Introduction

Chronic kidney disease is a progressive condition that results in significant morbidity and mortality. Because of the important role the kidneys play in maintaining homeostasis, chronic kidney disease can affect almost every body system. Early recognition and intervention are essential for slowing disease progression, maintaining quality of life and improving outcomes. (1),

Diabetic nephropathy is a complication of diabetes and is characterized by proteinuria (normal urinary albumin excretion is <30 mg/day; overt proteinuria is >300 mg/day). Before overt proteinuria develops, albumin excretion increases in those diabetic patients who are destined to develop diabetic nephropathy.

Case Presentation

A 57-Year-Old Man with Type 2 Diabetes, Hypertension and Microalbuminuria(2),

A 57-year-old man with type 2 diabetes was first diagnosed 2 years ago. Other medical problems included obesity and hypothyroidism. He had a history of heavy alcohol consumption but quit alcohol 2 years ago. He presents now for routine follow-up and is noted to have a blood pressure of 168/100 mmHg. He is asymptomatic.

Investigation

Laboratory evaluation reveals trace protein on urinalysis, blood urea nitrogen of 14 mg/dl, Serum Creatinine of 1.2 mg/dl, random serum glucose of 169 mg/dl, normal electrolytes, and normal thyroid-stimulating hormone levels. A 24-h urine collection reveals a urinary albumin excretion rate of 250 mg/day.

Background

Microalbumin a necessity in Diagnosis in Diabetes and CKD

Recent study published in the Diabetes Atlas 2006 (3), indicates that India has the largest number of diabetic patients in the world, and is expected to increase to >69.9 million by 2025.

Asian Indians have reported an increased in prevalence of diabetic nephropathy by 29.6%.

Prevalence of microalbuminuria and overt nephropathy was computed in relation to duration of diabetes and A1C (duration of diabetes <1.0 year: 22.3%, 1–5 years: 25.7%, 6 - 10 years: 33.5%, and >10 years: 30.2 %( 4, 5, 6, 7)

Discussion

• The case-report demonstrates the approach for screening diabetic patients for microalbuminuria.
• Recognize hypertension in diabetic patients with a blood pressure >140/90 mmHg.
• Diabetic nephropathy is a clinical syndrome characterized by albuminuria, hypertension, and progressive renal insufficiency. Diabetic nephropathy is the most common cause of end-stage renal disease (ESRD), accounting for ~35% of all new ESRD cases. The life expectancy of patients with diabetic ESRD is <50% at 3 years, despite improvements in dialysis and renal transplantation
• American Diabetes Association recommends regular screening for microalbuminuria. Type 1 diabetic patients should be screened 5 years after diagnosis of diabetes and
  after puberty. People with type 2 diabetes should be screened from the time of diagnosis, since many such patients have had undiagnosed disease for some time. If the initial screening is negative, then annual screenings are indicated.

Diagnostic Significance

Assessing the potential for early onset of nephropathy in

• Acute hyperglycemia
• Urinary tract infection
• Marked hypertension
• Congestive heart failure

Methods in estimation of Microalbumin

• HPLC Method
• Urine analysis
• POCT
  • Dip stick method
  • Quantitative urine analysis through strips
• Immunoturbidimetric method

Advantages of Immunoturbidimetric method

• Applicable to all size laboratories
• Sufficient sensitivity over Urine strip method
• Minimal procedure time over HPLC methods
• No specific instrument required

References

1. Am Fam Physician. 2004 Nov 15;70(10):1921-1928.
2. CLINICAL DIABETESVOL. 18 NO. 3 summer 2000
3. Diabetes Atlas 2006
4. Gatling W, Knight C, Mullee MA, Hill RD: Microalbuminuria in diabetes: a population study of the prevalence and an assessment of three screening tests.Diabet Med 5:343–347, 1988
5. Neil A, Hawkins M, Potok M, Thorogood M, Cohen D, Mann J: A prospective population-based study
   of microalbuminuria as a predictor of mortality in NIDDM.Diabetes Care 16:996–1003, 1993
6. Collins VR, Dowse GK, Plehwe WE, Imo TT, Toelupe PM, Taylor HR, Zimmet PZ: High prevalence of
   diabetic retinopathy and nephropathy in Polynesians of Western Samoa. Diabetes Care 18:1140–
   1149, 1995
7. Collins VR, Dowse GK, Finch CF, Zimmet PZ, Linnane AW: Prevalence and risk factors for micro- and
   macroalbuminuria in diabetic subjects and entire population of Nauru. Diabetes 38:1602–1610, 1989