2. Overall aim
To evaluate the current clinical practice of
management albuminuria in diabetic in the
health center.
3. Objectives
To review current management of albuminuria in
diabetic.
To evaluate record keeping of plan of management.
To encourage clinician to focus on latest guideline in
proteinuria management.
To improve family medicine resident knowledge and
skills on conducting successful clinical audit activity
4. Background
• Albuminuria is a well-known predictor of poor renal outcomes in
patients with type 2 diabetes and in essential hypertension.
• Recently.. Albuminuria has also been shown to be a predictor of
cardiovascular outcomes in these populations.
• There is emerging data that reduction of albuminuria leads to
reduced risk of adverse renal and cardiovascular events.
• It has become increasingly clear that albuminuria should not only
be measured in all patients with type 2 diabetes and
hypertension, but also steps should be taken to suppress
albuminuria to prevent future renal and cardiovascular adverse
events.
5. Screening
By albumin to creatinine ratio (ACR).
Indicated in the following:
• At diagnosis in all type 2 diabetes.
• After 3-5 years of diagnosis in type 1
diabetes.
• In subjects with established retinopathy.
6. How to perform the test
• Ask the pt to collect early morning mid-
stream urine sample at home and bring it to
the clinic or this sample could be collected in
the clinic.
• Send the sample to the laboratory.
• Avoid doing this test in pts with UTI or in
female patients during menstruation.
7. Interpretation
Category Random spot collection
Male Female
Normal < 2.5 < 3.5
Micro- albuminuria ≥ 2.5 and < 30 ≥ 3.5 and < 30
Clinical albuminuria (nephropathy) ≥ 30 ≥ 30
Microalbuminuria is also defined as the excretion of between 30-300 mg of albumin in
urine over 24 hrs. Albumin excreted > 300mg per day is called macro albuminuria or
clinical albuminuria.
8. Diagnostic steps in diabetic nephropathy
Early morning spot urine test if
indicated
Exclude the following:
-UTI
-Uncontrolled DM
-exercise within the past 24 hrs.
-infection
-fever
-CHF
Negative
Repeat
annually
increased
Repeat the test on 3-6
months
If 2 test are
Overt
proteinuria
Start Medical therapy
Monitor:
- eGFR within 2-4 wks.
-ACR every 6 months
Maximize medical
therapy as tolerated
+-
9. Management
• Diabetic nephropathy can be prevented by:
Strict glycemic control.
Treatment of HTN to target.
Avoidance of nephrotoxic drugs.
(aminoglycoside, NSAID, contrast media)
Smoking cessation, early & effective
treatment of infection.
10. Therapeutic goals
• Optimise glucose control >> treat to target.
• Optimise blood pressure control >> treat to target.
• Continue monitoring ACR twice/year using eGFR to assess both
response to therapy and disease progression.
• Reduction of protein intake may improve measure of renal
function, refer to dietician for proper counseling.
• People with diabetes and albuminuria should be treated with ACE
inhibitors or ARBs.
• When ACE inhibitors, ARBs or diuretics are used, monitor serum
creatinine & electrolyte within 2-4 wks.
11. Indication for the referral to
nephrologist
• Uncertainty about etiology of the kidney disease.
• Pts with pre-existing renal disease.
• Pts with worsening proteinuria/ albuminuria in spite of medical
therapy.
• Worsening renal function.
• Side effects of ACE inhibitors or ARBs such as persistent
hyperkalemia.
• Pts with small kidney size on renal ultrasound.
12.
13. Methodology:
• Auditing was included all abnormal , not done ACR in
2017.
• Target population: all the diabetic patients with abnormal
ACR or did not done in 2017 in North Alkhwair health
center.
• Total number of diabetic pts with not done or abnormal
ACR in 2017 was 133 pts.
• The collected data was entered and analyzed via SPSS
program version20.
14.
15.
16. Factor affecting the result
• Documentation of some of the information
were missing.
• Lab not inform that the urine is for ACR not
only GKP.
• Lack of Knowledge about guideline.
17. Recommendation
Insure proper documentation of plan of
management.
Inform lab when ACR request.
Encourage Health care providers to be updated
about guidelines of proteinuria in diabetic.
Updated about dose, titration & follow up when
start on ACE/ARB medication.
A remainder paper for the algorithm.
Compare the result of this audit with next audit
that we recommend to be done annually.
