1. بسم الله الرحمن الرحيم

2. تفسیر میکروآلبومین / کراتینین در بیماران دیابتی ( معرفی CASE)
کنگره غدد و متابولیسم
دانشگاه علوم پزشکی اصفهان یکم اردیبهشت 1396
سخنران:
دکتر مژگان کریمی فر فوق تخصص غدد و متابولیسم
استادیار دانشگاه علوم پزشکی اصفهان

3. INTRODUCTION Diabetic nephropathy occurs in: type 1
type 2 diabetes mellitus, and
in other secondary forms of diabetes mellitus, in which duration of diabetes is long-enough and level of glycemia high enough to result in complications.

4. Diabetic nephropathy
is a common problem that is most likely to occur in patients who have:
Worse glycemic control
Hypertension
Glomerular hyperfiltration or
A genetic predisposition
The lifetime risk of nephropathy is roughly equivalent in type 1 and type 2 diabetes

6. CLINICAL FEATURES 
Diabetic kidney disease is defined by characteristic structural and functional changes. The predominant structural changes include:
Mesangial expansion
Glomerular basement membrane thickening
Podocyte injury
Glomerular sclerosis

7. Clinical Features of Diabetic kidney disease
Mesangial expansion
Glomerular basement membrane thickening
Podocyte injury
Glomerular sclerosis

8. The major clinical manifestations of diabetic nephropathy are
Albuminuria
Hematuria (less often),
progressive chronic kidney disease, which can be slowed with optimal therapy.

9. Measurement of albumin alone
Measurement of a spot urine sample for albumin alone (whether by immunoassay or by using a sensitive dipstick test specific for albuminuria) without simultaneously measuring urine creatinine (Cr) is less expensive but susceptible to false-negative and false positive determinations as a result of variation in urine concentration due to hydration.
ADA2017

11. Persistent Albuminuria
because of biological variability in urinary albumin excretion, two of three specimens of UACR collected within a 3- to 6-month period should be abnormal before considering a patient to have albuminuria

12. Additional causes of kidney disease
An active urinary sediment (containing red or white blood cells or cellular casts)
Rapidly increasing albuminuria or
Nephrotic syndrome
Rapidly decreasing eGFR, or
The absence of retinopathy (in type 1 diabetes) may suggest alternative or additional causes of kidney disease.

13. Albuminuria 
moderately increased albuminuria, formerly called "microalbuminuria" (defined as urinary albumin excretion between 30 and 300 mg/day or between 30 and 300 mg/g creatinine on a random urine sample) or albumin excretion rate mcg/min
and severely increased albuminuria, formerly called "macroalbuminuria" (defined as urinary albumin excretion above 300 mg/day or above 300 mg/g creatinine on a random urine sample).

14. Degree of albuminuria
For reasons that are not understood, the degree of albuminuria is not necessarily linked to disease progression in patients with diabetic nephropathy associated with either type 1 or type 2 diabetes

16. Hematuria 
— The urine sediment in diabetic nephropathy is usually bland
but microscopic hematuria can occur
as it can in any form of glomerular disease, including disorders such as membranous nephropathy that are not associated with glomerulonephritis. This is an important issue in diabetic nephropathy since nondiabetic renal disease, either alone or with diabetic nephropathy, is occasionally seen in patients with diabetes.

17. Red blood cell casts have also been described in patients with diabetic nephropathy

19. The urine dipstick is a relatively insensitive marker for albuminuria, not becoming positive until albumin excretion exceeds 300 to 500 mg/da

20. DETECTION OF ALBUMINURIA
Establishing the diagnosis of moderately increased albuminuria (formerly called "microalbuminuria") requires the demonstration of:
an elevation in albumin excretion (30 to 300 mg/day) that persists over a three- to six-month period.

21. Approach to detection of the urine albumin-to-creatinine ratio
Measurement of the urine alb/cr ratio in an untimed urinary sample is the preferred screening strategy for moderately increased albuminuria in all diabetic patients

22. Transient elevations in the excretion of albumin
Fever
Infection
Exercise
Heart failure
Nonspecific joint inflammation
Poor glycemic control (hemoglobin A1c greater than 8 percent)
Elevation in blood pressure (greater than 160/100 mmHg)
Hyperlipidemia (LDL cholesterol greater than 120 mg/dL)
Vigorous exercise can cause a transient increase in albumin excretion . As a result, patients should refrain from vigorous exercise in the 24 hours prior to the test.

23. Recommendations Measurement of the urine albumin-to-creatinine ratio
in an untimed urinary sample is the preferred screening strategy for moderately increased albuminuria .

24. خانم 60 ساله ای با دیابت تیپ 2 (از 7 سال پیش) و هیپرکلسترولمیا جهت پیگیری و معاینات دوره ای مراجعه نموده است.داروهای مصرفی وی شامل متفورمین 500 میلیگرم و گلیکلازید 80 میلیگرم دو بار در روز میباشد. در معاینه اگاه به زمان و مکان واشخاص میباشد. قد 165 سانتی متر، وزن 82/6 کیلوگرم، فشار خون 130/80 mmhg و ضربان 76 ضربه در دقیقه دارد. روی شکم استریا ندارد و تیروئید نرمال است بدون ندولاریتی و زخم پا ندارد و نبضها به خوبی لمس میشوند. سایر معاینات طبیعی است. نتایج آزمایشات وی به شرح زیر است:
FBS = 192 mg/dL
Hemoglobin A1C = 9.5 %
Sodium = 138 mEq/L
Potassium = 4.5 mEq/L
Creatinine = 0.8 mg/dL
Total Cholesterol = 165 mg/dL
Triglyceride = 157 mg/dL
HDL Cholesterol = 38 mg/dL
LDL = 104 mg/ dL
Urine Micro Albumin (Random) = 1.9 mg/dL
Urine Creatinine (Random) = 380 mg/L
تفسیر شما از تست آلبومین اوری بیمار فوق چیست؟

25. Urine Micro Albumin (Random) = 1
Urine Micro Albumin (Random) = 1.9 mg/dL Urine Creatinine (Random) = 380 mg/L
Urine Albumin(mg/L)/ Urine Creatinine(g/L)
ابتدا برای بدست اوردن نسبت باید واحد حجم را یکسان کنید. مثلا واحد البومین را به لیتر تبدیل کنید، که میشود: 19 mg/L
سپس واحد البومین به میلیگرم و واحد کراتینین را به گرم تبدیل کنید که واحد کراتینین میشود: 0/38g/L
اینک نسبت را محاسبه کنید:
19 تقسیم بر 0/38 برابر 50 mg/g میزان میکرو البومین اوری بیمار محاسبه میشود.

26. ولیکن با توجه به اینکه در حال حاضر قند خون بیمار کنترل نیست و HbA1c بالاتر از 8% دارد انجام تست مجدد را تا بعد از کنترل مناسب قند خون، موکول میکنید.
در صورتیکه مجددا بالا بود طی 3 تا 6 ماه بعد مجددا چک شود.