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First-Morning Urine Good Predictor of Kidney Complications in Diabetes

Doing a laboratory test—called the albumin-to-creatinine ratio (ACR)—on the first-morning urine sample may be the best predictor of possible kidney complications in patients with type 2 diabetes and associated kidney disease (diabetic nephropathy). This was the finding of a new paper from the landmark “Reduction in Endpoints in Non Insulin Dependent Diabetes Mellitus with the Angiotensin-II Antagonist Losartan” (RENAAL) trial reported in the Journal of the American Society of Nephrology.

Generally, doctors would request for a 24-hour collection of the urine to assess the degree of protein spillage in the urine called proteinuria, which reflects the injury in the kidney tubules. Proteinurua is a bad predictor, and is directly correlated with heart and other blood-vessel complications, and even with earlier death in diabetics. The more severe the proteinuria, the worse is the expected outcome in diabetics.

“From a clinical point of view, these results are very important, because they imply that collection of first morning voids, which is clearly more convenient than collecting a 24-hour urine, can be used for assessment of proteinuria,” explained Hiddo Lambers Heerspink, PharmD, PhD, lead author of the study from the University Medical Center Groningen, in Groningen, the Netherlands.

The researchers used the urine samples of 701 participants with type 2 diabetes and nephropathy enrolled in the RENAAL trial. They compared which test was a better predictor of kidney complications: urinary protein excretion (UPE) and urinary albumin excretion (UAE) from a 24-hour urine collection vs urinary albumin concentration (UAC) and ACR from a first-morning urine sample. As parameters, they used time to a doubling of serum creatinine—a blood test to measure level of kidney function; or development of end-stage kidney disease wherein the patient would already require dialysis.

The authors concluded: “For predicting renal disease progression in patients with type 2 diabetes and nephropathy, collecting first morning void urine samples and measuring the albumin:creatinine ratio appear to be superior when compared with measuring 24-hour urinary albumin excretion.”

Professors Bryan Kestenbaum, MD, and Ian de Boer, MD, from the University of Washington in Seattle, wrote an editorial in the same issue of the journal and they reiterated how this study could impact on clinical practice. They said in their editorial: “Given data from this study and the considerable patient effort required for a 24-hour urine collection, we agree with the authors that the first morning albumin:creatinine ratio is in general the logical choice for quantifying proteinuria in clinical practice.”

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