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1.  The Relationship between Proteinuria and Coronary Risk: A Systematic Review and Meta-Analysis 
PLoS Medicine  2008;5(10):e207.
Background
Markers of kidney dysfunction such as proteinuria or albuminuria have been reported to be associated with coronary heart disease, but the consistency and strength of any such relationship has not been clearly defined. This lack of clarity has led to great uncertainty as to how proteinuria should be treated in the assessment and management of cardiovascular risk. We therefore undertook a systematic review of published cohort studies aiming to provide a reliable estimate of the strength of association between proteinuria and coronary heart disease.
Methods and Findings
A meta-analysis of cohort studies was conducted to obtain a summary estimate of the association between measures of proteinuria and coronary risk. MEDLINE and EMBASE were searched for studies reporting an age- or multivariate-adjusted estimate and standard error of the association between proteinuria and coronary heart disease. Studies were excluded if the majority of the study population had known glomerular disease or were the recipients of renal transplants. Two independent researchers extracted the estimates of association between proteinuria (total urinary protein >300 mg/d), microalbuminuria (urinary albumin 30–300 mg/d), macroalbuminuria (urinary albumin >300 mg/d), and risk of coronary disease from individual studies. These estimates were combined using a random-effects model. Sensitivity analyses were conducted to examine possible sources of heterogeneity in effect size. A total of 26 cohort studies were identified involving 169,949 individuals and 7,117 coronary events (27% fatal). The presence of proteinuria was associated with an approximate 50% increase in coronary risk (risk ratio 1.47, 95% confidence interval [CI] 1.23–1.74) after adjustment for known risk factors. For albuminuria, there was evidence of a dose–response relationship: individuals with microalbuminuria were at 50% greater risk of coronary heart disease (risk ratio 1.47, 95% CI 1.30–1.66) than those without; in those with macroalbuminuria the risk was more than doubled (risk ratio 2.17, 1.87–2.52). Sensitivity analysis indicated no important differences in prespecified subgroups.
Conclusion
These data confirm a strong and continuous association between proteinuria and subsequent risk of coronary heart disease, and suggest that proteinuria should be incorporated into the assessment of an individual's cardiovascular risk.
Vlado Perkovic and colleagues show, through a systematic review and meta-analysis of cohort studies, that there is a strong and continuous association between proteinuria and subsequent risk of coronary heart disease.
Editors' Summary
Background.
Coronary heart disease (CHD) is the leading cause of death among adults in developed countries. With age, fatty deposits called atherosclerotic plaques coat the walls of arteries, the vessels that nourish the organs of the body by carrying blood and oxygen to them. Because they narrow the arteries, atherosclerotic plaques restrict the blood flow to the body's organs. If these plaques form in the arteries that feed the heart muscle (the coronary arteries), the result is CHD. The symptoms of CHD include shortness of breath and chest pains (angina). In addition, if a plaque breaks off the wall of a coronary artery, it can completely block that artery, which kills part of the heart muscle and causes a potentially fatal heart attack. Smoking, high blood pressure, high blood levels of cholesterol (a type of fat), having diabetes, being overweight, and being physically inactive are established risk factors for CHD. Treatments for CHD include lifestyle changes (for example, losing weight) and medications that lower blood pressure and blood cholesterol. The narrowed arteries can also be widened using a device called a stent or surgically bypassed.
Why Was This Study Done?
In addition to the established risk factors for CHD, several other factors may also increase a person's risk of developing CHD, including kidney disease, which affects one in six adults to some degree. An early sign of kidney dysfunction is high amounts of a protein called albumin or of total proteins in the urine (albuminuria and proteinuria, respectively). Some studies have suggested that proteinuria is associated with an increased risk of CHD, but the results of these studies are inconsistent. Consequently, it is unclear whether proteinuria should be considered when assessing and managing an individual's CHD risk. In this study, the researchers undertake a systematic review (a study in which predefined search criteria are used to identify all the research on a specific topic) and a meta-analysis (a statistical method for combining the results of several studies) of published studies that have investigated the association between proteinuria and CHD.
What Did the Researchers Do and Find?
The researchers' systematic review identified 26 published studies that provided estimates of the association between CHD risk and proteinuria and albuminuria by measuring baseline urinary protein and albumin levels in people who were then followed for several years to see whether they developed CHD. Nearly 170,000 individuals participated in these studies, which recorded more 7,000 fatal and nonfatal heart attacks and other coronary events. In the meta-analysis, proteinuria (urinary protein of more than 300 mg/d or dipstick 1+ or more) increased CHD risk by 50% after adjustment for other known CHD risk factors. Furthermore, individuals with microalbuminuria (a urinary albumin of 30–300 mg/d) were 50% more likely to develop CHD than those with normal amounts of urinary albumin; people with macroalbuminuria (urinary albumin of more than 300 mg/d) were more than twice as likely to develop CHD. Finally, the association between proteinuria and CHD did not differ substantially between specific subgroups of participants such as people with and without diabetes.
What Do These Findings Mean?
These findings suggest that there is a strong, possibly dose-dependent association between proteinuria and the risk of CHD and that this association is independent of other known CHD risk factors, including diabetes. The finding that people with proteinuria have a 50% or greater increased risk of developing CHD than people without proteinuria may be a slight overestimate of the strength of the association between proteinuria because of publication bias. That is, studies that failed to show an association may not have been published. However, because this systematic review and meta-analysis includes several large population-based studies done in various parts of the world, these findings are likely to be generalizable. Thus, these findings support the inclusion of an evaluation of proteinuria in the assessment of CHD risk and suggest that medications and other strategies that reduce proteinuria might help to reduce the overall burden of CHD.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050207.
The MedlinePlus encyclopedia has pages on coronary heart disease, atherosclerosis, and chronic kidney failure (in English and Spanish)
Information is available from the US National Heart Lung and Blood Institute on coronary heart disease
The UK National Health Service Direct health encyclopedia also provides information about coronary heart disease (in several languages)
Information for patients and caregivers is provided by the American Heart Association on all aspects of heart disease.
The British Heart Foundation also provides information on heart disease and on keeping the heart healthy
doi:10.1371/journal.pmed.0050207
PMCID: PMC2570419  PMID: 18942886
2.  Prevalence of microalbuminuria and diagnostic value of dipstick proteinuria in outpatients from HIV clinics in Bukavu, the Democratic Republic of Congo 
BMC Nephrology  2014;15(1):146.
Background
Microalbuminuria is a marker of early kidney disease and high cardiovascular risk in various populations, including HIV positive patients. However, the diagnostic value of qualitative (dipstick) proteinuria and the burden of microalbuminuria in HIV positive patients living in sub-Saharan Africa are relatively unclear.
Methods
In a cross-sectional study, 235 HIV- positive outpatients were screened for proteinuria in 3 HIV-clinics in Bukavu. A spot urine sample from each subject was tested both by a dipstick and albumin-creatinine-ratio (ACR) assay. The performance of dipstick proteinuria exceeding 1+ was compared with that of microalbuminuria (≥30 mg/g creatinine).
Results
The prevalence of microalbuminuria and dipstick proteinuria ≥ (1+), ≥ (2+) and ≥ (3+) was 11%, 41%, 3.5% and 0.7%, respectively.
