Diabetes: Measuring albumin, its ratio with creatinine in urine has diagnostic significance

India has emerged as the diabetes capital of the world, with the incidence steadily on the rise over the last three decades. The prevalence of diabetes in India stood at 8.9% in 2019. With more than 77 million people with diabetes, India ranks second in the number of cases worldwide. It is also estimated that approximately 43.9 million people are undiagnosed and account for 57% of adults. Undiagnosed diabetes further exacerbates the risk of diabetes-related complications resulting in increased deaths.

What is albumin and how is it useful in diabetes?

Albumin is a protein produced by the liver and performs critical functions. Albumin enters the bloodstream and helps prevent fluid from leaking out of the blood vessels into other tissues. It also transports vitamins, hormones, and enzymes in the body. It is the single most abundant protein in the plasma. Serum albumin tests are routinely performed to check for renal and liver health. However, albumin is usually absent in the urine or in minimal amounts. Therefore, measuring albumin and its ratio with creatinine in the urine has diagnostic significance and is crucial for people with diabetes as it can help predict the onset of diabetes-related complications like diabetic nephropathy/ischemic nephropathy before the clinical signs and symptoms.

What is Microalbuminuria?

Albuminuria means the presence of small quantities of albumin in the urine. It is strongly associated with incipient kidney disease. Studies suggest that insulin resistance precedes and possibly contributes to the development of Microalbuminuria in diabetic patients. Studies also indicate that Microalbuminuria precedes diabetic nephropathy by at least 10 to 14 years. Therefore, the early diagnosis of Microalbuminuria and early intervention through intense glycaemic control or ACE inhibitors can aid in the reversal of diabetic nephropathy or at least help prevent its progression. Individuals with Microalbuminuria are possibly more insulin resistant than those with normal albumin excretion.

Microalbuminuria is a strong predictor of diabetic nephropathy, arterial hypertension, peripheral neuropathy, and proliferative retinopathy. (Peripheral neuropathy occurs when nerves that carry messages from the brain and spinal cord to different parts of the body are affected, resulting in pain and other symptoms. Proliferative retinopathy occurs when retinal vessels are damaged and may even lead to vision loss.)

Microalbuminuria can also predict the onset of future major adverse cardiac events (MACEs). It can also predict morbidity and mortality in patients with no concomitant renal disease due to diabetes.

Diagnosing Microalbuminuria:

There are multiple ways to screen for Microalbuminuria:

1. Urine dipstick test – Not very reliable for Microalbuminuria

2. Measuring through a 24-hour urine collection (30-300 mg/day is microalbuminuria)

3. Estimating albumin/creatinine ratio on a spot urine sample (30-300 mg/g is Microalbuminuria)
Traditionally, doctors preferred 24-hour urinary albumin excretion measurements, but a spot urine collection is now considered just as valid.

One particular study in India estimated a prevalence of Microalbuminuria at 37% in type 2 diabetic individuals. However, it is important to note that Microalbuminuria may not always be associated with abnormal creatinine clearance or serum creatinine levels; therefore, renal damage may be permanent if important warning signals are not detected in time.

Specific interventions can help manage albuminuria:

• improving insulin sensitivity through weight loss and exercise
• intensified glycaemic control
• maintaining normal blood pressure levels
• ACE inhibitor therapy.

These interventions can prevent organ damage and reverse or slow down diabetic nephropathy.

Indications of this screening test:

1. The microalbuminuria test is recommended at least once a year in Type II diabetes patients.

2. People with one or more risk factors for kidney disease, such as

• Cardiovascular disease
• Hypertension
• A family history of kidney disease
• Obesity
• Chronic Smokers

People with diabetes are at significant risk of various complications, and therefore, lifestyle and diet changes, exercise and regular monitoring of important parameters can help improve quality of life in the long term and protect health. People with diabetes must be well informed, aware of possible complications, and take appropriate steps to stay healthy.

The author is the President & Mentor, SRL Diagnostics. Views expressed are personal. 

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