ࡱ> CEB zbjbj . hhl YYYYYmmm8m+t0+2+2+2+2+2+2+$%-/V+YV+YYk+YY0+0+@)*#CmJ)++0+)u0JRu0(*u0Y*(V+V+X+u0 : COST-EFFECTIVE MICROALBUMINURIA SCREENING IN DIABETES Background Diabetes is now the commonest single cause of end-stage renal disease. Some 20-30% of patients with type 1 and type 2 diabetes will develop diabetic nephropathy (proteinuria). The earliest manifestation of diabetic nephropathy is the appearance of low but abnormal levels of albuminuria ((30<300 mg/24h), known as microalbuminuria It is more convenient to measure the albumin/creatinine ratio (ACR, mg/mmol) in first morning urine than to undertake timed collections (mg/24h). An ACR (3.5 equates to albuminuria (30 mg/24h How and Who to Screen THE PCT EXPECTS PRACTICES WILL EXCLUDE / EXCEPTION REPORT PATIENTS FROM THE DIABETES 13 QOF INDICATOR WHERE THEY MEET THE CRITERIA LISTED BELOW test urine with conventional dipstick first; if proteinuria is 0.3 g/L or greater do not screen for microalbuminuria - send 24h urine for protein instead) do not screen for microalbuminuria if urine infection suspected - leucocytes, nitrites etc. do not screen for microalbuminuria if patient is menstruating do not screen for microalbuminuria if patient already on an ACEi or ARB blocker do not screen for microalbuminuria if patient has renal impairment (serum creatinine >120 (mol/L) screen for microalbuminuria annually; if abnormal repeat a further two times at 3-6 monthly intervals to establish diagnosis (at least 2 of 3 abnormal required) as microalbuminuria has high day-to-day variability Patients with Type 1 Diabetes as above all patients with (5 years diabetes duration Patients with Type 2 Diabetes as above but: do not screen for microalbuminuria at initial diagnosis of diabetes - test urine with conventional dipstick only. Screen for microalbuminuria at 6 months do not screen for microalbuminuria if patient hypertensive (BP (140/90) or is already on antihypertensive therapy Drug Treatment Once microalbuminuria is established, start ACE inhibitor (ACEi) and increase (double dose at weekly intervals) to maximal recommended dose (Ramipril 10mg, Lisinopril 40mg or equivalent). Patients intolerant of ACEi (cough) should receive a maximal dose of an angiotensin receptor blocker (ARB; Candersartan 16mg, Irbesartan 300mg or equivalent). Monitor serum potassium and creatinine concentrations weekly for first month and during dose titration. Targets initial target is a maximal dose of ACEi or ARB aim for BP <130/80 mmHg; ideally <125/75 in type 1 diabetes best choice second drug is a thiazide diuretic at low dose (e.g. Bendroflumethiazide 2.5mg) Sample preparation Microalbumin Collect early morning urine into plastic universal. Perform Dipstick evaluation for protein. 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