Compared to microalbuminuria, the dipstick (proteinuria of 1+ or greater) had an overall sensitivity of 60% and a specificity of 61%. The positive predictive value was 15.4% and the negative predictive value 92.8%.
Conclusion
Proteinuria is highly prevalent in HIV positive patients. The limited sensitivity and specificity of the dipstick to detect significant microalbuminuria make it unattractive as a screening tool in HIV positive patients.
doi:10.1186/1471-2369-15-146
PMCID: PMC4164710  PMID: 25189092
Dipstick proteinuria; Albumin/creatinine ratio; Diagnostic value; HIV-patients
3.  Early Detection of Chronic Kidney Disease: Results of the PolNef Study 
American Journal of Nephrology  2008;29(3):264-273.
Background
Continuous increase in the number of patients with end-stage renal disease demands early detection of chronic kidney disease (CKD). The aim of the present study was to diagnose CKD in its earliest stages in a randomly selected population using a diagnostic algorithm developed by the working group.
Methods
An algorithm for the diagnostic procedure was created to identify patients with CKD requiring further nephrological care. Randomly chosen adult inhabitants of a city with a population of 60,000 were invited to participate in this study. Screening procedures included a microalbuminuria dipstick test accompanied by blood pressure measurement and medical questionnaire. In further diagnosis of CKD, estimated glomerular filtration rate (eGFR), albumin concentration in urine, urinalysis and ultrasound examination were used according to the algorithm. Multivariate logistic regression was performed to identify associations between participants’ characteristics and albuminuria.
Results
Out of 9,700 invited subjects, 2,471 individuals participated in the PolNef study. Albuminuria was detected in 15.6% of the investigated population using the dipstick test and thereafter confirmed in 11.9% by the turbidimetric method. The modeling of multivariate logistic regression indicated the following independent predictors of albuminuria: male sex, diabetes, nocturia and hypertension. For people without diabetes and without hypertension, nocturia independently predicted detection of albuminuria. 481 people received a consultation with a nephrologist, and 96% of them were recognized as having CKD. At least 9% of patients with CKD had eGFR by MDRD <60 ml/min/1.73 m2. Six persons were referred for further treatment because of newly diagnosed kidney tumor.
Conclusions
CKD in early stages occurs frequently in the studied population. The proposed diagnostic algorithm seems to be a powerful tool to identify subjects at risk of CKD. The role of nocturia as an independent predictor of albuminuria, both in the general population and in people without diabetes or hypertension, should be further examined.
doi:10.1159/000158526
PMCID: PMC2786021  PMID: 18812692
Albuminuria; Chronic kidney disease; Diagnostic algorithm; Nocturia
4.  Microalbuminuria: associations with height and sex in non-diabetic subjects. 
BMJ : British Medical Journal  1993;306(6872):240-242.
OBJECTIVES--To study the association(s) between microalbuminuria and cardiovascular risk factors in non-diabetic subjects. DESIGN--Patients aged 40-75 years were randomly selected from a general practice list and invited to participate. SETTING--Health centre in inner city London. SUBJECTS--Of those invited, 1046 out of 1671 (62.6%) attended. Subjects were excluded for the following reasons: not being white (44); urinary albumin excretion rate > 200 micrograms/min (3); having a urinary infection (5); taking penicillamine or angiotensin converting enzyme inhibitors (7); older than 75 (2); having diabetes (25); missing data on glucose concentration (1). MAIN OUTCOME MEASURES--Glucose tolerance test results, albumin excretion rate from overnight and timed morning collections of urine; blood pressure; height. RESULTS--Mean albumin excretion rate was significantly lower in women than men (mean ratio 0.8, 95% confidence interval (0.69 to 0.91)). Mean albumin excretion rate was significantly associated with age, blood pressure, and blood glucose concentration (fasting, 1 hour, and 2 hour) in men and inversely with height. Men who had microalbuminuria in both samples were significantly shorter (by 5 cm (1.3 to 9.3 cm)) than those who had no microalbuminuria in either sample when age was taken into account. In the case of women only systolic pressure was significantly associated with albumin excretion rate. CONCLUSIONS--Microalbuminuria and short stature in men are associated. Cardiovascular risk has been associated with both of these factors and with lower birth weight. The inverse association of microalbuminuria with height is compatible with the suggestion that factors operating in utero or early childhood are implicated in cardiovascular disease. The higher prevalence of microalbuminuria in men compared with women may indicate that sex differences in cardiovascular risk are reflected in differences in albumin excretion rate.
PMCID: PMC1676743  PMID: 8443522
5.  Persistent Microalbuminuria in Human Immunodeficiency Virus Infected Children in Kano, Nigeria 
Microalbuminuria has been reported to be a precursor of HIV related renal disease, which if detected early and coupled with appropriate intervention may slow or retard the progress of the disease. One hundred and seventy-eight HIV infected children aged 15 years and below were recruited from the Paediatric Infectious Disease Clinic of Aminu Kano Teaching Hospital (AKTH), Kano, to determine the prevalence of persistent microalbuminuria using the albumin creatinine ratio (ACR). Early morning urine samples and spot urine samples were analyzed using a dipstick specific for microalbumin. Those who tested positive had their samples reanalyzed in the laboratory using immunometric assay and Jaffe reaction method for albumin and creatinine, respectively. Patients that had ACR of 30–300 mg/g were said to have microalbuminuria and had their urine samples retested after 6 to 8 weeks. Twelve children (6.7%) had persistent microalbuminuria and had a mean age of 7.5 ± 3.3 years, with a male to female ratio of 1 : 1. There was no significant relationship between the finding of microalbuminuria and age, sex, duration of infection, and the use of highly active antiretroviral therapy. Periodic screening for microalbuminuria using albumin specific dipstick should be considered for children with HIV infection.
doi:10.1155/2014/567838
PMCID: PMC3958656  PMID: 24724027
6.  Risk factors for development of microalbuminuria in insulin dependent diabetic patients: a cohort study. Microalbuminuria Collaborative Study Group, United Kingdom. 
BMJ : British Medical Journal  1993;306(6887):1235-1239.
OBJECTIVE--To investigate the risk factors for the development of persistent microalbuminuria in insulin dependent diabetic patients. DESIGN--Four year follow up of a cohort of diabetic patients. SETTING--Outpatient departments of teaching and district general hospitals in England. SUBJECTS--148 non-microalbuminuric, non-hypertensive insulin dependent diabetic patients. MAIN OUTCOME MEASURES--Urinary albumin excretion rate and arterial blood pressure. RESULTS--137 patients completed four year follow up, of whom 11 developed persistent microalbumin-uria (albumin excretion rate > or = 30 micrograms/min on at least two consecutive occasions), giving a cumulative frequency of 8%. 103 remained normoalbuminuric and 23 exhibited intermittent microalbuminuria. At baseline the persistent microalbuminuric group had had significantly raised blood pressure (mean 137.9 (SD 14.9)/82.3 (7.6) v 123.5 (13.2)/72.8 (9.1) mm Hg), glycated haemoglobin concentration 10.4% (2.0%) v 8-9% (2.0%), and albumin excretion rate (median (interquartile range) 17.5 (13.0-22.3) v 4.8 (3.7-6.7) micrograms/min) (p < 0.05 for all) compared with the normo-albuminuric group. Blood pressure and glycated haemoglobin remained significantly higher in the persistent microalbuminuric group throughout the study (p < 0.05). Multiple regression analysis showed initial albumin excretion rate, blood pressure, and smoking to be significant determinants of persistent microalbuminuria (p < 0.02). CONCLUSION--In insulin dependent diabetic patients with poor glucose control, which may initially increase albumin excretion rate, an early rise of arterial pressure and smoking are implicated in the development of persistent microalbuminuria.
