Recent years have seen a radical shift in the focus of renal medicine. Rather than aiming to avoid complications from hemodialysis and kidney transplantation, nephrologists have turned to secondary prevention...

Detection while there is time to act

Recent years have seen a radical shift in the focus of renal medicine. Rather than aiming to avoid complications from hemodialysis and kidney transplantation, nephrologists have turned to secondary prevention – keeping kidney disease from progressing to its end stage.

Secondary prevention, however, is only a step in the right direction. The true goal must be to prevent kidney disease before it starts, long before a nephrologistis is involved. Microalbuminuria screening is a critical step toward primary prevention, which allows damage to be discovered while therapy is still effective.

A vital risk marker

Microalbuminuria, a condition in which low but abnormal amounts of albumin are present in the urine, is well recognized today as an early risk marker for chronic kidney disease (CKD). In particular, numerous studies have shown that an elevated level of urine albumin in people with diabetes corresponds to a dramatically increased risk of diabetic nephropathy.

Less widely known is the fact that microalbuminuria can indicate more tan renal dysfunction. Microalbuminuria can also be a sign of more generalized vascular damage among people with diabetes, people with hypertension and the general population. This makes microalbuminuria a powerful risk marker not only for CKD, but also for cardiovascular disease (CVD) and stoke.

Screening for microalbuminuria thus creates opportunities for early risk detection and subsequent treatment that can slow or prevent the onset of CKD and CVD. Several treatment strategies may lower the urinary excretion of albumin, including antihypertensive therapies that intervene in the rennin-angiotensin-aldosteron-system. Such reduction in albuminuria, as well as the achieved level of urinary albumin, predicts the degree of protection of both vital organs.

A global burden

The potential importance of using microalbuminuria as a renal and cardiovascular risk marker is emphasized by the prevalence of diabetes. Today diabetes has reached pandemic proportions, and younger individuals are now being diagnosed with the disease. This means that greater numbers are surviving to develop major complications, which include both CKD and CVD.

As CKD becomes more common, the incidence of end-stage renal disease (ESRD) is also increasing. The number of people worldwide undergoing renal replacement therapy has already reached 1.1 million and is expected t double within ten years. This entails not only human suffering, but also a tremendous strain on health care budgets. Developed countries spend 7-12% of their health care budgets on ESRD patients, and the cost is growing by 10% annually.

When the high rate of CVD among CKD patients is also taken into account, the picture becomes even more disturbing. The costs of treating renal failure, heart failure and diabetes combined currently represent 80% of world health care budgets.

A call to action

Because microalbuminuria is such a clear risk marker for CKD and CVD, the potential benefits of screening for it are enormous. If people with diabetes, prople with hypertension and eventually the general population were proactively screened, human suffering and health care spending could be greatly reduced. Today, however, only a relatively small proportion of people known to have type 2 diabetes or hypertension are regularly tested for the presence of microalbuminuria.

Immediate worldwide action is therefore needed. The International Society of Nephrology (ISN), in an effort to promote the early detection and prevention of kidney disease, has asked national health bodies to consider the urgent implementation of microalbuminuria screening. The organization has issued a formal call to action, whose content is reflected in the following statement.

We know now that simple testing for albuminuria is extremely efficient as an early indicator of renal malfunction. It is essential that systematic screening programs for high-risk patients are begun immediately – and it will be advisable to extend this to the public at large as a second step.

The role of Irish Centre of Integrated Medicine

Screening for microalbuminuria is not a question for nephrologists, but rather for those in primary care like the Irish Centre of Integrated Medicine. By the time a nephrologists enters the picture, extensive renal damage may have occurred and treatment options may be limited.

General practitioner, physician or medical professional have an advantage over nephrologists, because they make regular contact with potential CKD and CVD risk patients at an early stage. This means they can identify microalbuminuria at its outset while its progression can still be stopped. If microalbuminuria is detected, their close interaction with patients provides an opportunity to influence diet and behaviour and to initiate proactive treatment.

Today, the ISN and Irish Centre of Integrated Medicine are calling to action urging systematic and thorough screening for microalbuminuria in people with type 2 diabetes or hypertension, as well certain other risk groups. Eventually, however, we would like to see standard screening of all patients visiting primary care physicians. Since microalbuminuria indicates potential CVD as well as renal damage, it has a rightful place alongside the more common tests of blood pressure and cholesterol.

Microalbumin Urine Analysis

A microalbumin urine analysis evaluates urine for the presence of a protein called albumin. Albumin is normally found in the blood and filtered by the kidneys. When the kidneys are working properly, albumin is not present in the urine. However when the kidneys are damaged small amounts of albumin leak into the urine.

A microalbumin urine analysis is done to detect protein (albumin) in the urine. Early detection may change treatment in an effort to preserve as much kidney function as possible.

There is normally no discomfort involved with collecting a urine sample and there are no risks associated with collecting a urine sample.

What can effect on the test

• High blood sugar levels, urinary tract infections, high blood pressure, heart failure, or a high fever during an infection

• Menstrual bleeding and vaginal discharge, which may dilute the urine.

You may need more than one test to find out how well your kidneys or your heart are working. If a microalbumin urine analysis shows an abnormal result then further testing may be recommended which will allow the health professional to identify the main cause or contributing factors.