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Question:

From Minot, North Dakota, USA:

My 12 year old daughter, who has had type 1 diabetes for almost seven years, recently had an abnormal random urine microalbumin so she then did a 24 hour collection, and her excretion rate was 138 micrograms per minute. Both tests were ordered by our pediatrician who then consulted with a pediatric endocrinologist who indicated my daughter should immediately be started on an ACE inhibitor.

The problem is, we then spoke with our doctor who is a diabetologist and has been for 30 years, who flat out stated that we are "chasing numbers" and that we didn't need the test done. There is no way that she has any kidney damage because she has such good control (A1cs:6.2-8.7%). Her thyroid is slightly elevated, but all other tests are normal. Furthermore, he stated that if we were to test, it should have been collected as two different specimens of one during the night and one during the day. He is willing to 'bet money' that she is only spilling protein during the day.

If she does a separate urine test of only during the night, she never gets up to urinate during the night, and very little during the day. It was a very minimal sample to work with. If she is only spilling protein during the day, is that considered normal with no treatment necessary? She has been very active in sports on a daily basis, including the day before the test. How much influence could have had on the results? In previous questions to your team, answers indicate no exercise for 24-48 hours prior to the test.

We feel we are between a rock and a hard place with the decision being left to us on whether or not to start her on an ACE inhibitor right away. I am scared for my daughter if we don't treat her, and scared of putting her on a drug that she may not need and risking side effects. Please provide any information you can to help us determine the most appropriate decision for our child at this time. These three doctors obviously have different views and are all in separate cities, which makes it more difficult for us as a whole.

Answer:

Decisions about microalbuminuria are difficult ones. Most diabetologists around the world routinely screen for kidney disease with either an overnight microalbumin sample, a "spot" microalbumin sample during an office visit or a full 24 hour urine collection. There are big debates about which one is the best, and there are no conclusive answers, unfortunately. My own preference is for an overnight sample since this decreases the chances of finding exercise-related protein leakage.

Exercise protein leakage is a normal variant and not related to any kidney problems as far as we now know. So, the doctors who advised you that this was likely exercise-related could be correct. This is easy to check by splitting a daytime and a night time sample and checking it several times to see what results are obtained.

There are also debates about what levels constitute enough microalbumin leakage to warrant treatment. The best treatment for diabetes related microalbumin or protein leakage still remains improving the day-to-day glucose control and also improving the hemoglobin A1c levels. If there is even subtle hypothyroidism (normal T4 and elevated TSH), many people would also recommend treating the hypothyroidism to see if the protein leakage gets better. Other causes of protein leakage should also be investigated and blood pressure levels should be checked as well.

If the microalbuminuria is persistent on three samples, then most diabetologists would start a medication like an ACE inhibitor. Lisinopril (brand names Prinivil and Zestril) is the most common one used since it can be given just once a day. Others like enalapril are also okay but may require twice a day dosage. We don't know if treating the microalbuminuria preserves long term kidney function but hope that this is the case. Studies are ongoing to try to determine this but will require many more years followup before conclusions can be reached.

As far as what to do with three different medical opinions about the same situation, I would suggest that you call all three doctors and ask them to have a conference call so that the three of them can discuss their different ideas and come up with a unified plan that makes sense to them and to you and your adolescent as well.

SB

DTQ-20031020002659
Original posting 23 Oct 2003
Posted to Complications

  
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Last Updated: Tuesday April 06, 2010 15:09:52
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