Images
PMCID: PMC1677581  PMID: 8499853
7.  Renal Dysfunction in the Presence of Normoalbuminuria in Type 2 Diabetes: Results from the DEMAND Study 
Cardiorenal Medicine  2011;2(1):1-10.
Background/Aims
Microalbuminuria is associated with diabetes and is an independent risk factor for developing diabetic nephropathy. We have previously reported the overall prevalence of normoalbuminuria, microalbuminuria, and macroalbuminuria to be 51, 39, and 9.8%, respectively, in an unselected population of patients with type 2 diabetes. Renal dysfunction was present in a large proportion of these patients without proteinuria, assessed by a single random albumin-to-creatinine ratio (ACR). We therefore undertook to characterize the nature of this association of non-proteinuric renal dysfunction in type 2 diabetes.
Methods
In the DEMAND (Developing Education on Microalbuminuria for Awareness of Renal and Cardiovascular Risk in Diabetes) study, a global, cross-sectional study which described the prevalence and risk factors for albuminuria in a clinic-based cohort, kidney function was assessed in 11,573 patients; ACR was measured using the Bayer reagent strip Multistix® 10SG. Normoalbuminuria was defined as ACR <30 mg/g, microalbuminuria as 30–299 mg/g, and macroalbuminuria as >300 mg/g.
Results
Among the patients with estimated kidney function determined, chronic kidney disease was noted in 17% of those with normoalbuminuria (stage 3–5), and significant kidney dysfunction was found in 27% of those with microalbuminuria and 31% of those with overt proteinuria. CrCl was <60 ml/min in 20.5% of normoalbuminurics, 30.7% of microalbuminurics, and 35.0% of macroalbuminurics (p < 0.0001).
Conclusion
A large proportion of diabetic patients with completely normal urinary albumin excretion or microalbuminuria presented with significant kidney dysfunction. Therefore, further investigation is warranted.
doi:10.1159/000333249
PMCID: PMC3318932  PMID: 22493597
Albuminuria; Chronic kidney disease; Diabetes; Diabetic nephropathy; Normoalbuminuria; Proteinuria
8.  Role of glycaemic control in development of microalbuminuria in patients with insulin dependent diabetes. 
BMJ : British Medical Journal  1994;309(6969):1608-1612.
OBJECTIVE--To ascertain which factors determine the progression from very low rates of albumin excretion to persistent microalbuminuria in patients with insulin dependent diabetes mellitus. DESIGN--A 10 year prospective study of a cohort of diabetic patients. SETTING--Outpatient department of the Portsmouth District Hospitals. SUBJECTS--97 patients with insulin dependent diabetes mellitus who were initially free of microalbuminuria and hypertension. MAIN OUTCOME MEASURE--Urinary albumin: creatinine ratio. RESULTS--Eight of the 97 patients had developed microalbuminuria (urinary albumin:creatinine ratio > 3 mg/mmol in three consecutive early morning samples) by the 10 year follow up. The group who developed microalbuminuria had higher baseline log10 plasma glucose concentrations (mean (SD), 1.210 (0.122) v 0.984 (0.196) mmol/l, P < 0.001) and glycated haemoglobin concentrations (1.112% (0.069%) v 0.997% (0.076%), P < 0.001) and a younger age at onset of diabetes (10.0 (5.5) v 15.6 (7.8) years, P < 0.05). There was no difference in baseline duration of diabetes, smoking, sex, insulin dose, body mass index, serum creatinine concentration, or systolic, diastolic, or mean arterial blood pressure between the two groups. Multiple linear regression analysis showed that urinary albumin:creatinine ratio at 10 years was influenced by initial albumin:creatinine ratio (P = 0.006), initial glycated haemoglobin concentration (P = 0.002), and duration of diabetes (P = 0.045). Genotype for angiotensin converting enzyme was not related to the development of microalbuminuria nor, in a larger group of patients, the presence of any degree of diabetic nephropathy. CONCLUSION--In patients with insulin dependent diabetes mellitus the progression of minimal albuminuria and the development of microalbuminuria is determined primarily by poor long term glycaemic control. There is a weaker relation with longer duration of disease and younger age at onset of diabetes, but blood pressure does not seem to be implicated. Gene polymorphism for angiotensin converting enzyme is not linked to the development of microalbuminuria or established diabetic nephropathy.
PMCID: PMC2541974  PMID: 7819935
9.  A Comparative Study of Clinical Utility of Spot Urine Samples with 24-h Urine Albumin Excretion for Screening of Microalbuminuria in Type 2 Diabetic Patients 
Twenty-four hour urinary albumin excretion (UAE) is considered as gold standard method for albuminuria measurement, but collection of 24-h urine is inconvenient. The aim of present study was to evaluate whether albumin: creatinine ratio (ACR) and urinary albumin concentration (UAC) in different spot urine samples correlate or not with 24-h UAE for screening of microalbuminuria in type 2 diabetic patients. We collected first morning void (FMV), random urine sample (RUS) and 24-h urine, separately on consecutive days from 104 type 2 diabetic patients. ACR and UAC in each spot urine sample compared with 24-h UAE with regard to Pearson correlation coefficient. Pearson’s correlation of albumin: creatinine ratio (ACR) with 24-h UAE was (r = 0.802 and 0.623) in first morning void (FMV) and random urine sample (RUS), respectively. Pearson’s correlation coefficient of urinary albumin concentration (UAC) compared with 24-h UAE was (r = 0.943 and 0.920), in FMV and RUS, respectively, P < 0.01. Results revealed that values in first morning void (FMV) were better correlated with 24-h urinary albumin excretion (UAE), than the values in random urine sample (RUS). We conclude that the first morning void (FMV) may be able to replace 24-h urine collection, preferably urinary albumin concentration (UAC) in the initial screening of microalbuminuria in diabetic patients.
Electronic supplementary material
The online version of this article (doi:10.1007/s12291-011-0136-0) contains supplementary material, which is available to authorized users.
doi:10.1007/s12291-011-0136-0
PMCID: PMC3162961  PMID: 22754194
Diabetes mellitus; Microalbuminuria; Screening; Spot urine sample; Urinary albumin concentration
10.  Urinary Total Protein as the Predictor of Albuminuria in Diabetic Patients 
Background
In order to detect nephropathy, measurement of total (24 hrs) urinary albumin or albumin/creatinin ratio in random urine samples is being recommended. But methods of albumin measurement are not available in all laboratories and also cost about 6 times more than that of urinary total protein measurement.
Objectives
This Study was performed to determine appropriate cut off point in 24 hours urine total protein to diagnose micro- and macroalbuminuria in patients with diabetes mellitus.
