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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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