When was the last time you collected your urine for a 24 hour period and had it tested for microalbumin? If it wasn't within the last year, it's time to get it done again. Annual tests for microalbumin are an important part of regular care for all diabetic adults, regardless of how long we've had diabetes. People with Type 2 diabetes should begin testing for micro- albuminuria at the time they are diagnosed and then test again at least once a year. This test should be also be accompanied by a creatinine clearance test, which involves drawing a blood sample, too. There are three ways to check the microalbumin levels: 1) random, spot collection in the doctor's office (preferably with first-void of the morning urine, due to known variations in albumin excretion throughout the day) 2) timed collection (e.g., 4 hour urine collection) 3) 24 hr urine collection with creatinine, & creatinine clearance The 24 hour urine collection is perhaps the best approach. The other tests may be generally adequate, but the 24 hour test removes some variables that might later be important for comparing test results over the years. Microalbumin tests are NOT the same as the little dipstick "protein" test your doctor's office might do. Even if you get a negative "protein" dipstick test in the doctor's office, you need to have a microalbumin urine test with creatinine clearance every year. Please don't let someone convince you not to bother with the test. It is inconvenient, but it's not hard or painful. Rules of thumb about how it takes a certain amount of time to develop kidney damage are NOT to be relied upon, especially for people with Type 2 diabetes. Please get your microalbumin level tested. If your doctor does not think it is important, please refer to the American Diabetes Association Standards of Medical Care at the end of this message. Paula ===== HOW TO DO A 24-HR URINE COLLECTION TEST: Essentially, you get a little jug from the lab and go home with instructions to collect all urine for a 24 hour period in the little jug. If your BG levels are high and/or you are urinating a lot, you might want to ask for 2 jugs, just to be sure you don't run out of collection space. (I've needed two.) The lab will give you instructions on when to begin collecting the urine. Be sure to follow their advice. One common approach is to get up on the morning you are going to begin testing and urinate as usual, noting the time. Now your bladder is empty. From THEN on, you collect all the urine you void for the next 24 hours, which will include the first morning urine on the following day, 24 hours after you first urinated into the toilet on the previous day. Once you start collecting the urine, keep the jug in the refrigerator. When you are done, take the jug up to the lab. If you are having a creatinine clearance test, you will also get your blood drawn and be asked to give them your weight. (Don't fudge this, it's important for calculating results.) Hints: You need to do this when you know you will get up at about the same time for 2 days in a row. This means if you have to do it on a Saturday (when you're not at work), you'll need to get up at the same time on Sunday so don't stay up too late.(g) You might find it easier to get a 2 quart measuring cup (your bladder might hold more than 1 qt.) and use that to collect your urine, then pour the urine from the measuring cup into the collection jug. ====== DIABETIC KIDNEY DISEASE: The deterioration that characterizes kidney disease of diabetes takes place in and around the glomeruli, the blood-filtering units of the kidneys. Early in the disease, the filtering efficiency diminishes, and important proteins in the blood are lost to the urine. Medical professionals gauge the presence and extent of early kidney disease by measuring protein in the urine. Later in the disease, the kidneys lose their ability to remove waste products, such as creatinine and urea, from the blood. Symptoms related to kidney failure usually occur only in late stages of the disease, when kidney function has diminished to less than 25 percent of normal capacity. For many years before that point, kidney disease of diabetes exists as a silent process. There are five stages of diabetic kidney disease: Stage I. The flow of blood through the kidneys, and therefore through the glomeruli, increases--this is called hyperfiltration-- and the kidneys are larger than normal. Some people remain in stage I indefinitely; others advance to stage II after many years. Stage II. The rate of filtration remains elevated or at near-normal levels, and the glomeruli begin to show damage. Small amounts of a blood protein known as albumin leak into the urine--a condition known as microalbuminuria. In its earliest stages, microalbuminuria may come and go. But as the rate of albumin loss increases from 20 to 200 micrograms per minute, microalbuminuria becomes more constant. (Normal losses of albumin are less than 5 micrograms per minute.) A special test is required to detect microalbuminuria. People with NIDDM and IDDM may remain in stage II for many years, especially if they have normal blood pressure and good control of their blood sugar levels. Stage III. The loss of albumin and other proteins in the urine exceeds 200 micrograms per minute. It now can be detected during routine urine tests. Because such tests often involve dipping indicator strips into the urine, they are referred to as "dipstick methods." Stage III sometimes is referred to as "dipstick-positive proteinuria" (or "clinical albuminuria" or "overt diabetic nephropathy"). Some patients develop high blood pressure. The glomeruli suffer increased damage. The kidneys progressively lose the ability to filter waste, and blood levels of creatinine and urea-nitrogen rise. People with IDDM and NIDDM may remain at stage III for many years. Stage IV. This is referred to as "advanced clinical nephropathy." The glomerular filtration rate decreases to less than 75 ml. per minute, large amounts of protein pass into the urine, and high blood pressure almost always occurs. Levels of creatinine and urea-nitrogen in the blood rise further. Stage V. The final stage is ESRD. The glomerular filtration rate drops to less than 10 milliliters per minute. Symptoms of kidney failure occur. ===== From: "American Diabetes Ass'n.: Clinical Practice Recommendations 1997" (Diabetes Care, vol.20, supplement 1, 1997): "...SCREENING FOR ALBUMINURIA -- Routine urinalysis should be performed yearly in adults. If positive for protein, a quantitative measure is frequently helpful in development of a treatment plan. If the urinalysis is negative for protein, a test for the presence of microalbumin is necessary. Because microalbuminuria rarely occurs with short duration of type I diabetes or before puberty, screening in individuals with type I diabetes should begin with puberty and after 5 years' disease duration. Because of the difficulty in precise dating of the onset of type II diabetes, such screening should begin at the time of diagnosis. ... Microalbuminuria is said to be present if urinary albumin excretion is >30 mg/24 h (equivalent to 20 µg/min on a timed specimen or 30 mg/g creatinine on a random sample) (Table 1). Short-term hyperglycemia, exercise, urinary tract infections, marked hypertension, heart failure, and acute febrile illness can cause transient elevations in urinary albumin excretion. ... Table 1--Definitions of abnormalities in albumin excretion ---------------------------------------------------------------------- Category 24-h Timed Spot collection collection collection ---------------------------------------------------------------------- Normal <30, mg/24 h <20 µg/min <30 µg/mg creatinine Microalbuminuria 30­300 mg/24 h 20­200 µg/min 30­300 µg/mg creatinine Clinical albuminuria >300 mg/24 h >200 µg/min >300 µg/mg creatinine ---------------------------------------------------------------------- ... Because of variability in urinary albumin excretion, two of three specimens collected within a 3- to 6-month period should be abnormal before considering a patient to have crossed one of these diagnostic thresholds. Exercise within 24 h, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension may elevate urinary albumin excretion over baseline values. ... SUMMARY -- Annual screening for microalbuminuria will allow the identification of patients with nephropathy at a point very early in its course. Improving glycemic control, aggressive anti- hypertensive treatment, and the use of ACE inhibitors will slow the rate of progression of nephropathy. In addition, protein restriction and other treatment modalities such as phosphate lowering may have benefit in selected patients."