Proteinuria is a relatively frequent complication in both adults and children after kidney transplantation (40%-80%). It is usually mild and predominantly of tubular origin and is caused mainly by rejection, mTOR inhibitors, or hypertension; however, proteinuria could also be in the nephrotic range and of glomerular origin if caused by the recurrence of idiopathic FSGS or rejection. Proteinuria is a risk factor impacting graft and patient survival in adults and graft survival in children. Proteinuria should be assessed by protein/creatinine ratio regularly in pediatric kidney transplant recipients. In children with idiopathic FSGS, proteinuria should be assessed daily during the first 2-3 weeks post-transplant to enable prompt diagnosis of recurrence. The etiology of proteinuria should be identified (recurrence, rejection, mTOR-inhibitors, hypertension, etc.). If no apparent cause is found, a graft biopsy should be considered. Antiproteinuric therapy is primarily focused on treating the causes of the proteinuria, and this is usually done using Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs). The long-term follow-up goal should be normalization of proteinuria with a protein/creatinine ratio < 20 mg/mmol (200 mg/g). Because of the role elevated blood pressure may play in exacerbating proteinuria, antihypertensive medications should be used in those who are resistant to initial antiproteinuric therapy to achieve lower BP.

Children's Hospital of Eastern Ontario Research Institute and Children's Hospital of Eastern Ontario Division of Pediatric Nephrology University of Ottawa Ottawa Ontario Canada

Children's Hospital of Philadelphia Philadelphia Pennsylvania USA

Department of Pediatrics 2 University Hospital of Essen University of Duisburg Essen Essen Germany

Department of Pediatrics 2nd Faculty of Medicine Charles University Prague Czechia

Department of Pediatrics University Hospital Ostrava and Medical Faculty University of Ostrava Ostrava Czechia

Division of Pediatric Nephrology Department of Pediatrics Gynecology and Obstetrics Geneva University Hospitals Geneva Switzerland

Division of Pediatric Nephrology Washington University in St Louis School of Medicine St Louis Missouri USA

Faculty of Health Sciences Tel Aviv University Tel Aviv Israel

Kidney Research Center Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario Canada

Schneider Children's Medical Center Petach Tiqva Israel

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