Referat
Screening of renal disease in diabetics with special reference to microalbumia
By C.E. Mogensen, Århus, Denmark.
From International Journal of Metabolism Dec 1, 1999.Screening for diabetic renal disease, including microalbuminuria, is now standard in the management of patients with both type 1 and 2 diabetes (2) with the purpose of early diagnosis and treatment.
Diabetic patients usually go through well-defined stages of renal disease, starting initially with normoalbuminuria follwed in a large proportion about 30% by microalbuminuria (2,3). Structural damage and BP increase, and later patients may develop overt renal disease. Microalbuminuria is usually defined (3) as an albumin excretion rate between 20 and 200 mcrogram per minute. Lower values are termed normoalbuminuria; higher values macroalbuminuria.Importance
It is clear that diabetic renal disease is an extremely important health problem and treatment programs should aim at preventing further progression.We have developed well-accepted treatment modalities. It is clear that patients at all stages of diabetic renal disease should be optimally treated with respect to glycemic control.
However, a relatively new strategy is that patients with microalbuminuria and albuminuria should be treated with antihypertensive agents, especially ACE inhibitors in moderate to high doses, often combined with diuretics,even so-called normotension, in order to reduce transglomerular pressure.
At present, about 10 longterm studies more than 2 years have been carried out and practically all document a reduction in microalbuninruia by this treatment, even if blood pressure is normal or within the normal range. However,there is usually a reduction in blood pressure of 3 to 6 mm Hg, in contrast to a similar increase seen without treatment over a few years. Even a slight BP increase is, however, a risk factor.
Importantly, a new study now shows that the fall in glomerular filtration rate (GFR) can be preserved by this intervention. This means that the fall in GFR usually seen with the progression to overt diabetic nehropathy may be prevented over many years (4).
Even more exciting, new studies show that the structural damage in microalbumiuric patients can be arrested by antihypertensive treatment, both ACE inhibitors and betablockers (5). These findings strengthen the argument for early antihypertensive renal protective treatment in these patients. Of course, blood pressure reduction, even slight, is important, and a combination of various agents may be used.In summary
Screening for microalbuminuria is easy and cheap and the problem can be detected at a very early stage of disease. Testing is certainly acceptable for patients, and the natural history of disease is well defined. Progression is seen without treatment. There is an agreed policy of screening and treatment, and findings should be continuous over the years in a dianetic clinic or with GP.
Thus, we can conclude that all the criteria for screening for diseases developed by the WHO are in these cases fulfilled, and it should be implemented in all patients.References
1. Mogensen CE.Diabetologia 1999;42;263-285
2. Mogensen CE,et al Diabetes 1983;32:suppl 2;64-78
3. Mogensen CE et al Uremia Invest 1985;86;85-95
4. Mathiesen ER et al BMJ 1999;315:24-25 www.bmj.com
5. Rudberg et al Diabetologia 1999;42:589-595Red
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