Albuminurea in dm, audit

1. Albuminuria in diabetic pts
Audit

2. Overall aim
To evaluate the current clinical practice of
management albuminuria in diabetic in the
health center.

3. Objectives
 To review current management of albuminuria in
diabetic.
 To evaluate record keeping of plan of management.
 To encourage clinician to focus on latest guideline in
proteinuria management.
 To improve family medicine resident knowledge and
skills on conducting successful clinical audit activity

4. Background
• Albuminuria is a well-known predictor of poor renal outcomes in
patients with type 2 diabetes and in essential hypertension.
• Recently.. Albuminuria has also been shown to be a predictor of
cardiovascular outcomes in these populations.
• There is emerging data that reduction of albuminuria leads to
reduced risk of adverse renal and cardiovascular events.
• It has become increasingly clear that albuminuria should not only
be measured in all patients with type 2 diabetes and
hypertension, but also steps should be taken to suppress
albuminuria to prevent future renal and cardiovascular adverse
events.

5. Screening
By albumin to creatinine ratio (ACR).
Indicated in the following:
• At diagnosis in all type 2 diabetes.
• After 3-5 years of diagnosis in type 1
diabetes.
• In subjects with established retinopathy.

6. How to perform the test
• Ask the pt to collect early morning mid-
stream urine sample at home and bring it to
the clinic or this sample could be collected in
the clinic.
• Send the sample to the laboratory.
• Avoid doing this test in pts with UTI or in
female patients during menstruation.

7. Interpretation
Category Random spot collection
Male Female
Normal < 2.5 < 3.5
Micro- albuminuria ≥ 2.5 and < 30 ≥ 3.5 and < 30
Clinical albuminuria (nephropathy) ≥ 30 ≥ 30
Microalbuminuria is also defined as the excretion of between 30-300 mg of albumin in
urine over 24 hrs. Albumin excreted > 300mg per day is called macro albuminuria or
clinical albuminuria.

8. Diagnostic steps in diabetic nephropathy
Early morning spot urine test if
indicated
Exclude the following:
-UTI
-Uncontrolled DM
-exercise within the past 24 hrs.
-infection
-fever
-CHF
Negative
Repeat
annually
increased
Repeat the test on 3-6
months
If 2 test are
Overt
proteinuria
Start Medical therapy
Monitor:
- eGFR within 2-4 wks.
-ACR every 6 months
Maximize medical
therapy as tolerated
+-

9. Management
• Diabetic nephropathy can be prevented by:
Strict glycemic control.
Treatment of HTN to target.
Avoidance of nephrotoxic drugs.
(aminoglycoside, NSAID, contrast media)
Smoking cessation, early & effective
treatment of infection.

10. Therapeutic goals
• Optimise glucose control >> treat to target.
• Optimise blood pressure control >> treat to target.
• Continue monitoring ACR twice/year using eGFR to assess both
response to therapy and disease progression.
• Reduction of protein intake may improve measure of renal
function, refer to dietician for proper counseling.
• People with diabetes and albuminuria should be treated with ACE
inhibitors or ARBs.
• When ACE inhibitors, ARBs or diuretics are used, monitor serum
creatinine & electrolyte within 2-4 wks.

11. Indication for the referral to
nephrologist
• Uncertainty about etiology of the kidney disease.
• Pts with pre-existing renal disease.
• Pts with worsening proteinuria/ albuminuria in spite of medical
therapy.
• Worsening renal function.
• Side effects of ACE inhibitors or ARBs such as persistent
hyperkalemia.
• Pts with small kidney size on renal ultrasound.

13. Methodology:
• Auditing was included all abnormal , not done ACR in
2017.
• Target population: all the diabetic patients with abnormal
ACR or did not done in 2017 in North Alkhwair health
center.
• Total number of diabetic pts with not done or abnormal
ACR in 2017 was 133 pts.
• The collected data was entered and analyzed via SPSS
program version20.

16. Factor affecting the result
• Documentation of some of the information
were missing.
• Lab not inform that the urine is for ACR not
only GKP.
• Lack of Knowledge about guideline.

17. Recommendation
Insure proper documentation of plan of
management.
Inform lab when ACR request.
Encourage Health care providers to be updated
about guidelines of proteinuria in diabetic.
Updated about dose, titration & follow up when
start on ACE/ARB medication.
A remainder paper for the algorithm.
Compare the result of this audit with next audit
that we recommend to be done annually.