Patients and Methods
In this study, 204 patients with diabetes mellitus type I and II were selected. In collected 24 hours urine from patients, protein and albumin were measured by using Pyrogallol and Immunoturbidimetry methods, respectively.
Results
Normoalbuminuri (albumin < 30 mg/24 hrs urine), microalbuminuri (albumin = 30-300 mg/24 hrs urine), and macroalbuminuri (albumin > 300 mg/24 hrs urine) were detected in 130, 51, and 23 patients, respectively. In 24 hrs urine collections, amounts of protein and albumin were compared to calculate cut off point of exerted protein for nephropathy diagnosis. cut off point of 73 mg/day for urinary total protein had appropriate sensitivity (94.5 %, CI = 91.4 % -97.6 %) and specificity (77.9 %, CI = 72.8 % -82.9 %) for microalbuminuria, while cut off point of 514 mg/day (sensitivity 95.7 %; specificity 98.9 %) was detected for diagnosis macroalbuminuria. Urine protein exertion of 150 mg/day that is currently considered as a normal value in most laboratory kits had a sensitivity of 73.1 % by which 30 % of microalbuminuric cases remained undiagnosed.
Conclusions
Urinary total protein cut-off points of 73 mg/day and 514 mg/day were diagnostic for micro- and macroalbuminuria, respectively.
doi:10.5812/ijem.4236
PMCID: PMC3693628  PMID: 23843814
Urinary Albumin; Urinary Protein; Diabetic Nephropathy
11.  Beta 2-glycoprotein-1 (apolipoprotein H) excretion and renal tubular malfunction in diabetic patients without clinical proteinuria. 
Journal of Clinical Pathology  1993;46(5):465-469.
AIM--To compare the urinary excretion of beta 2-glycoprotein-1 with that of two other markers of early tubular disorder in diabetic patients without clinical proteinuria. METHODS--The urinary excretion of retinol binding protein, beta 2-glycoprotein-1, and N-acetyl-beta-D-glucosaminidase was measured in 90 known diabetic patients who had a negative reagent strip test for proteinuria. RESULTS--Among 43 patients with urinary albumin excretion within the reference range, 23 (53%) had raised urinary N-acetyl-beta-D-glucosaminidase activity, five (12%) increased excretion of beta 2-glycoprotein-1, and five (12%) increased loss of retinol binding protein. Among 47 patients with an albumin excretion of 0.9-7.9 mg/mmol creatinine, 42 (89%) had increased urinary N-acetyl-beta-D-glucosaminidase, 23 (49%) an increased output of beta 2-glycoprotein-1, and 16 (34%) a raised excretion of retinol binding protein. The excretion of these markers of tubular defects seldom exceeded two and a half times the upper reference limit and the differences between the findings in the insulin dependent and non-insulin dependent patients with similar albumin excretion were small and insignificant. CONCLUSIONS--In diabetic patients with a negative dipstick test for proteinuria: (a) assay of urinary beta 2-glycoprotein-1 may be a more sensitive test for the detection of impaired tubular reabsorption of protein than measurement of retinol-binding protein; (b) assay of N-acetyl-beta-D-glucosaminidase can detect tubular injury at a time when protein reabsorption remains normal; and (c) impaired renal tubular function may be present in the absence of evidence of glomerular malfunction.
PMCID: PMC501261  PMID: 8320329
12.  Prevalence of microalbuminuria and risk factor analysis in type 2 diabetes patients in Albania: the need for accurate and early diagnosis of diabetic nephropathy 
Hippokratia  2013;17(4):337-341.
Background: Microalbuminuria is often the first sign of renal dysfunction in diabetes. This study aimed to investigate the prevalence of microalbuminuria in Albanian type 2 diabetes patients and its association with other cardiovascular risk factors.
Methods: Three hundred and twenty-one patients with type 2 diabetes attending, diabetes centers in Albania were enrolled in this cross-sectional, multicenter study. The subjects, aged 40–70 years, had no known proteinuria or other kidney disease. Pregnant women and patients with acute infections were excluded. Data including waist circumference, duration of diabetes and history of hypertension were obtained by questionnaire. Blood samples were drawn after 12 h overnight fasting to measure glycosylated hemoglobin (HbA1c), serum cholesterol, triglyceride and creatinine. Microalbuminuria was assessed using dipstick kits in early morning urine samples.
Results: The prevalence of normoalbuminuria was 56.3%, microalbuminuria 40.8% and macroalbuminuria 2.8%. Systolic and diastolic blood pressure (p<0.01), HbA1c (p<0.01) and fasting plasma glucose (p<0.001) were significantly higher in microalbuminuric than in normoalbuminuric subjects. Independent risk factors for microalbuminuria were duration of diabetes (OR: 2.785, 95% CI: 1.156-3.759), systolic blood pressure (OR: 2.88, 95% CI: 1.85-6.85) and waist circumference (OR: 2.15, 95% CI: 1.01-5.45) in males and poor glycemic control (OR: 4.51, 95% CI: 1.45-13.98), duration of diabetes (OR: 2.568, 95% CI: 1.702-3.778) and waist circumference (OR: 4.87, 95% CI: 1.80-13.11) in females.
Conclusions: The high proportion of type 2 diabetes patients with microalbuminuria raises implications for health policy in Albania. Screening programs and optimized control of modifiable risk factors are needed to reduce the risk of diabetic nephropathy.
PMCID: PMC4097415  PMID: 25031513
Microalbuminuria; type 2 diabetes; epidemiology; Albania
13.  Development of Contrast-Induced Acute Kidney Injury after Elective Contrast Media Exposure in Patients with Type 2 Diabetes Mellitus: Effect of Albuminuria 
PLoS ONE  2014;9(9):e106454.
Background
The influence of albuminuria and urinary pH on the development of contrast-induced acute kidney disease (CI-AKI) in patients with type 2 diabetes mellitus (T2DM) after elective coronary angiography (CAG) or percutaneous coronary intervention (PCI) is unknown.
Methods
CI-AKI was defined as an increase in serum creatinine >26.4 µmol/L or ≥50% of baseline value within 48 hours after contrast media exposure. Demographics, traditional risk factors, clinical outcomes and CI-AKI incidence were compared between groups. Univariate analysis and multivariate logistic regression were performed to assess risk factors of CI-AKI.
Results
We observed 597 patients with T2DM after CAG or PCI. Patients were divided into 3 groups based on early morning urinary albumin: negative group (urine dipstick negative, n = 483), trace group (urine dipstick trace, n = 60), and positive group (urine dipstick ≥1+, n = 54). CI-AKI occurred in 33 (5.5%) patients, including 19 (3.9%) in the negativealbuminuria group, 4 (6.7%) in the trace group, and 10 (18.5%) in the positive group (p< 0.001), respectively. After adjusting for potential confounding risk factors, positive albuminuria (OR = 3.8, 95% CI: 1.5 to 9.2, p = 0.004) and urinary pH<6 (OR = 2.4, 95% CI: 1.1 to 5.1, p = 0.020) remained significantly associated with CI-AKI.
