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December 1, 2007

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Question from Nashville, Tennessee, USA:

My 14-year-old son has had type 1 diabetes for one year, eight months. Six months ago, during a routine urine test, his microalbumin test came back elevated, in the low 70s. They then did a second test, but on a sample taken first thing in the morning. That one came back more normal. They said we should keep an eye on it. We moved out of state and now he has a new endocrinologist.

His microalbumin was checked a third time and came back at 76. They did a fourth sample on urine collected overnight. That result was lowered to 38, but the endocrinologist said it is still abnormal, even if it is closer to normal. She stated it is very concerning because it is the third abnormal test and likely points to a problem. She also stated that it would be rare in a young kid who has only had diabetes for about a year and a half. She did not feel it was orthostatic proteinuria because it still came back abnormal.

He has vesicoureteral reflux (VUR) that was retested several years ago, to be at grade 1. He has been very fatigued and the school has also called me because they were concerned about his fatigue at school. His A1c is great at 6.8. His blood pressure is normal to low. The endocrinologist feels he needs to see a urologist and also a pediatric nephrologist to find the cause for his proteinuria.

My questions:

How likely is it that his VUR caused some kidney damage?

How elevated is 76 or 38, compared to normal ranges? Is it really high enough for me to be concerned at this point?

What tests or treatment should I be insisting on and what is the protocol for handling these test results?

Answer:

From: DTeam Staff

I would agree that such proteinuria (microalbuminuria, technically) is rare in someone with diabetes of less than two years duration. I would also agree that this should be investigated by a pediatric nephrologist with some experience also with diabetes and likely this would be diagnosed as a non-diabetic condition. Family history is also important. Whether or not the reflux you describe has caused some unknowing damage to kidney function would also need investigation by a nephrologist. There are many causes to consider in a differential diagnosis and some more important than others because there may be very specific treatment needs. More importantly, there needs to be some decision about instituting treatment (I suspect this will be needed with several abnormal tests consecutively) to try to slow down, protect the kidneys. Usually this would involve an ACE inhibitor such as lisinopril no matter what the specific culprit/cause. Any improvement in glucose control and lowering A1c levels would, of course, also be most important and extremely helpful.

SB