1. I work in UK in community as a District Nurse. I am researching into microalbuminuria as a first sign of diabetic nephropathy in diabetic patients. Already I have come up with a lot of data in my literature search. I would like to know how often you screen your patients, and if you have an age cut-off?

    Here in Uk cut-off is 70, on the premise that it takes 20 years to contract.......

    Thanks for your comments..........
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    About Larry

    Joined: Nov '01; Posts: 98; Likes: 1
    District Nurse running caseload and team of nurses serving the community in Inner London.


  3. by   MollyJ
    I don't have any experience with screening for diabetic nephropathy in high risk patients BUT i used to work in public health where we "dipped" urines for patients with a screening methodology. We got ALOT of low level 1+ results on spot checks and they were frustrating. Some of our family planning clients would consistently show 1+ albumins. To refer this healthy population was usually expensive with a low yield of true disease (that is, the test had a high false positive rate).

    additionally, I did a brief clinical in a diabetic teaching clinic and I was astounded at how many clients of very young age were routinely dx'd with nephropathy.

    In short, I worry about the sensitivity and specificity of your tool (single specimen urine albumin dip test) and your target testing group.

    I went to www.dogpile.com and put in "Clinical Practice Guidelines" and got a lot of hits. Here is just one:


    You might see what is in this. Is nephropathy being looked at at least annually. It doesn't seem too much to ask that a diabetic in routine medical care would get a metabolic profile annually, which might include some BUN, CR info that might be helpful here.

    I'm sure there are nurses with much greater diabetes specific knowledge that could chime in here too.
  4. by   MollyJ
  5. by   WashYaHands
    Nephropathy first manifests as microalbuminuria (>30 mg/day urinary albumin excretion). This progresses over 10-15 years to overt nephropathy or clinical albuminuria with hypertension also developing. Once overt nephropathy develops, 50% of patients with Type 1 diabetes will have End stage renal disease within 10 years and 75% by 20 years. The American Diabetes Assn recommends annual urinalysis and screening. In the U.S. we do not have an age cut off for screening. Also, the Diabetes Control and Complications Trial (DCCT) conclusively demonstrated that intensive blood glucose control will reduce the risk of developing nephropathy. Hypertension will markedly accelerate the progression of diabetic nephropathy, so goal BP should be <130/85. It is also recommended that ACE inhibitors be given to patients with Type 1 diabetes and microalbuminuria even if they are normotensive. Do a search for the American Diabetes Association, the site offers clinical practice recommendations. Hope this helps.

  6. by   Larry
    I finished my essay and its now in for marking.

    When I get it back I'll publish paper here.


    Mainous & Gill (2001) found that in the USA the majority of patients in a large private health plan with diabetes mellitus, did not receive annual screening for microalbuminuria. The American Diabetics Association (ADA) and the National Committee for Quality Assurance (NCQA) (2001) recommend that patients with Type I and Type II diabetes be screened annually for kidney disease by testing for microalbuminuria.

    Mainous AG 3rd, Gill JM (2001) The lack of screening for diabetic nepropathy: evidence from a privately insured population. Family Medicine 33(2): 115-9.

    Obviously in the USA there are health inequalities.
  7. by   WashYaHands
    Obviously in the USA there are health inequalities

    Yes there are! We call them Health Maintenance Organizations (HMO's).
  8. by   Larry
    HMOs ??? So the failure of HMOs to provide needed preventative health care will ultimately put a strain on the US economy.
  9. by   MollyJ
    Larry, the humor in all of this is that HMO stands FOR "Health Maintenance Organization". The original notion of HMO's is that you would teach clients to be better self care agents and then they wouldn't get sick as much. (Yeah, right. Pass me a donut.)

    American health care has tried many shenanigans to maintain the American Style, technology heavy, you can get anything you want even if you don't really need it, we gotta pill for anything, you CAN have your cake and eat it too STYLE of health care. The nurses who post here are working in a crumbling house of cards.

    My old ethics teacher said that we can PRODUCE more health care than we can AFFORD. Americans are in heavy denial about this fact because they want it all.

    HMO's did not single handedly cause the downfall of American health care. Rather, I think, it took a concerted effort by patients, doctors, the health care providers and insurors. Health care started to inexorably change when fee for service care AND health insurance began (the 50's). The current day happenings are rather an event in a long continuum.

    In america, we have children who are maintained at home on ventilators at the cost of hundreds dollars a day without any hope of normalcy or productivity AND we have normal healthy children who cannot get routine dental care. We have senior citizens who have been demented for years getting state of the art intensive care for their inevitably failing body systems AND heads of families who cannot get mammograms for early detection of their curable cancer. EIGHTY PERCENT of the uninsured are employed. I could go one about the contradictions in our system.

    We have a system that inherently favors technology OVER prevention and tertiary care OVER public health. Health care policy is fascinating to study and I claim no expertise. But the contradictions are mind boggling.
  10. by   WashYaHands
    Excellent post, Molly. Thanks!

  11. by   Audreyfay
    As an RN of 26 years and a diabetes educator for 7+ years, I can tell you how often the recommended yearly microalbumin is done on people with diabetes. I just don't understand it. Even when it is reinforced with MDs, it still isn't done. I've worked in many different states, and it's all the same. Usually <30% get the microalbumin. Even my parents, who both have diabetes, had never had an A1c or a microalbumin done until I started asking questions...have you ever had? Another pet peeve, people who aren't started on insulin when it's obvious they should be. By the time the insulin is started, the damage has gone too far.
    You hit a nerve. A microalbumin should be done yearly, with an A1c being done every 3 months in type 1, every 6 months in type 2. Lipids should be done yearly. These are ADA recommendations, and the recommendations of the endocrinologists association (ACEA?)
    Thanks for bringing up this very important topic in the area of diabetes management.
  12. by   Youda
    As a nurse and a type I diabetic, I have read this thread with a great deal of interest. From a personal standpoint, living in a rural community (read 10 years behind the times of urban areas), my doctor does the A1C q 3 months, and the ACE inhibitors as preventative care. He also does lipid profiles q 6 months (a little more often than recommended). His treatment of me seems to be always geared toward tightening control without hypoglycemia, and the recommendations of the ADA for prevention.

    BUT, in the last 20 years as I think back on my diabetic care, I have had a microalbumin recommended and done by a doctor only once, and that was part of a complete physical, not as a diabetic screening. During that time I have lived in 4 different states, with different doctors, of course.

    As for insulin resistance (by doctors and patients, not the physiological kind), most would rather run a little high and take a pill than get under better control with insulin. My doc hesitantly says, 'we could do X, Y,Z, but you'd have to have another shot a day . . .' and then looks forlorn because he already thinks I wouldn't do it. Of course, he is pleasantly surprized when I readily agree and start implementing his suggestions. But, I'm not the average diabetic patient, either.

    Just one patient's experience in the US.
  13. by   Larry
    Youda - if you on an ACE inhibitor - it is quite likely that you already have microaluminurea in your urine. I am not in a position where I can give you an exact diagnosis of your condition. I would need to assess you holistically taking into account other factors. This website may help your quest for more information http://www.diabetesonestop.com/Diabe...nal/front_door

    Good Luck
  14. by   Youda
    Larry, you are probably right about the microaluminurea. That wouldn't surprise me a bit, considering how long I've been diabetic. But, as I near the big FIVE-0, I have no LE circulatory impairments, no neuropathy, no retinopathy, my B/P is well below recommended limits, lipid profiles are below recommended limits, A1C's occasionally get out of "normal" ranges, but . . . I am either extremely lucky, or I've done a pretty good job.

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