URINARY ALBUMIN EXCRETION

The presence of increased UAE denotes an increase in the transcapfilary escape rate of albumin and is therefore a marker of microvascuiar disease. Persistent UAE greater than 20p.g/min represents a twentyfold greater risk for the development of clinically overt renal disease in patients with type 1 and type 2 diabetes. Prospective studies have demonstrated that increased UAE precedes and is highly predictive of diabetic nephropathy, end-stage renal disease, cardiovascular mortality, and total mortahty in patients with diabetes mel-litus. The DCCT and UKPDS showed that intensive diabetes therapy can significantly reduce the risk of devel- 

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V3. Vermes, I., Spooren, P. F. M. J., Kalsbeek-Batenburg, E. M., and Haanen, C., In addition to von Willebrand factor and urinary albumin excretion, plasma endothelin is an indicator of endothelial dysfunction in diabetes mellitus. Diabetes 36,472-473 (1993). 

Insulin resistance, frequently accompanied by obesity, is an important risk factor for HF development. Diabetes Mellitus itself increases the risk for HF as well. Those who are positive for urinary albumin excretion may develop more sever HF and are more at risk for mortal events. A recent report showed that diabetes is a potent, independent risk factor for mortality in patients hospitalized with HF. Interestingly, the excess risk in diabetic patients appears to be particularly prominent in females. In treating the patient with diabetes, one should pay attention to such variables. 

Nakamura, T., Ushiyama, C., Suzuki, Y., Shoji, H., Shimada, N., Koide, H. Hemoperfusion with polymyxin B immobilized fibers for urinary albumin excretion in septic patients with trauma. ASAIO J 48 (2002) 244-248. 

The prevalence of diabetic neuropathy rises from 7.5% at the time of diagnosis to 50% after 25 years and seems to be directly related to the duration of diabetes. The commonest type is a symmetric sensory and autonomic polyneuropathy. Once symptomatic autonomic neuropathy is present the prognosis for survival is substantially diminished. The clinically silent phase of diabetic nephropathy in Type-II diabetes may last 5-10 years. It is characterized by rising urinary albumin excretion caused by a capillary lesion in the glomerulus. Microalbuminuria varies and can be found in 15-60% of all Type-II diabetics it is defined by an excretion rate between... 

Claudi T, Cooper JG. Comparison of urinary albumin excretion rate in overnight urine and albumin creatinine ratio in spot urine in diabetic patients in general practice. Scand J Prim Health Care 2001 19 247-8. 

There is ongoing controversy as to whether intensive glucose therapy alone can prevent progression of incipient to overt nephropathy. Other factors, such as lowering blood pressure and blockade of ACE and All, are important. High blood pressure accelerates the progressive increase in albuminuria in patients with initially normal urinary albumin excretion and accelerates loss of kidney function in those with overt nephropathy in type 2 diabetes. A subgroup analysis of the Swedish Hypertension Optimal Trial (HOT)... 

Chavers BM, Bilous RW, EUis EN, Steffes MW, Mauer SM. Glomerular lesions and urinary albumin excretion in type I diabetes without overt proteinuria. 

Diabetic patients with or without hypertension who demonstrate persistent microalbuminuria despite intensive insulin therapy should have their ACEI or ARB dose titrated to achieve maximal suppression of urinary albumin excretion to halt or slow CKD progression. 

BP, blood pressure DM, diabetes mellitus GFR, glomerular filtration rate Sq, serum creatinine UP Cr, urinary protein creatinine ratio UPE, urinary protein excretion UAE, urinary albumin excretion. 

Based on the available clinical and experimental data, pharmacologic interventions can help to limit the progression of CKD in diabetic patients. Eigure 43-9 summarizes these interventions in the form of an algorithm. All patients with type 1 diabetes of more than 5 years duration and all type 2 diabetics should be screened yearly for microalbuminuria (annual urinary albumin excretion or urinary albumin creatinine ratio). Blood glucose should be maintained within or close to the normal range by frequent insulin injections or by use... 

FIGURE 43-9. Therapeutic strategies to prevent progression of renal disease in diabetic individuals. UAE = urinary albumin excretion SC = subcutaneous JNC VII = the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 

Holl RW, Grabert M, Heinze E, Debatin KM. Objective assessment of smoking habits by urinary cotinine measurement in adolescents and young adults with type 1 diabetes. Reliability of reported cigarette consumption and relationship to urinary albumin excretion. Diabetes Care 1998 21 787-791. 

Warwick GL, Fox JG, Boulton-Jones JM. The relationship between urinary albumin excretion rate and serum cholesterol in primary glomerular disease. Clin Nephrol 1994 41 135-137. 

There are no reports of human nephrotoxicity caused by release of mercury from amalgam fillings. This is supported by experimental data from ten humans where standard measurements of renal function (glomerular filtrate rate, urinary albumin excretion, P2-microglobuUn, N-acetyl-P-D-glucosaminidase) were monitored before and 60 days after the removal of mercury amalgam fillings [102]. 

Morgensen CE. Urinary albumin excretion in early and long term juvenile diabetes. Scand J Clin Lab Invest 1971 281 101-... 

Parving HH, Mogensen CE, Jensen HA, Evrin PE. Increased urinary albumin-excretion rate in benign essential hypertension. Lancet 1974 1 1190-1192. 

Microalbuminuria may be defined as an albumin excretion rale intermediate between normality (2.5-25 mg/day) and macroalbuminuria (>250 mg/day). The small increase in urinary albumin excretion is not delected by simple albumin slick tests and requires confirmation by careful quantitation in a 24h urine specimen. The importance of microalbuminuria in the diabetic patient is that it is a signal of early, reversible renal damage. 

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