Conclusion
Preprocedural albuminuria and urinary pH <6 are independent risk factors of CI-AKI in patients with T2DM undergoing elective cardiac catheterization, and may be used to identify patients at high risk of post-procedural CI-AKI.
doi:10.1371/journal.pone.0106454
PMCID: PMC4156370  PMID: 25192238
14.  Predictive value of microalbuminuria in patients with insulin-dependent diabetes of long duration. 
BMJ : British Medical Journal  1992;305(6861):1051-1053.
OBJECTIVE--To investigate the predictive value of microalbuminuria (albumin excretion rate 30-300 mg/24 h) as a risk factor for overt diabetic nephropathy in patients with longstanding insulin dependent diabetes. DESIGN--10 year follow up of patients with normoalbuminuria (albumin excretion rate < 30 mg/24 h), microalbuminuria (30-300 mg/24 h), and macroalbuminuria (> 300 mg/24 h) based on two out of three timed overnight urine samples. SETTING--Outpatient clinic of Helsinki University Hospital. SUBJECTS--72 consecutive patients who had had insulin dependent diabetes for over 15 years. MAIN OUTCOME MEASURES--Urinary albumin excretion rate, mortality, and prevalence of diabetic complications after 10 years. RESULTS--56 patients were re-examined at 10 year follow up, 10 had died, five were lost to follow up, and one was excluded because of non-diabetic kidney disease. At initial screening 22 patients had macroalbuminuria, 18 had microalbuminuria, and 26 had normal albumin excretion. Only five (28%, 95% confidence interval 10% to 54%) of the microalbuminuric patients developed macroalbuminuria during the 10 year follow up and none developed end stage renal failure. Two (8%, 1% to 25%) normoalbuminuric patients developed macroalbuminuria and four (15%, 4% to 35%) became microalbuminuric. Seven (32%, 14% to 55%) of the macroalbuminuric patients developed end stage renal failure and six (27%, 11% to 50%) died of cardiovascular complications. CONCLUSION--Microalbuminuria is not a good predictor of progression to overt nephropathy in patients with longstanding insulin dependent diabetes.
PMCID: PMC1883577  PMID: 1467683
15.  Urinary ATP and visualization of intracellular bacteria: a superior diagnostic marker for recurrent UTI in renal transplant recipients? 
SpringerPlus  2014;3:200.
Renal transplant recipients (RTR) are highly susceptible to urinary tract infections (UTIs) with over 50% of patients having at least one UTI within the first year. Yet it is generally acknowledged that there is considerable insensitivity and inaccuracy in routine urinalysis when screening for UTIs. Thus a large number of transplant patients with genuine urine infections may go undiagnosed and develop chronic recalcitrant infections, which can be associated with graft loss and morbidity. Given a recent study demonstrating ATP is released by urothelial cells in response to bacteria exposure, possibly acting at metabotropic P2Y receptors mediating a proinflammatory response, we have investigated alternative, and possibly more appropriate, urinalysis techniques in a cohort of RTRs.
Mid-stream urine (MSU) samples were collected from 53 outpatient RTRs. Conventional leukocyte esterase and nitrite dipstick tests, and microscopic pyuria counts (in 1 μl), ATP concentration measurements, and identification of intracellular bacteria in shed urothelial cells, were performed on fresh unspun samples and compared to ‘gold-standard’ bacterial culture results.
Of the 53 RTRs, 22% were deemed to have a UTI by ‘gold-standard’ conventional bacteria culture, whereas 87%, 8% and 4% showed evidence of UTIs according to leukocyte esterase dipstick, nitrite dipstick, and a combination of both dipsticks, respectively. Intracellular bacteria were visualized in shed urothelial cells of 44% of RTRs, however only 1 of the 23 RTRs (44%) was deemed to have a UTI by conventional bacteria culture. A significant association of the ‘gold-standard’ test with urinary ATP concentration combined with visualization of intracellular bacteria in shed urothelial cells was determined using the Fisher’s exact test.
It is apparent that standard bedside tests for UTIs give variable results and that seemingly quiescent bacteria in urothelial cells are very common in RTRs and may represent a focus of subclinical infection. Furthermore, our results suggest urinary ATP concentration combined with detection of intracellular bacteria in shed urinary epithelial cells may be a sensitive means by which to detect ‘occult’ infection in RTRs.
doi:10.1186/2193-1801-3-200
PMCID: PMC4022969  PMID: 24839587
Intracellular bacteria; IBC; Pyuria; Urinary ATP; Bladder; Acridine orange stain
16.  Microalbuminuria in patients with rheumatoid arthritis. 
Annals of the Rheumatic Diseases  1995;54(3):189-192.
OBJECTIVES--To assess (a) the prevalence of microalbuminuria in patients with rheumatoid arthritis, (b) the association between urinary albumin excretion and disease activity as estimated by the erythrocyte sedimentation rate and C reactive protein (CRP), and (c) the association between urinary albumin excretion and treatment with antirheumatic drugs. METHODS--Sixty five patients with rheumatoid arthritis attending two rheumatology clinics were compared with 51 control subjects matched by age and sex. The controls consisted of 20 healthy subjects, 16 patients with osteoarthritis and 15 with non-articular rheumatism. Patients with hypertension, diabetes mellitus, or evidence of previous renal disease were not included. Urinary albumin was assayed by immunoturbidimetry in random urine samples on two occasions within seven months. The results were expressed as the ratio of urinary albumin to urinary creatinine ratio. Disease activity was assessed by the erythrocyte sedimentation rate and CRP. A drug history for the year before entry to the study was obtained for each patient. RESULTS--Urinary albumin to creatinine ratio in patients with rheumatoid arthritis was significantly greater than in controls (p < 0.01). Microalbuminuria (urinary albumin to creatinine ratio 3-30 mg/mmol in either or both urine samples) was present in 27.7% of patients with rheumatoid arthritis and 7.8% of the control subjects. A significant relation was noted between urinary albumin to creatinine ratio and CRP, and the duration of disease. The number of patients treated with either gold or penicillamine was significantly greater in patients with microalbuminuria than in patients with normoalbuminuria. CONCLUSIONS--Microalbuminuria is frequently present in patients with rheumatoid arthritis. Treatment with gold and penicillamine seems to increase the risk of developing microalbuminuria. Urinary albumin measured by immunochemical methods is a simple and sensitive test to detect early subclinical renal dysfunction and drug induced renal damage in rheumatoid arthritis. Urinary albumin excretion was found to be significantly correlated with CRP and may be a sensitive indicator of disease activity in patients with rheumatoid arthritis.
PMCID: PMC1005554  PMID: 7748016
17.  Laboratory Measurement of Urine Albumin and Urine Total Protein in Screening for Proteinuria in Chronic Kidney Disease 
The Clinical Biochemist Reviews  2011;32(2):97-102.
