From Baltimore, Maryland, USA:
My 11 year old daughter was diagnosed with Type 1 diabetes 2 1/2 years ago. Recently, there has been protein in her urine. After a 24 hour urine titration (with no exercise), her diabetes team feels she has something called "orthostatic protein". Should I be overly concerned about this? What exactly does this mean? She is in good control, but incredibly active.
Orthostatic proteinuria - protein leaking into the urine when a person is upright - is relatively common. Provided your daughter has no proteinuria when she is supine (lying down), then this is probably of no significance. It is really too early anyway for her to have diabetes-related proteinuria unless her diabetic control were very poor.
[Editor's comment: This question, about orthostatic urine protein, caused some concern amongst some of our readers. Protein in the urine is rarely normal; Dr. Robertson discusses one of the few circumstances where it is okay.
Diabetic kidney changes can sometimes be detected even earlier by measuring a special version of urine protein, called microalbumin (or when measured in the urine, microalbuminuria). I have asked Steph Schwartz to discuss some of the issues about measuring microalbumin in kids with diabetes (see below). WWQ]
Additional Comments from Stephanie Schwartz, diabetes nurse specialist:In the ISPAD standards of care for children and adolescents with diabetes, the screening process for kidney complications is clearly delineated. I believe that these standards are practiced by the majority of pediatric endocrinologists caring for multitudes of children with diabetes. Indeed, Luther Travis, MD, CDE (who happens to be a nephrologist) has a detailed protocol for screening including not only microalbumin testing but assessing trends in blood pressure measurements according to norms as well.
In our program we do the following: all kids older than 12 and those under 12 who have had diabetes for more than 5 years have 24 urine collections done for microalbumin annually. Children under 12 who have had diabetes less than 5 years are screened every 3 years in the same manner. All newly diagnosed kids have 24 urine collections for microalbumin done about 2 months after diagnosis (i.e., after blood glucose levels are fairly stable). If the result is greater than 30mcg/minute, a repeat split sample (day vs. night) is done. This is because growing children, especially those who are very athletic, can spill microalbumin during daytime hours but will not at night. If this is greater than 30mcg/minute, the child is started on ACE inhibitors.
A recent article in Practical Diabetology suggested than initial screens for microalbumin can be performed on a first morning void using a dipstick method. This is a much easier sample to obtain. Accurate 24 hour collections are extremely difficult to do as anyone who has done them will attest. A 24 hour collection should then be done if this is positive. The authors go on to say that treatment should be initiated if the result is greater than 20mcg/minute.
Dr. Travis has suggested that ACE inhibitors should be used if BP measurements deviate one channel from the child's norm even in the absence of microalbuminuria.
Two additional thoughts --- since microalbuminuria/proteinuria can be exercised induced, collections should not be done on days when a child will be engaged in such activities. Additionally, since vaginal discharges can produce erroneous results, I suggest that collections are not obtained if there is a vaginal discharge and in menstruating girls, 24 hour urine collections should always be done in mid-cycle.
Hope this information is helpful.
Original posting 29 Oct 1998
Additional comments added 7 Nov 1998
Posted to Complications
Last Updated: Tuesday April 06, 2010 15:09:02
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