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January 5, 2010

Complications, Meal Planning, Food and Diet

Question from Dayton, Ohio, USA:

Now 47, I have had diabetes for 10 years and have never had any problems. My last A1c was 6.1 and I have been in this range for the last eight years, since I went on a pump. Last December, I had an abnormal urine test. The albumin was 30 mg/L; the creatinine was 50 mg/dL and the A:C was given as 30 to 300 mg/g. I went back the next June and the numbers were exactly the same. They had me do a 24-hour urine at this time and said the results were normal. Last week, I had another dipstick test and was abnormal again. The albumin was 10 mg/L, creatinine 10 mg/dL and A:C was again 30 to 300. I am confused as to why the 24-hour test was normal and the dipsticks were not. I am also hypothyroid and try to exercise. My blood pressure is okay. I do not remember if I had been exercising except for the test last week and I had been exercising the day before that test. The doctor wants me to go on an ACE inhibitor. She could not really tell me how bad my test results were, just said she wanted to try to stop or reverse it. How much does diet affect deterioration of the kidneys? Are there foods I should avoid? I have a fairly healthy diet, pretty well balanced. I drink a lot of water, seldom have soft drinks. This is very confusing to me. I thought kidney problems came with poor control, but mine has been pretty good.

Answer:

You have several good questions there. First, doctors switched to random spot urine specimens for measuring albumin excretion in patients with diabetes over 10 years ago. There are so many problems with doing 24-hour urine collections that the results are generally quite variable in a single person. Therefore, you have to get multiple 24-hour urine determinations and average them for a more accurate determination of the overall albumin excretion rate. Values between 30 and 300 mg/g creatinine are referred to as reflecting microalbuminuria. This designation came about because this amount of albumin does still not register on the generic protein dipstick tests but is still consider more than usual. Practice guidelines suggest that if more than one urine test were positive for microalbuminuria, it would be recommended that a drug from the ACE inhibitor or angiotensin receptor blocker class be used. Randomized, placebo-controlled, prospective studies have shown that when these agents are used when microalbuminuria develops, it results in preservation of kidney function when measured five years or more down the line. In fact, when you use these agents, it is recommended that the drug be titrated up so as to normalize albumin excretion. This is considered the appropriate treatment for the condition. We used to think that albuminuria meant a very high likelihood of kidney failure, but that is clearly not the case. Other treatments, such as dietary restriction of protein intake, are not as helpful when kidney function is normal and microalbuminuria is present. Protein restriction has been shown to be beneficial if kidney function deteriorates markedly, which is not the case with you. Obviously, if high blood pressure is also around, this should be treated. However, these agents are also blood pressure-lowering agents.

In the end, don’t blame yourself for not doing enough. This often happens and that is why testing for albumin excretion is one of the yearly screening tests recommended for all patients with diabetes.

JTL