Laboratory measurement of urine total protein has been important for the diagnosis and monitoring of renal disease for decades, and since the late 1990s, urine albumin has been measured to determine whether a diabetic patient has incipient nephropathy. Evolving understanding of chronic kidney disease (CKD) and, in particular, the cardiovascular risks that CKD confers, demands more sensitive detection of protein in urine. As well, evidence is now emerging that cardiovascular and all-cause mortality risks are increased at levels within the current ‘normal’ range for urine albumin. Standardisation is essential to permit valid application of universal decision points, and a National Kidney Disease Education Program/International Federation of Clinical Chemistry and Laboratory Medicine (NKDEP/IFCC) Working Party is making progress towards a reference system for urine albumin. In the meantime, available data suggest that Australasian laboratory performance is adequate in terms of precision and accuracy above current decision limits for urine albumin. In contrast, the complexity of proteins in urine makes standardisation of urine total protein measurement impossible. As well, urine total protein measurement is insufficiently sensitive to detect clinically important concentrations of urine albumin. An Australasian Expert Group, the Proteinuria Albuminuria Working Group (PAWG) has proposed that urine albumin/creatinine ratio is measured in a fresh, first morning, spot sample to screen for proteinuria in CKD. Both NKDEP/IFCC and PAWG emphasise the need for standardisation of sample collection and handling.
PMCID: PMC3100287  PMID: 21611083
18.  Prevalence of abnormal urinary albumin excretion in adolescents and children with insulin dependent diabetes: the MIDAC study 
Archives of Disease in Childhood  2000;83(3):239-243.
OBJECTIVE—To examine the prevalence of microalbuminuria, defined as an albumin to creatinine ratio (UAC) equal to or greater than 2mg/mmol in at least two of three early morning urine samples, in adolescents and children with insulin dependent diabetes mellitus.
DESIGN—Centrally coordinated, cross sectional, multicentre study in paediatric diabetes outpatient clinics in the United Kingdom and Republic of Ireland.
METHODS—Blood and urine samples collected between July 1997 and July 1998 were analysed at a central reference laboratory for HbA1C using high performance liquid chromatography, and for urinary albumin and creatinine concentrations from which the UAC was derived (mg/mmol). Clinical data were collected locally and coordinated centrally.
SUBJECTS—Patients, aged between 10 and 20 years, with insulin dependent diabetes mellitus for more than a year, attending diabetes outpatient clinics.
RESULTS—A total of 1007 patients, comprising 69% of the eligible population of 1451, provided three early morning urine samples. Ninety eight (9.7%) had microalbuminuria using the currently accepted screening cut off of UAC ⩾ 2 mg/mmol in at least two of three early morning urine samples. Significantly more girls than boys and significantly more pubertal and postpubertal patients had abnormal albumin excretion. Microalbuminuria was not associated with raised blood pressure.
CONCLUSIONS—A prevalence of 9.7% for abnormal UAC was found in a cohort of 1007 children and adolescents aged 10-20 years. Thus a tenth of this national sample of young people were identified as being at particular risk of microvascular and later macrovascular disease.


doi:10.1136/adc.83.3.239
PMCID: PMC1718460  PMID: 10952644
19.  Urinary N-acetyl beta glucosaminidase and gamma glutamyl transferase as early markers of diabetic nephropathy. 
Albumin and enzymes-N-acetyl-beta-glucosaminidase (NAG) and gamma glutamyl transferase (GGT) were estimated in the morning random urine samples of 196 albustix negative diabetic patients to evaluate the clinical utility of these urinary enzymes as early markers of diabetic nephropathy. Albumin was estimated by immunoturbidimetric method and enzymes by linetic essay within six hours of voiding of urine. The urinary albumin and urinary enzyme concentration was calculated in terms of ratio with respect to urinary creatinine. Correlation coefficient (r) bewween urinary albumin and urinary enzymes in normoalbuminuric, microalbuminuric and overall diabetic cases was 0.23, 0.32 and 0.40 respectively for NAG, and 0.08, 0.06 and 0.18 respectively for GGT. NAG excretion was found increased in 34%, 63.7% and 49.5% of normoalbuminuric, microalbuminuric and overall diabetic cases respectively while GGT in 6.4%, 24.5% and 15.8%. The correlation coefficient between urinary albumin and NAG in normoalbuminuric, microalbuminuric, and overall diabetic patients with increased NAG excretion was found only 0.31, 0.27 and 0.35 respectively. No correlation was found between duration of diabetes and enzyme excretion. The study suggests that urinary NAG or GGT or both together do not have any clinical significance as an early marker of diabetic nephropathy.
doi:10.1007/BF02912930
PMCID: PMC3454003  PMID: 23105632
Microalbuminuria; Diabetic nephropathy; N-acetyl-beta-glucosaminidase; Gamma glutamyl transferase
20.  Urinary albumin excretion and prevalence of microalbuminuria in a general Chinese population: a cross-sectional study 
BMC Nephrology  2014;15(1):165.
Background
Microalbuminuria has been shown to be a risk factor for cardiovascular and renal disease in patients with hypertension and diabetes as well as in the general population. Urinary albumin excretion over 24 h is considered a ‘gold standard’ to detect microalbuminuria. Few studies have used 24-h urinary albumin excretion to analyze the prevalence of and related factors for microalbuminuira in a general Chinese population.
Methods
This study included 1980 adults aged 18–69 years from the Shandong-Ministry of Health Action on Salt and Hypertension (SMASH) Project 2011 survey. Blood pressure, height, weight and waist circumference were measured, and a venous blood and timed 24-h urine samples were collected from each participant. Linear and logistic regression analyses were used to test associations between established cardiovascular risk factors and microalbuminuria.
Results
The median (25th–75th percentile) of 24-h urinary albumin excretion was 6.1 mg/d (4.5–8.7 mg/d) for all adults, 6.0 mg/d (4.4–8.5 mg/d) for men and 6.2 mg/d (4.6–8.9 mg/d) for women. The overall prevalence of microalbuminuria was 4.1% (95% confidence interval [CI]: 3.2–5.0%), 3.7% (95% CI: 2.9–4.5%) for men and 4.6% (95% CI: 3.7–5.5%) for women. Microalbuminuria was present in 8.1% (95% CI: 6.9–9.3%) of individuals with hypertension, 11.4% (95% CI: 10.0–12.8%) of those with diabetes and 15.6% (95% CI: 14.0–17.2%) of those with both. Multiple logistic regression analysis indicated that systolic blood pressure (odds ratio [OR] 1.02; 95% CI: 1.01–1.03) and fasting blood glucose (OR 1.19; 95% CI: 1.05–1.35) were the independent risk factors for microalbuminuria.
Conclusions
Adults in the general population of Shandong Province have a moderate prevalence of microalbuminuria. Those with hypertension and diabetes are at high risk of having microalbuminuria, suggesting the need for screening and early intervention for microalbuminuria among these individuals.
doi:10.1186/1471-2369-15-165
PMCID: PMC4209030  PMID: 25308236
Diabetes; Hypertension; Microalbuminuria
21.  New Rapid Diagnostic Tests for Neisseria meningitidis Serogroups A, W135, C, and Y 
PLoS Medicine  2006;3(9):e337.
Background
Outbreaks of meningococcal meningitis (meningitis caused by Neisseria meningitidis) are a major public health concern in the African “meningitis belt,” which includes 21 countries from Senegal to Ethiopia. Of the several species that can cause meningitis, N. meningitidis is the most important cause of epidemics in this region. In choosing the appropriate vaccine, accurate N. meningitidis serogroup determination is key. To this end, we developed and evaluated two duplex rapid diagnostic tests (RDTs) for detecting N. meningitidis polysaccharide (PS) antigens of several important serogroups.
