 24-hour urine collection according
to the general nephrology references [16]. A 24-hour urine
creatinine excretion value below 15 mg/kg and above 20 mg/kg,
calculated using pre-pregnancy weight, was considered as
inadequate 24-hour urine collection. Repeat collections were not
performed in cases who had inadequate collection. Cases who had
incomplete 24-hour urine collection and proteinuria <300 mg
were excluded.
Preeclampsia is considered as new-onset persistent hyperten-
sion after the 20th week of gestation with at or greater than 140/
90 mmHg or urine protein >300 mg per 24 h. Twenty-four hour
urine collection started from 8 am in the morning following
admission. Spot urine P/C samples were gathered immediately
after the 24-hour urine collection. A Foley catheter was not used
for obtaining mid-stream urine sample. Urinary protein quantita-
tion was done by the Biuret method, and urinary creatinine
estimation was done by Jaffes method [17,18]. Detailed medical
and obstetric history including age, body mass index (BMI),
gravida, parity, history of preeclampsia, family history of
preeclampsia, and diabetes were recorded.
The correlation between 24-hour urine protein excretion and
spot urine P/C ratio was analyzed with the Pearson correlation
coefcient. Using protein values of 300 mg and 2000 mg on 24-
hour collections, receiver operating characteristic (ROC) curves
were constructed and the best P/C ratio cut-off was identied. Area
under the ROC curve was calculated. Sensitivity, specicity and
predictive values of the urine P/C at various cut-offs for prediction
of signicant proteinuria were estimated.
3. Results
A total of 200 pregnant women with suspicion of preeclampsia
were selected; 186 (93%) and 14 (7%) of them completed the 24-
hour urine collection as inpatients and outpatients, respectively.
Characteristics of the 200 cases as inpatients and outpatients are
shown in Table 1. Seventy-three cases were excluded, due to
inadequate 24-hour urine collection in 36 (18%) patients and
proteinuria below 300 mg/day in 37 (18.5%) patients.
A total of 127 patients (63.5%) who had 24-hour urine protein
value of >300 mg were considered as preeclampsia: 94 patients
had a 24-hour protein value of 300-2000 mg and 33 had
>2000 mg. The demographic characteristics of the patients with
preeclampsia are shown in Table 2. The mean age was 29.1 5.8
years and the mean gestational age was 33.5 5.2 weeks. The mean
urinary protein excretion of 24-hour urine collections in group with
300-2000 mg and >2000 mg were 669 432 mg and 2900 642 mg,
respectively. By the ROC curve analysis, a P/C ratio of 0.28 was
identied as the best threshold to detect urine protein excretion of
300 mg per 24 h, with a sensitivity and a specicity of 60.4% and
77.9%, respectively. The positive predictive value (PPV) and negative
predictive value (NPV) were 77.5% and 60.9%, respectively. A spot P/C
ratio less than 0.19 could exclude preeclampsia with a sensitivity of
100%. The best threshold of the P/C ratio to detect urine protein
excretion >2000 mg per 24 h was 0.77, with a sensitivity and a
specicity of 96.8% and 98.6%, respectively. With this cut-off, PPV was
98.8% and NPV was 98.6% (Table 3). The areas under the ROC curves
for 300 and 2000 mg of protein per 24-hour were 0.74 and 0.99,
respectively (Figs. 1 and 2).
4. Comments
Assessment of urinary protein is mandatory to establish the
diagnosis of preeclampsia. Measurement of protein excretion in a
24-hour urinary collection is the gold standard for the quantitative
evaluation of proteinuria in pregnancy, when signicant protein-
uria is dened as proteinuria of 300 mg/day or more [4]. The urine
requires refrigeration, however, and its collection is cumbersome
and time-consuming for women and clinicians. Also, the results
may be misleading if collected inaccurately. Outside pregnancy the
24-hour urine collection has well-documented problems with
completeness, timeliness, and ease of performance. In pregnancy,
problems are increased by the physiological dilation of the ureters
Table 1
Characteristics of 200 women with suspicion of preeclampsia as inpatients and
outpatients {n (%), mean SD, or median [IQR]}.
Inpatients
(n = 186)
Outpatients (n= 14)
Age, years (median) 29.2 4.8 28.3 4.7
Gravidity (n) 2.4 1.5 3.2 1.4
Parity (n) 0.9 1.1 1.1 1.1
Prepregnancy weight (kg) 74.3 16.2 72.2 14.5
24 hour urine protein (g) 0.8 [0.22.8] 0.4 [0.10.6]
Proteinuria 300-2000 mg/24 h (%) 54.8 28.5
Proteinuria >2000 mg/24 h (%) 12.2 0
Inadequate collection (%) 17 28.5
Table 2
Demographic characteristics of 127 participants with preeclampsia.
Mean + SD or n IQR or %
Age, years (median) 29.1 5.8 21-38
Gravidity (n) 2.2 1.5 1-6
Parity (n) 0.9 1.4 0-5
Abortion (n) 0.3 0.8 0-4
Body mass index (kg/m
2
) 30.9 5.8 22-37.5
Previous history of preeclampsia (n) 32 24.6%
Family history of hypertension (n) 30 24%
Family history of diabetes mellitus (n) 61 47.6%
IQR, interquartile range.
Table 3
Test performance of spot P/C ratio assessment for 24-hour urine protein results.
