1
‫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
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.
Diabetic nephropathy
• is a common problem that is most likely to occur in patients
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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
CLINICAL FEATURES
• Diabetic kidney disease is defined by characteristic
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structural and functional changes. The predominant
structural changes include:
Mesangial expansion
Glomerular basement membrane thickening
Podocyte injury
Glomerular sclerosis
Clinical Features of Diabetic kidney disease
Mesangial expansion
Glomerular basement membrane thickening
Podocyte injury
Glomerular sclerosis
The major clinical manifestations of
diabetic nephropathy are
• Albuminuria
• Hematuria (less often),
• progressive chronic kidney disease, which can be slowed
with optimal therapy.
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 falsenegative and false positive determinations as a result of
variation in urine concentration due to hydration.
Persistent Albuminuria
• because of biological variability in urinary albumin excretion,
two of three specimens of UACR collected within a 3- to 6month period should be abnormal before considering a patient
to have albuminuria
Additional causes of kidney disease
• An active urinary sediment (containing red or white blood
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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.
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 20-200 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).
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
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.
Red blood cell casts have also been
described in patients with diabetic
nephropathy
The urine dipstick is a relatively insensitive marker
for albuminuria, not becoming positive until
albumin excretion exceeds 300 to 500 mg/da
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.
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
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)
Recommendations
Measurement of the urine albumin-tocreatinine ratio
• in an untimed urinary sample is the preferred screening
strategy for moderately increased albuminuria .
‫• خانم ‪ 60‬ساله ای با دیابت تیپ ‪( 2‬از ‪ 7‬سال پیش) و هیپرکلسترولمیا جهت پیگیری و معاینات‬
‫دوره ای مراجعه نموده است‪.‬داروهای مصرفی وی شامل متفورمین ‪ 500‬میلیگرم و گلیکالزید‬
‫‪ 80‬میلیگرم دو بار در روز میباشد‪ .‬در معاینه اگاه به زمان و مکان واشخاص میباشد‪ .‬قد ‪165‬‬
‫سانتی متر‪ ،‬وزن ‪ 82/6‬کیلوگرم‪ ،‬فشار خون ‪ mmhg 130/80‬و ضربان ‪ 76‬ضربه در دقیقه‬
‫دارد‪ .‬روی شکم استریا ندارد و تیروئید نرمال است بدون ندوالریتی 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؟‬
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‫‪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 .‬مثال واحد البومین را به‬
‫لیتر تبدیل کنید‪ ،‬که میشود‪mg/L 19 :‬‬
‫سپس واحد البومین به میلیگرم و واحد کراتینین را به گرم تبدیل کنید که واحد کراتینین‬
‫میشود‪g/L0/38 :‬‬
‫اینک نسبت را محاسبه کنید‪:‬‬
‫‪ 19‬تقسیم بر ‪ 0/38‬برابر ‪ mg/g 50‬میزان میکرو البومین اوری بیمار محاسبه میشود‪.‬‬
‫• ولیکن با توجه به اینکه در حال حاضر قند خون بیمار کنترل نیست و ‪HbA1c‬‬
‫باالتر از ‪ %8‬دارد انجام تست مجدد را تا بعد از کنترل مناسب قند خون‪ ،‬موکول‬
‫میکنید‪.‬‬
‫• در صورتیکه مجددا باال بود طی ‪ 3‬تا ‪ 6‬ماه بعد مجددا چک شود‪.‬‬