My daughter is 13 years old and has had diabetes for four years. She uses an insulin pump to manage her diabetes and does an excellent job. She hasn’t had an A1c higher than 6.1. She recently went to see her endocrinologist and she ordered a microalbumin to be done. The urine test came back positive for albumin. Since I was concerned, we went to see a pediatric nephrologist. He repeated the test, however, gave us the direction for her to empty her bladder before going to bed. When she woke up in the morning, the first thing she did was give the specimen. This repeated microalbumin came back negative. He has diagnosed her with orthostatic proteinuria. His explanation of the diagnosis makes sense, but I haven’t heard of this before. Can you tell me anything more about this condition and most importantly does this make her even more susceptible to kidney problems when she is older?

I am surprised that your endocrinologist referred you directly to a nephrologist before confirming the increased protein in her office/clinic.

The earliest signs of diabetes-related kidney disease can only be seen with special microscopic techniques on a tissue biopsy of the kidneys. It is not reasonable to “screen” for diabete-related kidney disease with a needle biopsy every year. But, the next common irregularity that is recognized with diabetes-related kidney disease is the “spillage” of a small amount of albumin protein into the urine. This is called “microalbuminuria.” And while it is a fairly sensitive marker of diabetes-related kidney disease, it is not specific for diabetes-related kidney disease. In other words, other conditions can also cause the kidneys to leak small amounts of albumin. What are those conditions? Well, some are indeed kidney diseases, but not related to diabetes. Examples would be a urinary tract infection or a process call “nephrotic syndrome.” But conditions not primarily related to the kidney can cause microalbumin leakage also, including some innocuous issues such as fever or even exercise. This latter issue is sometimes referred to as “orthostatic proteinuria” which signfies that when you stand up, there is leakage of albumin in the urine, presumably due to some increased blood flow to the kidneys. But remember, the urine she eliminates from her bladder at any given time, has been accumulating since the last time she emptied her bladder. So, if she was active before bed last night, she might have some protein in this morning’s first urine sample.

If a person with diabetes has a random urine collection that has increased microalbumin, oftentimes a carefully obtained, quantified and timed urine collection is requested over 24 hours, thus trying to “balance out the times of activity with the times of rest.” Many centers try to avoid this issue by only requesting the first urine obtained in the morning before much moving around, provided that the LAST thing the patient did before sliding into bed was emptying of the bladder. This is why the nephrologist was very wise and asked for the urine as they did.

So, orthostatic proteinuria is a benign, non-worrisome process. As far as I know, there should be no further risk of diabetes-related kidney disease to your daughter as a consequence of orthostatic proteinuria. But remember that in the future, her urine screens for diabetic complications should be on days of relative rest or first morning samples as noted above. As a rule, most abnormal, unexpected lab results generally should be confirmed before undergoing more intense diagnostic testing or treatment.

You may wish to Search this site for other questions regarding urinary microalbumin.

DS