Microalbuminuria Screening in Diabetes



|CG10001-1 | |

|Microalbuminuria Screening in Diabetes |

|For use in (clinical areas): |General Practice and MK General Diabetes Clinic |

|For use by (staff groups): |All clinicians |

|For use for (patients): |All Adult diabetic patients |

|Document owner: |MK Diabetes NSF LIT |

|Status: |Approved |

Purpose of the Guideline

The guideline aims to introduce microalbuminuria screening in a standardized way in Milton Keynes, following the NICE guidelines for type 1 and type 2 diabetes.1,2

Contents

Definitions

Screening Protocol

Algorithm page 5

Treatment

Main body of document

Aims

• To screen adult patients (>17 years old) with both type 1 and type 2 diabetes annually for proteinuria and microalbuminuria.

• To measure serum creatinine annually.

• To treat all patients who are found to have raised levels of albumin in the urine according to NICE guidelines.

Introduction

Microalbuminuria is a low level of albumin in the urine which is above normal levels, but below what is normally detected by standard urine dipstick. Proteinuria relates to a larger level of protein in the urine, and represents the progression of microalbuminuria. Proteinuria is usually detected with a standard dipstick.

Patients with persistent microalbuminuria are at risk of progression to proteinuria, diabetic nephropathy and end stage renal failure. Microalbuminuria also predicts cardiovascular morbidity and mortality in both type 1 and type 2 diabetes.

Microalbuminuria is measured as a urinary albumin/creatinine ratio (ACR), in a first-voided sample in the morning. There is a 40% day to day variability in albumin excretion, so NICE recommends following up positive tests with two further tests, and only if 2 out of 3 are positive labelling the patient as having microalbuminuria.

Definitions

Microalbuminuria

Albumin/creatinine ratio ≥ 2.5mg/mmol for men

≥ 3.5mg/mmol for women

Proteinuria

Albumin concentration ≥ 0.2g/l

Albumin/creatinine ratio ≥ 30mg/mmol

Protocol for microalbuminuria screening (see algorithm)

• It is anticipated that microalbuminuria screening will be performed from general practice, even for those patients who are attending the hospital diabetic clinic.

• All adult patients with diabetes should be offered microalbuminuria screening annually with the following exceptions:

-pregnant women

-type 1 diabetes for less than 5 years duration

-patients with pre-existing proteinuria

-terminally ill or very frail

• First pass morning urine specimens should be collected in plain white bottles, and dipped in the practice with a standard dipstick, before being sent to the laboratory. Mark the request card as “other” and add “microalbuminuria”.

• Serum creatinine should be measured annually.

• Follow the attached algorithm, and use the Read codes as suggested below.

Read codes

These codes are nGMS contract Quality and Outcomes compliant, and the codes used by the local laboratory for pathology links.

4 byte

46TC Albumin creatinine ratio

46N3 Urine total protein (ie urine protein concentration)

C261 DM and persistent proteinuria.

C260 DM and persistent microalbuminuria

5 byte

46TC Albumin creatinine ratio

46N3 Urine total protein (ie urine protein concentration)

C10EK Type 1 DM and persistent proteinuria

C10FL Type 2 DM and persistent proteinuria

C10EL Type 1 DM and persistent microalbuminuria

C10FM Type 2 DM and persistent microalbuminuria

Exemption codes.

Patients coded for proteinuria will automatically be exempted from microalbuminuria screening by the quality and outcomes software.

Any other patients who are exempted from microalbuminuria screening will need to have an exemption code added. The following code is suggested (4 and 5 byte).

9h41 Exception report diab qual ind: pt uns

Treatment of microalbuminuria and proteinuria in type 1 and type 2 diabetes.

For those patients with confirmed abnormal albumin excretion:

• Suspect other renal disease if:

-particularly high blood pressure -systemic ill health

-sudden proteinuria -no progressive retinopathy

-significant haematuria

• Discuss the significance of the findings with the patient.

• Ensure tight blood glucose control. Target HbA1C 150µmol/l.

• Treat as high cardiovascular risk.

• Commence aspirin 75mg daily, once systolic BP ................
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