The 1994 St Vincents Declaration on "Guidelines For The Prevention of
Diabetic Renal Failure" gives >2.5 for men and >3.5 for women. However other
facts to be taken into consideration is that there is a large
intra-individual variation. Most of the original work was done on timed
collections rather than EMUs (or even worse random urines).
Correcting for concentration with creatinine only partially reduces the
intra-individual variation.
In my experience the majority of patients have albumins of considerably less
than 10mg/l, so these are probably "normal" The rest have urinary albumins
greater than 10mg/l.
I suspect that unless you choose very low cut off levels you are going to
miss some patients who may have benefited from early treatment. However
diabetic nephropathy does not develop overnight and if you do annual
screening and they are getting worse you should pick them up sooner or
later!.
Our problem is getting the medical staff to request the test, and getting
the patients to collect three samples.
In practice we use a cut off level of at least 2 out of three EMUs with
microalbumin >20mg/l or ACR >3.0. We realise that this is a compromise but
it does make it easier to remember!
Incidentally if I develop diabetes I will be on ACE inhibitors as soon as
there is any albumin detectable in my urine, along with the Statins etc.
Tim
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-----Original Message-----
From: p=NHS NATIONAL
INT;a=NHS;c=GB;dda:RFC-822=ACB-CLIN-CHEM-GEN(a)JISCMAIL.AC.UK;
Sent: 24 September 2002 12:32
To: p=NHS NATIONAL
INT;a=NHS;c=GB;dda:RFC-822=ACB-CLIN-CHEM-GEN(a)JISCMAIL.AC.UK;
Subject: Microalbuminuria screening
Dear All
We now have the technical capacity to cope with our
request workload for microalbumin, and are in the
process of introducing the albumin:creatinine ratio as
a screening test. From the literature, there seems to
be little consensus over reference values. Mike Mead
in Br J Diab & Vac Dis May/June 20022002;2:191-4
states that "microalbuminuria is usually defined as a
urinary albumin: creatinine ratio (ACR) of >2.5
mg/mmol in men and >3.5 mg/mmol in women." However, in
the CALM Study (Mogensen et al, BMJ
2000;321:1440-1444) 2.5 was used as the cutoff in both
sexes.
Others I know use > 2 in men and >3.3 in
women.Official guidance in the UK makes little or no
mention of the screening test.
Who is right? There are huge implications for the
numbers of timed urine collections we might have to do
dependent on the screening cutoffs used.
Dr Lance N Sandle BSc MBChB FRCPath
Consultant Chemical Pathologist/Associate Medical
Director
Trafford General Hospital
Moorside Road
Davyhulme
Manchester M41 5SL
(T) 0161 746 2473
(F) 0161 746 8545
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