Methods and Findings
Mouse monoclonal IgG antibodies against N. meningitidis PS A, W135/Y, Y, and C were used to develop two immunochromatography duplex RDTs, RDT1 (to detect serogroups A and W135/Y) and RDT2 (to detect serogroups C and Y). Standards for Reporting of Diagnostic Accuracy criteria were used to determine diagnostic accuracy of RDTs on reference strains and cerebrospinal fluid (CSF) samples using culture and PCR, respectively, as reference tests. The cutoffs were 105 cfu/ml for reference strains and 1 ng/ml for PS. Sensitivities and specificities were 100% for reference strains, and 93.8%–100% for CSF serogroups A, W135, and Y in CSF. For CSF serogroup A, the positive and negative likelihood ratios (± 95% confidence intervals [CIs]) were 31.867 (16.1–63.1) and 0.065 (0.04–0.104), respectively, and the diagnostic odds ratio (± 95% CI) was 492.9 (207.2–1,172.5). For CSF serogroups W135 and Y, the positive likelihood ratio was 159.6 (51.7–493.3) Both RDTs were equally reliable at 25 °C and 45 °C.
Conclusions
These RDTs are important new bedside diagnostic tools for surveillance of meningococcus serogroups A and W135, the two serogroups that are responsible for major epidemics in Africa.
There are several strains ofNeisseria meningitidis that can cause seasonal outbreaks of meningitis in Africa. Treatment of patients and containment of the epidemic through vaccination depends on which strain is responsible. The new dipstick tests described here are accurate and suitable for storage and use in resource-poor settings.
Editors' Summary
Background
Bacterial meningitis, a potentially deadly infection of tissues that line the brain and spinal cord, affects over 1 million people each year. Patients with bacterial meningitis usually have fever, headache, and stiff neck, and may become unconscious and die if the disease is not treated within hours. Most cases of bacterial meningitis occur in Africa, particularly in the arid savannah region south of the Sahara known as the Sahel, where epidemic outbreaks of meningitis occur periodically. This region, also called the “meningitis belt,” extends from Senegal and adjacent coastal countries in West Africa across the continent to Ethiopia. Although most outbreaks tend to occur in the dry season, they differ in frequency in different areas of the meningitis belt, and may involve any of several kinds of bacteria. One of the major causes of epidemic meningitis is Neisseria meningitidis, a meningococcus bacterium that exists in several different groups. Group A has been a common cause of epidemic meningitis in Africa, and some outbreaks were due to group C. More recently, group W135 has emerged as an epidemic strain. In addition to prompt diagnosis and treatment of individual cases, effective public health strategies for controlling meningococcal meningitis include rapid identification of outbreaks and determination of the type of bacteria involved, followed by mass vaccination of people in the surrounding area without delay. Vaccines are chosen on the basis of the responsible meningococcal serogroup: either the inexpensive bivalent vaccine A/C or the expensive, less readily available trivalent vaccine A/C/W135. Before the advent of W135 as an epidemic clone, bivalent vaccine was applied in the meningitis belt without identification of the serogroup. With the appearance of the W135 strain in 2003, however, the determination of serogroup before vaccination is important to select an effective vaccine and avoid misspending of limited funds.
Why Was This Study Done?
Because there are few laboratories in the affected countries and epidemiological surveillance systems are inadequate, it is difficult for health authorities to mount a rapid and effective vaccination campaign in response to an outbreak. In addition, because the two main bacteria (meningococcus and pneumococcus) that cause meningitis require different antibiotic treatments, it is important for doctors to find out quickly which bacteria is causing an individual case. The authors of this study wanted to develop a rapid and easy test that can tell whether meningococcus is the cause of a particular case of meningitis, and if so, which group of meningococcus is involved. As most outbreaks in the meningitis belt occur in rural areas that are distant from well-equipped medical laboratories, it was necessary to develop a test that can be carried out at the patient's bedside by nurses, does not require refrigeration or laboratory equipment, and is highly accurate in distinguishing among the different groups of meningococcus.
What Did the Researchers Do and Find?
The researchers have developed a rapid test to determine whether a patient's meningitis is caused by one of the four most common groups of meningococcus circulating in Africa. The test is done on the patient's spinal fluid, which is obtained by a lumbar puncture (spinal tap) as part of the usual evaluation of a patient thought to have meningitis. The test uses two paper strips, also called dipsticks (one for groups A and W135/Y, and the other for groups C and Y), that can be placed in two separate tubes of the patient's spinal fluid. After several minutes, the appearance of red lines on the dipsticks shows whether one of the four groups of meningococcus is present. The dipsticks can be produced in large quantities and relatively cheaply. The researchers showed that the test dipsticks are stable for weeks in hot weather, and are therefore practical for bedside use in resource-poor settings. They examined the test on stored spinal fluid from patients in Niger and found that the dipstick test was able to identify the correct group of meningococcus more than 95% of the time for the three groups represented in these specimens (the results were compared to a standard DNA test or culture that are highly accurate for identifying the type of bacteria present but much more complicated and expensive).
What Do These Findings Mean?
The new dipstick test for meningococcal meningitis represents a major advance for health-care workers in remote locations affected by meningitis epidemics. This test can be stored without refrigeration and used at bedside in the hot temperatures typical of the African savannah during the meningitis season. The dipsticks are easier to use than currently available test kits, give more rapid results, and are more accurate in telling the difference between group Y and the increasingly important group W135. Further research is needed to determine whether the test can be used with other clinical specimens (such as blood or urine), and whether the test is dependable for detecting group C meningococcus, which is common in Europe but rare in Africa. Nonetheless, the dipstick test promises to be an important tool for guiding individual treatment decisions as well as public health actions, including vaccine selection, against the perennial threat of epidemic meningitis.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030337.
World Health Organization fact sheet on meningococcal meningitis
PATH Meningitis Vaccine Project
US Centers for Disease Control and Prevention page on meningococcal disease
doi:10.1371/journal.pmed.0030337
PMCID: PMC1563501  PMID: 16953658
22.  Effects of low dose ramipril on cardiovascular and renal outcomes in patients with type 2 diabetes and raised excretion of urinary albumin: randomised, double blind, placebo controlled trial (the DIABHYCAR study) 
BMJ : British Medical Journal  2004;328(7438):495.
Objective To investigate whether a low dose of the angiotensin converting enzyme (ACE) inhibitor ramipril lowers cardiovascular and renal events in patients with type 2 diabetes who have microalbuminuria or proteinuria.
Design Randomised, double blind, parallel group trial comparing ramipril (1.25 mg/day) with placebo (on top of usual treatment) for cardiovascular and renal outcomes for at least three years.
Setting Multicentre, primary care study conducted mostly by general practitioners in 16 European and north African countries.
Participants 4912 patients with type 2 diabetes aged >50 years who use oral antidiabetic drugs and have persistent microalbuminuria or proteinuria (urinary albumin excretion ≥ 20 mg/l in two consecutive samples), and serum creatinine ≤ 150 μmol/l.
Main outcome measures The primary outcome measure was the combined incidence of cardiovascular death, non-fatal myocardial infarction, stroke, heart failure leading to hospital admission, and end stage renal failure.
