March 23, 2009
Complications, Other Medications
Question from Orono, Maine, USA:
Last fall, my daughter’s laboratory tests revealed elevated microalbuminuria. Her endocrinologist then ordered a 24-hour urine collection, which came back in the normal range. In February, she saw her regular pediatrician due to a non-diabetes related illness, and, again, elevated protein levels were found. On follow-up, both the microalbumin (35) and the creatinine-to-protein ratio were above the normal range. Although our endocrinologist did not feel the numbers were high enough to warrant further study, the pediatrician did and contacted a nephrologist, who ordered an ultrasound, which was normal and morning/evening urine collection. It turns out that the morning numbers are normal and the evening numbers are elevated (diagnosis: orthostatic proteinuria). The nephrologist does not believe this to be related to her diabetes and has recommended continued monitoring. Do you think lisinopril is called for in this case for preventative use? Do you think the endocrinologist was right in not being concerned?
Answer:
One cannot decide based upon the information you provided. We usually – and most others – do three overnight microalbuminuria assessments to see if there were persistent abnormality. Rarely are other tests needed so it would depend upon the experience of the nephrologist regarding other adolescents with type 1 diabetes as well as the experience of the diabetologist. I would assume that the diabetologist may, indeed, have more experience in this regard. It also may depend upon degree of glycemic control, A1c level, smoking history, lipid status, family history of kidney/lipid/heart/blood pressure abnormalities since this changes risk assessment as well. I might suggest that you ask the nephrologist and the diabetologist to talk to each other, then they can decide mutually what might be best course, follow-up, etc.
SB
