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November 6, 2010

Complications

Question from Dublin, Ireland:

I just got a call from the diabetes nurse specialist to say that my eight-year-old daughter's last urine test showed high protein levels. My daughter just recently changed to four injections a day (NovoRapid and Lantus) and her A1c, which was previously in the 8.4 to 8.5% range, has dropped to 7.6%. I was very pleased with the change and began to think that, finally, we might get some regular control over this disease, but then I got this call. The nurse told me that as the urine was not taken fasting that it may be just a mistake, and asked me to send in three fasting urine samples, once a week for the next three weeks. She told me that if anything abnormal or high shows up in any of these three samples, my daughter will need to be taken in for 24 hour urine testing. She told me not to worry, that 80% of the time nothing unusual shows up but I'm worried sick. Can you please give me your opinion on this situation? Can protein show up in urine because the child was not fasting? My understanding was that protein should not show up in urine ever, regardless of food consumed that day. Also, if a problem shows up, what happens next? My daughter has had diabetes for only three years.

Answer:

Is is very unusual to have significant kidney damage from diabetes at this age. Lots of activity in the hours previously can sometimes cause protein leakage, as can illness. High A1c levels indicative of high sugar levels are associated with kidney damage and this often shows up first as microalbuminuria, protein in the urine sample. A 24 hour urine collection or overnight urine collection, as well as random urine collections, can all be used to determine protein leakage and this depends upon local laboratory setup and preference of diabetes team. It has nothing at all to do with fasting or non-fasting, however. It is important to get and keep her A1c below 7.5%; some would say below 7%. Multidose insulin or use of an insulin pump usually is best to achieve such improved control. Frequent monitoring of blood glucose, keeping records, and meal planning are all extremely helpful. I would agree that it is important to recheck several times before making a definitive diagnosis of diabetic nephropathy.

SB