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October 14, 2003

Complications

Question from Rockford, Illinois, USA:

My daughter, who has type�1 diabetes and currently has an hemoglobin A1c of 7.5%, spilled protein in her urine. They suggested this may be because she is an athlete but want to do another test with the first urine of the day which is scheduled. Can you explain what are medical reasons for spilling protein? When it is found, how do you correct the problem?

Answer:

There are many reasons for the kidneys to “spill” a bit of protein into the urine. The type of protein is typically microalbumin. For someone with (generally) poorly controlled diabetes for a number of years, the kidneys can be damaged to a slight degree, allowing the “leakage” of protein into the urine. Offhand, I would not expect a pre-adolescent with diabetes for less than a year to have diabetes-related kidney disease.

Other things that can allow the spillage of protein are: acute illness, fever, moderate strenuous activity but also other kidney issues not directly related to diabetes, perhaps even a urinary tract infection. So many diabetes clinicians will “screen” the urine with a random moment-in-time “spot” urine to assess for the presence of small amounts of albumin, which is referred to as “microalbumin.” If the results are normal, you pass the screen. If there is a higher concentration of microalbumin than what is considered normal, then there typically is a follow up with a carefully timed urine collection to better quantitate the amount of albumin excreted throughout the day thereby trying to no longer get a random sample and thus balancing out restful times with the active times. Some prefer a 24 hour urine collection; other clinicians prefer an overnight urine collection (since most young people are resting at nighttime.)

The important take-home messages is this. Your athletic child likely does not have diabetes-related kidney disease, but she failed a screen. Recognize that a screen is simply a screen and needs to be followed up with a more definitive test. Other, typically not-too-worrisome conditions can cause the kidneys to spill the protein.

As for possible treatment, the most correct treatment depends on the most correct diagnosis. In general, excess microalbumin in the urine due to diabetes is treated with attention to excellent glucose control and often a n ACE inhibitor to decrease the “pressure” to the kidney. If this is simply activity related protein in the urine (often called orthostatic proteinuria), nothing needs to be done. Activities are not curtailed. Activity is good for diabetes control!

DS