E a r l y m a n a ge m e n t
Screening and diagnosis
of diabetic nephropathy
` Bo Feldt-Rasmussen
Screening for diabetic kidney disease (nephropathy) or its
earlier stage, microalbuminuria, is important. The person
with diabetes and the carer both need to know with
absolute certainty whether nephropathy is developing.
They need to know because it is possible to prevent or at
least delay further progression of the disorder. This again
is important because diabetic nephropathy, if left
untreated, is such a serious complication in both Type 1
and Type 2 diabetes. Diabetic nephropathy will develop in
about one third of people with diabetes Type 1 and in
about 8% of people with Type 2 diabetes.
People with diabetes now constitute between 20-50% of
all people needing dialysis. The survival rates for people
with diabetes at this late stage of the disease, when
dialysis treatment is needed, is unfortunately poor only
about 3 years on average. The major problem is
cardiovascular disease (CVD). Microalbuminuria and
diabetic nephropathy are both strong predictors of, and
are strongly associated with, CVD. Therefore, there is
every reason to prevent or delay progression of end-stage
kidney disease.
>>
August 2003
Volume 48 Special Issue
12
Diabetic nephropathy is present
when more than 0.5 g of protein is
found in the urine per 24 hours.
This is accompanied by a steadily
increasing blood pressure, and a
slow but progressive loss of kidney
function. Once the kidney function
has started to decline, it will, if
untreated, fall by about 10% per
year on average. Dialysis is required
when 10% of the function remains.
This figure can be dramatically
improved if nephropathy is
diagnosed and treatment started as
early as possible. Diabetic
nephropathy is most often seen
together with another important
complication of diabetes, eye
damage (diabetic retinopathy).
Screening for nephropathy has for
many years been replaced by
screening for microalbuminuria.
Screening for microalbuminuria
allows identification of the very
early presence of nephropathy.
Interventions at this time can do
far more good than in the later
stages.
Screening how?
In order to screen for
microalbuminuria or diabetic
nephropathy a specimen of urine is
necessary from the person in
question. Screening for
microalbuminuria can be carried
The presence of small amounts of protein (albumin) in the urine
(microalbuminuria) is the first sign of deteriorating kidney
function. As kidney function declines, the amount of albumin in
the urine increases, and microalbuminuria becomes proteinuria.
The level and type of proteinuria strongly determine the extent of
damage and whether a person in at risk for developing progressive
kidney failure. Proteinuria has also been shown to be associated
with cardiovascular disease.
Creatinine is a breakdown product of creatine, an important
component of muscle. It is removed from the blood by the kidneys.
The amount of creatinine in the blood is measured by a serum
creatinine test, and the test thus evaluates kidney function. If
kidney function is abnormal, creatinine levels will increase in the
blood, due to decreased loss of creatinine in the urine.
out in a number of ways, including:
timed urine collections over a
24-hour period
urine collected for 4 hours or
overnight
a random 'spot-urine' sample.
All of these methods can be used
for screening. The spot-urine
method is used to measure
albumin-to-creatinine ratio. For
further explanation of screening
methods, see the article by Richard
MacIsaac and George Jerums in this
issue of Diabetes Voice.
When?
Rates of microalbuminuria are high
In people with Type 2 diabetes
reportedly as high as 40%. Many
people with Type 2 diabetes will
show microalbuminuria at the time
of diagnosis of diabetes. Therefore,
all people with Type 2 diabetes
should be screened at diagnosis,
and yearly thereafter if the test is
normal. If microalbuminuria or later
stages of nephropathy are present,
the test should be repeated bimonthly in order to classify the
level of albumin in the urine.
Frequent measurements are
recommended because albumin
levels vary up to 40% from one day
to another. Once the diagnosis is
clear, 12-monthly measurements
should be sufficient.
()
People with
diabetes should
be screened for
microalbuminuria
once per year
for life.
