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Microalbuminuria

Microalbuminuria 

  • Although microalbuminuria is generally identified as an early maker of kidney disease it has now been firmly established as a potent predictor for the development of severe CAD (coronary artery disease) as well as a prognostic marker in people with pre-existing CAD. People with microalbuminuria usually have greater burden of atherosclerosis.
  • Microalbuminuria is also an independent predictor of cardiovascular (CVD) and all-cause mortality in people with and without diabetes or hypertension.1 As a result, patients with microalbuminuria need to be treated more aggressively especially in the presence of CAD.
  • Microalbuminuria is a common accompaniment of metabolic syndrome, chronic kidney disease, and CAD. Recent research indicates that the three conditions appear to be intertwined. 2, 3 4
  • Overconsumption of calories and/or their underutilization is resulting in an explosion of metabolic syndrome world-wide. Because of its high prevalence, some experts have even recommended including microalbuminuria as one of the components of metabolic syndrome.5 Intensive exercise and weight loss in individuals with metabolic syndrome result in improvement of kidney function.6
  • Hypertension and diabetes are associated with a 2 to 3-fold increase in microalbuminuria and it may be an early marker of renal disease in people with these conditions.7-9 Treatment of hypertension and diabetes particularly with angiotensin converting enzyme inhibitors (ACEI) and AT1-receptor blockers (ARBS) improve insulin sensitivity and ameliorate microalbuminuria in addition to their well documented cardiac and renal protective effects.10
  • Dyslipidemia, particularly high triglyceride and low HDL, are highly correlated with microalbuminuria and chronic kidney disease and treatment of dyslipidemia may reduce the progression of kidney disease.11-13
  • Statin use may retard the progression of renal dysfunction, which appears to be independent of their lipid-lowering effect.14
  • Metformin is contraindicate in patients with impaired renal function, but has shown to be effective in preventing the development of diabetes in pre-diabetic individuals.15
  • Clinical trials are clearly documented that changes in albuminuria over time with treatment translate to changes in cardiovascular risk. As a result, monitoring of albuminuria should be an integrated part of the management of hypertension and diabetes. If albuminuria is not decreased by the patient’s current treatment, further intervention with ACE-inhibitors or ARBS should be undertaken along with control and other modifiable risks factors.4, 16
  • Ramipril treatment has been shown to reduce coronary events and nephropathy in high risk patients.17, 18  Likewise, treatment with fosinopril and losartan significantly decreased microalbuminuria as well as CVD events.19, 20A target-driven, long-term, intensified intervention aimed at multiple risk factors in patients with diabetes and microalbuminuria has been shown to reduce CVD and microvascular events by about 50 percent.21

Sources 

1. Jarrett RJ, Viberti GC, Argyropoulos A, Hill RD, Mahmud U, Murrells TJ. Microalbuminuria predicts mortality in non-insulin-dependent diabetics. Diabet Med. May 1984;1(1):17-19.

2. Borch-Johnsen K, Feldt-Rasmussen B, Strandgaard S, Schroll M, Jensen JS. Urinary albumin excretion. An independent predictor of ischemic heart disease. Arterioscler Thromb Vasc Biol. 1999;19(8):1992-1997.

3. Sukhija R, Aronow WS, Kakar P, et al. Relation of microalbuminuria and coronary artery disease in patients with and without diabetes mellitus. Am J Cardiol. Aug 1 2006;98(3):279-281.

4. Gobal F, Deshmukh A, Shah S, Mehta JL. Triad of metabolic syndrome, chronic kidney disease, and coronary heart disease with a focus on microalbuminuria death by overeating. J Am Coll Cardiol. Jun 7 2011;57(23):2303-2308.

5. Palaniappan L, Carnethon M, Fortmann SP. Association between microalbuminuria and the metabolic syndrome: NHANES III. Am J Hypertens. Nov 2003;16(11 Pt 1):952-958.

6. Lindstrom J, Louheranta A, Mannelin M, et al. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care. Dec 2003;26(12):3230-3236.

7. Hodge AM, Dowse GK, Zimmet PZ. Microalbuminuria, cardiovascular risk factors, and insulin resistance in two populations with a high risk of type 2 diabetes mellitus. Diabet Med. May 1996;13(5):441-449.

8. Jiang X, Srinivasan SR, Radhakrishnamurthy B, Dalferes ER, Jr., Bao W, Berenson GS. Microalbuminuria in young adults related to blood pressure in a biracial (black-white) population. The Bogalusa Heart Study. Am J Hypertens. Sep 1994;7(9 Pt 1):794-800.

9. Srinivasan SR, Myers L, Berenson GS. Risk variables of insulin resistance syndrome in African-American and Caucasian young adults with microalbuminuria: the Bogalusa Heart Study. Am J Hypertens. Dec 2000;13(12):1274-1279.

10. Sharma AM. Is there a rationale for angiotensin blockade in the management of obesity hypertension? Hypertension. Jul 2004;44(1):12-19.

11. Manttari M, Tiula E, Alikoski T, Manninen V. Effects of hypertension and dyslipidemia on the decline in renal function. Hypertension. Oct 1995;26(4):670-675.

12. Fried L F, Orchard TJ, Kasiske BL. Effect of lipid reduction on the progression of renal disease: a meta- analysis. Kidney Int. 2001;59(1):260-269.

13. Muntner P, Coresh J, Smith JC, Eckfeldt J, Klag MJ. Plasma lipids and risk of developing renal dysfunction: the atherosclerosis risk in communities study. Kidney Int. Jul 2000;58(1):293-301.

14. Sukhija R, Bursac Z, Kakar P, et al. Effect of statins on the development of renal dysfunction. Am J Cardiol. Apr 1 2008;101(7):975-979.

15. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.

16. Ibsen H, Olsen MH, Wachtell K, et al. Reduction in albuminuria translates to reduction in cardiovascular events in hypertensive patients: losartan intervention for endpoint reduction in hypertension study. Hypertension. Feb 2005;45(2):198-202.

17.Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators [see comments] [published erratum appears in N Engl J Med 2000 Mar 9;342(10):748]. N Engl J Med. 2000;342(3):145-153.

18. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet. Jan 22 2000;355(9200):253-259.

19. Asselbergs FW, Diercks GF, Hillege HL, et al. Effects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria. Circulation. Nov 2 2004;110(18):2809-2816.

20. Ibsen H, Wachtell K, Olsen MH, et al. Does albuminuria predict cardiovascular outcome on treatment with losartan versus atenolol in hypertension with left ventricular hypertrophy? A LIFE substudy. J Hypertens. Sep 2004;22(9):1805-1811.

21. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. Jan 30 2003;348(5):383-393.

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