24-hour urine
protein (mg)
Optimal spot P/C (mg/mg) Sensitivity (%) Specicity (%) PPV (%) NPV (%) Positive likehood
ratio
Negative likehood
ratio
300 0.28 60.4 77.8 77.5 60.9 2.72 0.51
2000 0.77 96.8 98.6 96.8 98.6 6.97 0.03
S. Kayatas et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 368371 369
and incomplete bladder emptying as a result of the enlarging
uterus, both of which may cause signicant collection errors [19].
These errors can be avoided by adequate hydration to maintain
urine ow (500 ml uid to generate a urine ow of >6 ml/min) and
standardization of the technique at the beginning (urine discard)
and end of the collection (lying in left lateral recumbency for
45 min to remove any partial obstruction of the ureters related to
supine or upright posture). Urine collection may not be possible
when the delivery occurs and this may cause undetermined
proteinuria status and a unsubstantiated diagnosis of preeclamp-
sia. Previous studies have demonstrated inadequate collected
urine volumes in up to 37% of samples.
In our study, the accuracy was assessed by urinary creatinine
excretion. As the 24 hour urinary creatinine excretion reects
muscle mass, the excretion is relatively constant. Because in
pregnancy muscle mass does not change, urinary creatinine
excretion is also unchanged [19,20]. Eighteen per cent of 24-hour
urine collections were inaccurate based on prepregnancy weight
and urinary creatinine excretion outside the acceptable ranges
(15-20 mg/kg per day). This is lower than reported in the literature.
Possible reasons are strict instructions for proper 24-hour urine
collection and low numbers of ambulatory cases. There is
controversy, however, about the accuracy of the 24-hour urine
collection according to urinary creatinine excretion. Cote et al.
reported that rates of inaccurate collection were 13-54% according
to prepregnancy weight and between-measurement difference for
serial collections [21].
Waiting for the results of 24-hour urine collection can often
delay diagnosis and management of preeclampsia. A rapid and
accurate test may provide efcient inpatient and outpatient
monitoring of proteinuria and may shorten the duration of
hospitalization. Alternatives such as urinary dipsticks, urine
collections over a shorter period, the urinary spot P/C ratio and
the urinary spot albumin/creatinine ratio have been considered for
the diagnosis of proteinuria.
In this study, we aimed to evaluate the urine P/C ratio in
pregnancy to predict 24-hour proteinuria at different cut-offs.
Although there are some reports with conicting results, our study
demonstrated a good correlation between spot urine P/C ratio and
24-hour urine total protein (r = 0.828, p < 0.0001). Some studies
have previously assessed a good correlation between 24-hour
urine protein and spot urine P/C ratio with correlation coefcients
ranging between 0.80 and 0.97 [2224]. Unlike our study,
Durnwald and Mercer [13] and Wikstro m et al. [25] found a poor
correlation between urine P/C ratio and 24 hour urine protein with
lower correlation coefcients of 0.56 and 0.4, respectively. With
these concerns about the strength of correlation, there has been a
challenge to nd a spot P/C ratio value with acceptable PPV and
NPV. A recent systematic review of spot P/C ratios in preeclampsia
concluded that the spot P/C ratio is a reasonable rule out test for
proteinuria of 0.3 g/day or more, among otherwise healthy women
with gestational hypertension with or without proteinuria on
dipstick [9], but no consensus for specic P/C cut-off values has
been obtained. In our study using protein values of 300 mg and
2000 mg on 24-hour urine collections, ROC curves were con-
structed and the best P/C cut-off points were calculated as 0.28 for
300 mg per 24 h and 0.77 for 2000 mg per 24 h. The areas under the
ROC curves for 300 mg and 2000 mg of protein on a 24-hour urine
collection were 0.74 and 0.99, respectively. Unlike the literature,
our study did not indicate that P/C ratio is adequate to detect or
rule out for proteinuria of 0.3 g/day or more. A P/C ratio greater
than 0.77, however, has a higher NPV and PPV of 98.6 and 96.8,
respectively for detecting proteinuria of 2000 mg per 24 h.
The study of Wahbeh et al., including 68 outpatients with
proteinuria attending a nephrology clinic, demonstrated wide
deviation from the line of identity at high protein excretion levels.
For protein excretion <2.0 g/day, the limit of agreement of spot P/C
ratio was 1.48. They conclude that the spot P/C ratio in spot urine
specimens is an accurate method only when proteinuria is at
reasonably low levels [26]. Also, Jaschevatzky et al., in a study
including 35 preeclamptic patients and 70 healthy patients,
reported a close correlation (r = 0.9278, p < 0.001) between 24-
hour proteinuria and P/C ratio, but the degree of correlation
decreased in patients with proteinuria greater than 2 g [11]. Our
study does not agree with these studies, both of which had a
sample size smaller than ours. The strength of our study is that it
may be the largest case series with preeclampsia.
In conclusion, our study demonstrated that the spot P/C ratio is
a poor predictor of 24-hour proteinuria. As the proteinuria
increases, the PPV and NPV increase. Therefore, a spot P/C ratio
can predict proteinuria >2000 mg better than 300-2000 mg.
The high degree of association between the spot P/C ratio and
Fig. 1. Receiver operating characteristic curves (ROCs) for the urine protein
creatinine (>300 mg/day).
Fig. 2. Receiver operating characteristic curves (ROCs) for the urine protein
creatinine (>2000 mg/day).
S. Kayatas et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 368371 370
the 24-hour urine protein excretion does not give reliable
information on whether use of the ratio in a random sample will
enable clinicians to reduce their dependence on the 24-hour urine
collection.
Conict of interest
The authors have stated explicitly that there are no conicts of
interest in connection with this article.
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