In people with Type 1 diabetes,
microalbuminuria is not often seen
in pre-pubertal children and is rarely
seen within the first 5 years after
13
Hattie Young / Science Photo Library / Agentur Focus, Hamburg
E a r l y m a n a ge m e n t
diagnosis of the condition. However,
it is recommended to screen people
with diabetes for microalbuminuria
once per year for life.
Why screen?
Following a number of wellconducted, large-scale studies, we
are certain that aggressive lowering
of blood pressure can have a
positive effect. Treatment with
drugs known as ACE inhibitors or
the related so-called All-antagonists
is effective in the presence of
microalbuminuria or nephropathy,
even in people with normal blood
pressure (see article by Richard
MacIsaac and George Jerums in
this issue of Diabetes Voice).
Furthermore, every effort should
be made to optimize management
of blood sugar levels. This has been
shown to affect progression of the
disorder. Also, the close link to
CVD must be handled effectively. >>
August 2003
Volume 48 Special Issue
E a r l y m a n a ge m e n t
Mauritius
()
Microalbuminuria
is the strongest
independent
factor of all CVD
risk factors in
people with
diabetes.
Diabetic nephropathy
and CVD
CVD is the major cause of death in
people with diabetes. An increasing
number of large-scale studies have
shown that multifactorial
intervention directed against any
cardiovascular risk factor will
significantly reduce the number of
cardiovascular events. Treatments
which are known to be effective
are:
August 2003
Volume 48 Special Issue
blood pressure lowering
treatment with ACE inhibitors
and/or All-antagonists
blood fat (lipid) lowering
aspirin
smoking cessation
exercise
antioxidants such as vitamin E.
Blood pressure lowering and
ACE-inhibitors are the key players
in the prevention and reduction
of progression of diabetic
nephropathy. Therefore, one
shade of opinion says that
microalbuminuria no longer needs
to be measured that the
classical cardiovascular risk
factors should be the only focus.
This is wrong! Microalbuminuria is
the strongest independent factor
of all known cardiovascular risk
factors in people with diabetes. Its
presence should urge the doctor
and motivate the person with
diabetes to implement the
suggested treatments. The
presence of microalbuminuria
without the presence of other
cardiovascular risk factors should
lead to treatments for the
prevention of both the
destruction of the filtering units
of the kidneys and CVD.
Therefore, screening for
microalbuminuria in diabetic
nephropathy is still extremely
important and should be
implemented according to the
guidelines offered above.
14
` Bo Feldt-Rasmussen
Bo Feldt-Rasmussen is Head of
the Department of Nephrology
at Rigshospitalet, University of
Copenhagen, Denmark.
Further Reading
Mathiesen ER, Hommel E,
Hansen HP, Smidt UM, Parving
H-H. Randomised controlled trial
of long term efficacy of captopril
on preservation of kidney function
in normotensive patients with
insulin dependent diabetes and
microalbuminuria. BMJ 1999;
319: 24-25.
Parving H-H, Lehnert H, BrchnerMortensen J, Gomis R, Andersen S,
Arner P. The effect of Irbesartan in
patients with Type 2 diabetes.
N Engl J Med 2001; 345: 870-878.
Gaede P, Vedel P, Larsen N, Jensen
GVH, Parving H-H, Pedersen O.
Multifactorial intervention and
cardiovascular disease in patients
with Type 2 diabetes. N Engl J Med
2003; 348: 383-393.
Chaturvedi N, Bandinelli S,
Mangili R, Penno G, Rottiers RE,
Fuller JH on behalf of the
EURODIAB Prospective Complications
Study Group. Microalbuminuria in
Type 1 diabetes: Rates, risk factors
and glycemic threshold. Kidney
Internat 2001; 60: 219-227.
Borch-Johnsen K, Feldt-Rasmussen B,
Strandgaard S, Schroll M, Jensens SR.
Urinary albumin excretion. An
independent predictor of ischemic
heart disease. Aterioscler Thromb
Vasc Biol 1999; 19: 1992-1997.
