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September 21, 2008


Question from Clayton, North Carolina, USA:

Diagnosed at two, my now 13-year-old daughter is using an insulin pump. She has not been taking proper care of herself lately and her A1c has been as high as 13.1 more than once. They have discovered protein in her urine. The first morning level showed around 298 milligrams, I think, of protein and then they ordered a 24-hour urine test. Her level for that was almost 700. They are sending her to a pediatric nephrologist, but I was wondering what these numbers mean and what we can expect once we get to the nephrologist.


You are aware, I know, that poorly controlled diabetes leads to disruption of the microscopic part of the circulatory system, called capillaries. When the capillaries in the retina in the eye get injured, that can lead to blindness. When the capillaries supplying the nerves get disrupted, that can lead to a host of neurologic issues (including lack of sensation, poor stomach/intestinal motility, strokes, and others). When the capillaries of kidneys get disrupted, it is the first step to kidney failure. Other than performing routine kidney biopsies, the next earliest test to look for diabetes-related kidney disease is to see of the urine has “extra protein” in it. When the capillaries of the kidneys get messed up, they commonly will allow protein to “spill” into the urine. The amount of protein determines the extent of the concern.

Unfortunately, your letter is not completely clear as to how much protein was found in the urine, as you did not indicate the albumin-to-creatinine ratio or the other units of measurement. Assuming that the value of “700” was really 700 mg/24 hours, then this is a lot of protein, sometimes referred to as macroalbuminuria. If it were less than 300 mg/24 hours, this would be considered “microalbuminuria.”

I would anticipate that the reason you were referred to a pediatric nephrologist is to get their opinion whether or not there might be any other contributing factor to the extra urinary protein. I would anticipate that the nephrologist will get another urine collection, maybe some blood work, and possibly even an ultrasound of your daughter’s kidneys. The nephrologist may even discuss with you about scheduling your daughter for a kidney biopsy. I also anticipate that they will want to start your daughter on a medicine within the family of medicines called “ACE inhibitors.” These are medications that decrease the blood pressure to the kidneys. Assuming your daughter and you can get her glucoses and A1cs back down, then ACE inhibitors and related medications, taken indefinitely, can protect the kidney from future injury.

Do not take the finding of protein in the urine lightly. Unfortunately, having allowed the patient to get out of good glucose control, despite a pump, your daughter has crossed an important and worrisome threshold. This has been a grim reminder to your daughter and you and the family that she must get her glycemic control significantly better and keep it that way.


[Editor’s comment: You might wish to read some of our previous questions about teens and behavior. In most cases where teens become lax with their care and end up with hyperglycemia or in DKA, our medical experts recommend that parents take over their child’s diabetes care until the child is more responsible. This is something you may wish to discuss with your daughter’s diabetes team.