Moderately increased albuminuria (Microalbuminuria) in Diabetes Type 2

-Patient with moderately increased albuminuria (formerly microalbuminuria).
-Common causes of a transient moderately increased albuminuria reviewed.
–Classification of proteinuria reviewed with the patient.
-Will get 3 measurements of urine albumin-to-creatinine ratio over a 3-6 month period. At least 2 out of 3 of these tests will need to be in the same level of albuminuria (normal to mildly increased, moderately increased, or severely increased) to be defined at that severity level.

-Intensive diabetic management plus an ACE inhibitor or an ARB will be initiated as they have been showed to delay progression from moderately elevated to severely elevated albuminuria in both type 1 and type 2 diabetes patients.
-Reduction of protein intake. Will recommend a reduction of protein intake to 0.8–1.0 g/kg/day in the early stages of CKD, and to 0.8 g/kg/day in the late stages. This may improve renal function and would be considered in patients whose nephropathy seems to be progressive despite optimal glucose and blood pressure control and the use of an ACE inhibitor and/or an ARB.

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Pearls

Diabetic nephropathy develops in 20%–40% of patients with diabetes and is the leading cause of end-stage renal disease.

Moderately increased albuminuria is the earliest sign of nephropathy in patients with type 1 diabetes and is a marker for nephropathy in type 2 diabetes.

Patients who progress from moderately to severely increased albuminuria are likely to progress to end-stage renal disease over a period of years.

The following is from the ABFM

“Although timed 4- and 24-hour urine collections for creatinine can be used to screen for microalbuminuria, a random spot urine specimen for measurement of the albumin-to-creatinine ratio is the preferred method. A minimum of two of three tests showing a urine albumin level >30 µg/mg creatinine or more over a 6-month period confirms the diagnosis of microalbuminuria.

Treatment

Since the antiproteinuric effect is believed to be independent of blood pressure, current ADA guidelines recommend the use of ACE inhibitors or ARBs as first-line therapy for both type 1 and type 2 diabetic patients with microalbuminuria, even if their blood pressure is normal. Some studies, however, have raised questions about the value of early renin-angiotensin blockade for preventing microalbuminuria in normotensive patients with type 1 or type 2 diabetes, and ADA guidelines recommend against the use of these drugs for patients with normal blood pressure and no albuminuria.

Compared to whites, African-Americans and Asians have a three- to fourfold higher risk of angioedema associated with the use of ACE inhibitors. The American Heart Association recommends that ACE inhibitors not be initiated in any patient with a history of angioedema.

References

http://www2.kidney.org/professionals/kdoqi/guideline_diabetes/cpr1.htm

Moderately increased albuminuria (Microalbuminuria) in Diabetes Type 2

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