Conclusions And Recommendations

Measuring the UAER is a well documented and a well established part of monitoring Type 1 diabetic patients. The most simple urine sampling procedures can be used as long as the UAER is not significantly elevated i.e. as long as the albumin/ creatinine index is below 3.5 |g/mmol. It should be examined at least once a year. When microalbuminuria is suspected, a method of quantitating the UAER should be used at all subsequent visits in the outpatient clinic or until it is found normal at three consecutive visits. Presence of microalbuminuria warrants intensified follow up in order to diagnose and to intervene against retinopathy, nephropathy, hypertension and, if necessary to optimize the glycaemic control [89].

In patients with Type 2 diabetes, the UAER should be measured at diagnosis and once a year. Measuring the UAER is part of the general description of the cardiovascular risk profile of the individual patient. If the UAER is elevated treatment with ACE inhibitors or AII antagonists should be started; a multifactorial intervention strategy should be implemented [55].

Among non-diabetic subjects an increased UAER is a marker of cardiovascular disease as well as a risk factor of premature death. Examining the UAER is recommended as part of the routine medical check up of the adult and to replace the less sensitive examination for protein in the urine, which after all only serves to disclose diseases of the kidneys and the urinary tract. Examining of UAER should be restricted to those with presence of other modifyable risk factors such as dyslipidemia, arterial hypertension and other signs of the metabolic syndrome. As was the case in Type 2 diabetic patients presence of increased values will reinforce the need to intervene against any other risk factor present. Values of UAER above the microalbuminuric range should obviously lead to routine examinations to exclude nephro-urological diseases. The significance of an increased UAER on development of cardiovascular disease is to some extent clarified but so far no direct clinical consequences should be drawn of microalbuminuria per se.

Among non-diabetic subjects the present indications are that UAER is significantly elevated and predictive of disease at a much lower level than in diabetic patients i.e. at a level below the classical definition of microalbuminuria. Further research is needed for this clarification as well as for the investigation of interventional measures. Microalbuminuria is therefore still in focus in numerous epidemiological and pathophysiological studies.

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DYSFUNCTION OF THE VASCULAR ENDOTHELIUM AND THE DEVELOPMENT OF RENAL AND VASCULAR COMPLICATIONS IN DIABETES

Coen D.A. Stehouwer

Department of Internal Medicine and Institute for Cardiovascular Research, VU University Medical Centre, 1081 HVAmsterdam, the Netherlands

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