MRCGP Exam Update - Microalbuminuria

CURRENT SITUATION

- Microalbuminuria is the presence of 20-200mu g/min levels of albumin in the urine.

- It represents the first sign of diabetic nephropathy.

- It is an important indicator of increased cardiovascular risk and is associated with increased mortality.

- Half of patients with diabetes develop microalbuminuria.

WHAT IS THE EVIDENCE?

- A recent longitudinal study has shown that macro- and microalbuminuria are associated with an increased risk of cardiovascular and all-cause mortality, with a greater effect conferred by the presence of greater proteinuria (Br J Diabetes Vasc Dis 2005; 5: 334-40).

- A number of trials have shown that the progress of existing microalbuminuria and proteinuria can be slowed by the use of both ACE inhibitors and angiotensin-II receptor blockers (ARBs).

- A high dose of the ACE inhibitor ramipril improves the cardiovascular prognosis of patients with type-2 diabetes (BMJ 2002; 324: 699)

- However, ramipril at low dose has been found not to prevent cardiovascular events in people with type-2 diabetes and albuminuria (both microalbuminuria and proteinuria), although it slightly reduced their albuminuria and BP (BMJ 2004; 328: 495)

- The ACE inhibitor trandolapril (with or without verapamil) significantly slowed the progression to microalbuminuria by 53 per cent compared to placebo (N Eng J Med 2004; 351: 1,941).

- Patients with type-2 diabetes commonly experience regression or remission of microalbuminuria, especially when blood glucose is carefully controlled, according to one report (Diabetes 2005; 54: 2983).

- The early use of irbesartan in hypertensive type-2 diabetic patients with microalbuminuria has been shown to improve life expectancy and also reduce costs (Diabetes Care 2004; 27: 1,897).

IMPLICATION FOR PRACTICE

- The prescribing of ACE inhibitors or ARBs for diabetic patients with microalbuminuria is a GMS quality target.

FURTHER READING

- British Hypertension Society and NICE guidelines state that an ACE inhibitor or angiotensin II receptor antagonist should be used as first-line treatment in patients with diabetes and microalbuminuria or proteinuria.

- However, the Drug and Therapeutics Bulletin challenges the use of ACE inhibitors as it states that for patients with microalbuminuria there is insufficient evidence (June 2005).

Useful websites

www.nice.org.uk - NICE

www.bhsoc.org - British Hypertension Society

- Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practice', Pas Test 2004

KEY POINTS

- Around 50 per cent of diabetic patients develop microalbuminuria.

- Microalbuminuria is associated with increased mortality.

- ACE inhibitors and ARBs slow the progress of microalbuminuria and proteinuria.

- ACE inhibitors should be used in patients with microalbuminuria as first-line therapy.

JARGON BUSTER - CONNECTING FOR HEALTH

WHAT IS IT?

Set up on 1 April 2005, Connecting for Health is the DoH agency delivering England's multi-billion pound National Programme for IT. Connecting for Health aims to integrate IT systems, connect 30,000 GPs in England to 300 hospitals, and give patients access to their personal health information.

WHAT DOES THIS INVOLVE?

It involves a wider range of projects, including high-profile initiatives such as the National Electronic Library for Health, Choose and Book, the Electronic Prescription Service and the NHS Care Records Service.

HOW IS IT PROGRESSING?

The DoH website says141,006 Choose and Book appointments have been made.

However, the programme has faced criticism over rocketing costs (from £2.3 billion to £6.2 billion, with some estimates putting the likely total at £30 billion); failure to engage clinicians and an unrealistic time scale.

Visit www.connectingforhealth.nhs.uk for more information.

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