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Long Post ....Re: [IP] 24-hr urine test/kids
I'm cutting & pasting an "Ask the Diabetes Team" question from the
ChildrenwithDiabetes website. I objected to the initial response & was
gratified to see the additional, detailed comments from Stephanie Schwartz-
so be sure to read the whole page.
My concerns stemmed from Melissa's saga, <A
HREF="http://virtualnurse.com/diabetes/renee.html">An ounce of kidney
prevention...</A> in which she was "shedding" huge amounts of protein in her
urine, an anomaly that wouldn't have been problematic probably UNTIL her
diabetes began exacerbating this predisposition. Fortunately, ACE inhibitors
have been shown to be highly effective in retarding the inexorable loss of
kidney function that would have otherwise ensued. She's been taking Vasotec
(10 mgs) for 3 years now & it helped reduced the amount of protein by 80%.
2 clarifications to earlier posts on this topic:
a) on the 24 hour collection, the first a.m. urination is in the
toilet...then everything thereafter is collected, stored in a container in
the refrigerator & concludes with the first a.m. urine the following morning
b) my daughter's highly aberrant scenario showed NORMAL readings on a
first morning check - hence my personal belief in the annual 24 hour
screening to be thorough
c) don't be surprised if your doctor balks at your request to do this
test...this whole notion of kidney problems being detectable LONg before they
ever become symptomatic & of being able to intervene prophyllactically is a
relatively new concept & not all doctors react well to "input" from their
empowered patients/parents! LOL...
Regards, Renee ( scroll down for the rest of this long post)
>From Baltimore, Maryland, USA:
My 11 year old daughter was diagnosed with Type 1 diabetes 2 1/2 years ago.
Recently, there has been protein in her urine. After a 24 hour urine
titration (with no exercise), her diabetes team feels she has something
called "orthostatic protein". Should I be overly concerned about this? What
exactly does this mean? She is in good control, but incredibly active.
Orthostatic proteinuria - protein leaking into the urine when a person is
upright - is relatively common. Provided your daughter has no proteinuria
when she is supine (lying down), then this is probably of no significance. It
is really too early anyway for her to have diabetes-related proteinuria
unless her diabetic control were very poor.
[Editor's comment: This question, about orthostatic urine protein, caused
some concern amongst some of our readers. Protein in the urine is rarely
normal; Dr. Robertson discusses one of the few circumstances where it is
Diabetic kidney changes can sometimes be detected even earlier by measuring a
special version of urine protein, called microalbumin (or when measured in
the urine, microalbuminuria). I have asked Steph Schwartz to discuss some of
the issues about measuring microalbumin in kids with diabetes (see below).
Additional Comments from Stephanie Schwartz, diabetes nurse specialist:
In the ISPAD standards of care for children and adolescents with diabetes,
the screening process for kidney complications is clearly delineated. I
believe that these standards are practiced by the majority of pediatric
endocrinologists caring for multitudes of children with diabetes. Indeed,
Luther Travis, MD, CDE (who happens to be a nephrologist) has a detailed
protocol for screening including not only microalbumin testing but assessing
trends in blood pressure measurements according to norms as well.
In our program we do the following: all kids older than 12 and those under 12
who have had diabetes for more than 5 years have 24 urine collections done
for microalbumin annually. Children under 12 who have had diabetes less than
5 years are screened every 3 years in the same manner. All newly diagnosed
kids have 24 urine collections for microalbumin done about 2 months after
diagnosis (i.e., after blood glucose levels are fairly stable). If the result
is greater than 30mcg/minute, a repeat split sample (day vs. night) is done.
This is because growing children, especially those who are very athletic, can
spill microalbumin during daytime hours but will not at night. If this is
greater than 30mcg/minute, the child is started on ACE inhibitors.
A recent article in Practical Diabetology suggested than initial screens for
microalbumin can be performed on a first morning void using a dipstick
method. This is a much easier sample to obtain. Accurate 24 hour collections
are extremely difficult to do as anyone who has done them will attest. A 24
hour collection should then be done if this is positive. The authors go on to
say that treatment should be initiated if the result is greater than
Dr. Travis has suggested that ACE inhibitors should be used if BP
measurements deviate one channel from the child's norm even in the absence of
Two additional thoughts --- since microalbuminuria/proteinuria can be
exercised induced, collections should not be done on days when a child will
be engaged in such activities. Additionally, since vaginal discharges can
produce erroneous results, I suggest that collections are not obtained if
there is a vaginal discharge and in menstruating girls, 24 hour urine
collections should always be done in mid-cycle.
Hope this information is helpful.
Original posting 29 Oct 1998
Additional comments added 7 Nov 1998
Posted to Complications
The opinions expressed are for general information only and should not be
construed as medical advice or diagnosis, nor as advice about treatment of
any specific medical condition. This information is not intended to replace
the care of your own Diabetes Team. Before you make any changes in the
management of your diabetes or your child's diabetes, you should consult your
physician or other qualified medical professionals. For more information, see
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