Results Participants were followed for 3 to 6 (median 4) years. There were 362 primary events among the 2443 participants taking ramipril (37.8 per 1000 patient years) and 377 events among the 2469 participants taking placebo (38.8 per 1000 patient years; hazard ratio 1.03 (95% confidence interval 0.89 to 1.20, P = 0.65)). None of the components of the primary outcome was reduced. Ramipril lowered systolic and diastolic blood pressures (by 2.43 and 1.06 mm Hg respectively after two years) and favoured regression from microalbuminuria (20-200 mg/l) or proteinuria (> 200mg/l) to normal level (< 20 mg/l) or microalbuminuria (P < 0.07) in 1868 participants who completed the study.
Conclusions Low dose (1.25 mg) ramipril once daily has no effect on cardiovascular and renal outcomes of patients with type 2 diabetes and albuminuria, despite a slight decrease in blood pressure and urinary albumin. The cardiovascular benefits of a daily higher dose (10 mg) ramipril observed elsewhere are not found with an eightfold lower daily dose.
doi:10.1136/bmj.37970.629537.0D
PMCID: PMC351842  PMID: 14960504
23.  Physical Activity Alters Urinary Albumin/ Creatinine Ratio in Type 1 Diabetic Patient 
While the best way to identify microalbuminuria is to determine albumin excretion rate (AER) in a 24 h urine sample. Published data have shown that calculation of an albumin/creatinine ratio (ACR) in a spot urine sample has reasonable rate of sensitivity and specificity. We aimed to evaluate the effect of daily exercise on ACR and estimate the best time for the examination of the ACR in a spot urine sample. Sixteen eligible patients with Type 1 diabetes mellitus were asked to perform varying degree of exercise periods. Urinary albumin and creatinine excretion rates during each period were determined. ACR and AER of timed urinary samples were compared with the 24 hour urinary AER. We found significant correlations between timed and 24 hour urinary AER. According to diagnostic performance tests, ACR and AER of timed urine samples were both found to be significantly more sensitive during resting period when compared with mild or moderate active periods. It is concluded that ACR and AER of a timed urine sample are sensitive and specific methods for determining microalbuminuria, while overnight resting samples give the impression of being more diagnostic.
Key PointsTimed urine samples can predict microalbuminuria but because of the erroneous urine collections, microalbuminuria measurement should be calculated with creatiniuria measurement.With increasing physical activity during urine collection diagnostic performances of the cut-off values go downhill.For detecting microalbuminuria best results are reached with the early-morning urine samples.
PMCID: PMC3896114  PMID: 24497821
Microalbuminuria; albumin/creatinine ratio; type 1 diabetes mellitus; exercise; nephropathy
24.  Meta-analysis of Urine Heme Dipstick Diagnosis of Schistosoma haematobium Infection, Including Low-Prevalence and Previously-Treated Populations 
Background
Urogenital schistosomiasis remains highly endemic in Africa. Current control is based on drug administration, targeted either to school-age children or to high-risk communities at-large. Urine dipsticks for detection of microhematuria offer an inexpensive means for estimating infection prevalence. However, their diagnostic performance has not been systematically evaluated after community treatment, or in areas with continuing low prevalence. The objective of the present study was to perform meta-analysis of dipstick accuracy for S. haematobium infection in endemic regions, with special attention to performance where infection intensity or prevalence was low.
Methodology/Principal Findings
This review was registered at inception with PROSPERO (CRD42012002165). Included studies were identified by computerized search of online databases and hand search of bibliographies and existing study archives. Eligible studies included published or unpublished population surveys irrespective of date, location, or language that compared dipstick diagnosis of S. haematobium infection to standard egg-count parasitology. For 95 included surveys, variation in dipstick sensitivity and specificity were evaluated according to study size, age- and sex-specific participation, region, local prevalence, treatment status, and other factors potentially affecting test performance. Independent of prevalence, accuracy was greater in surveys of school-age children (vs. adults), whereas performance was less good in North Africa, as compared to other regions. By hierarchical ROC analysis, overall dipstick sensitivity and specificity for detection of egg-positive urine were estimated at 81% and 89%, respectively. Sensitivity was lower among treated populations (72%) and in population subgroups having lower intensity infection (65%). When the insensitivity of egg count testing was considered (and diagnosis inferred instead from combined hematuria and egg-count findings), overall dipstick sensitivity/specificity were 82%/97%, with significantly better sensitivity (92%) in high prevalence settings.
Conclusions/Significance
This analysis suggests that dipsticks will continue to serve as very useful adjuncts for monitoring community prevalence following implementation of population-based control of urogenital schistosomiasis.
Author Summary
Schistosomiasis is a chronic human disease caused by infection with multicellular trematode parasites of Schistosoma species. In particular, Schistosoma haematobium colonizes the veins in the pelvis, in and around the urinary tract, and causes inflammation that leads to ulceration and bleeding into the urine. One low-tech, inexpensive means of quickly identifying blood in the urine (hematuria) is to use a chemical reagent strip (dipstick) to test a patient's urine. While many studies have confirmed the usefulness of dipstick-detected hematuria as a proxy for infection in diagnosing infected people before treatment is given, their diagnostic performance after treatment has been uncertain. The current study systematically reviewed 95 available reports of dipstick performance in S. haematobium-endemic areas of Africa and determined, based on a meta-analysis of the primary data, that dipsticks appear to retain their diagnostic accuracy in low prevalence areas and after one or more rounds of treatment. This suggests that dipsticks will continue to be very useful tools in tracking and targeting regional requirements for treatment and prevention of S. haematobium infection as current school- and community-based programs go forward.
doi:10.1371/journal.pntd.0002431
PMCID: PMC3772022  PMID: 24069486
25.  Quantifying Proteinuria in Hypertensive Disorders of Pregnancy 
Background. Progressive proteinuria indicates worsening of the condition in hypertensive disorders of pregnancy and hence its quantification guides clinician in decision making and treatment planning. Objective. To evaluate the efficacy of spot dipstick analysis and urinary protein-creatinine ratio (UPCR) in hypertensive disease of pregnancy for predicting 24-hour proteinuria. Subjects and Methods. A total of 102 patients qualifying inclusion criteria were evaluated with preadmission urine dipstick test and UPCR performed on spot voided sample. After admission, the entire 24-hour urine sample was collected and analysed for daily protein excretion. Dipstick estimation and UPCR were compared to the 24-hour results. Results. Seventy-eight patients (76.5%) had significant proteinuria of more than 300 mg/24 h. Dipstick method showed 59% sensitivity and 67% specificity for prediction of significant proteinuria. Area under curve for UPCR was 0.89 (95% CI: 0.83 to 0.95, P < 0.001) showing 82% sensitivity and 12.5% false positive rate for cutoff value of 0.45. Higher cutoff values (1.46 and 1.83) predicted heavy proteinuria (2 g and 3 g/24 h, resp.). Conclusion. This study suggests that random urinary protein : creatine ratio is a reliable investigation compared to dipstick method to assess proteinuria in hypertensive pregnant women. However, clinical laboratories should standardize the reference values for their setup.
doi:10.1155/2014/941408
PMCID: PMC4181784  PMID: 25302114

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