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Related to Microalbumin: creatinine, Microalbuminuria
Synonym/acronym: Albumin, urine.
To assist in the identification and management of early diabetes in order to avoid or delay onset of diabetic associated renal disease.
SpecimenUrine (10 mL) from a random or timed specimen collected in a clean plastic collection container.
Simultaneous measurement of urine creatinine or creatinine clearance may be requested. Normal ratio of microalbumin to creatinine is less than 30:1 or 0–30 mg microalbumin/g creatinine/24 hr. The American Diabetes Association recommends annual measurement of serum creatinine and eGFR regardless of microalbumin levels; numerous factors such as hydration status, the presence of an infection, or significant hyperglycemia can produce falsely increased or decreased microalbumin levels. Therefore, the ADA recommends classification of microalbuminuria after two of three 24-hr samples collected in a 3–6 month period reflect abnormal results. The National Kidney Foundation defines microalbuminuria as equal to or greater than 30 mg/g creatinine/24 hr based on eGFR measurements.
|Test||Conventional Units||SI Units (Conventional Units x.001)|
|Random microalbumin||Less than 30 mcg albumin/mg creatinine||Less than 0.03 mg albumin/g creatinine|
|Normal||Less than 30 mg/g creatinine/24 hr||Less than 0.03 mg/g creatinine/24 hr|
|Microalbuminuria||30–299 mg/g creatinine/24 hr||0.03–0.3 mg/g creatinine/24 hr|
|Clinical albuminuria||300 mg or greater/g creatinine/24 hr||0.3 mg or greater/g creatinine/24 hr|
The term microalbumin describes concentrations of albumin in urine that are greater than normal but undetectable by dipstick or traditional spectrophotometry methods. Microalbuminuria precedes the nephropathy associated with diabetes and is often elevated years before creatinine clearance shows abnormal values. Studies have shown that the median duration from onset of microalbuminuria to development of nephropathy is 5 to 7 yr.
This procedure is contraindicated for
- Evaluate renal disease
- Screen diabetic patients for early signs of nephropathy
Conditions resulting in increased renal excretion or loss of protein.
- Diabetic nephropathy
- Hypertension (uncontrolled)
- Renal disease
- Urinary tract infections
- Drugs that may decrease microalbumin levels include captopril, dipyridamole, enalapril, furosemide, indapamide, perindopril, quinapril, ramipril, tolrestat, and simvastatin (Triflusal).
- All urine voided for the timed collection period must be included in the collection, or else falsely decreased values may be obtained. Compare output records with volume collected to verify that all voids were included in the collection.
Nursing Implications and Procedure
Potential nursing problems
|Problem||Signs & Symptoms||Interventions|
|Blood glucose (Related to sedentary lifestyle, circulating insulin deficiency secondary to pancreatic insufficiency; excessive dietary intake; insulin resistance; pregnancy)||Excess: Fatigue; mild dehydration; elevated blood glucose; weight loss; weakness; polyuria; polydipsia; polyphagia; blurred vision; headache; paresthesia; poor skin turgor; dry mouth; nausea; vomiting; abdominal pain; Kussmaul respirations. Deficit: tremor, sweating, decreased concentration; diaphoresis; elevated blood pressure; palpitations; headache; hunger; restlessness; lethargy; altered mental status; combativeness; altered speech; altered coordination||Check blood glucose before meals and at bedtime; administer prescribed insulin or oral agents; educate and encourage the patient to participate in glucose self-check and record results; assess readiness to learn and barriers to learning; collaborate with the health-care provider (HCP) and dietician to support medical nutritional therapy; work with dietician to assist the patient to select appropriate cultural foods; develop a plan of exercise commensurate with the patient’s physical abilities; discuss lifestyle alterations necessary to support positive health management secondary to disease process; teach good hygiene and infection prevention; monitor laboratory studies that may be impacted by altered glucose and trend results (HGB A1C; BUN; Cr; electrolytes; arterial pH; magnesium; urine ketones; urine microalbumin; WBC; amylase; HGB/HCT; WBC; C-reactive protein; liver enzymes); facilitate oral hydration; correlate blood glucose with other laboratory values and medical condition(s); address the psychosocial aspects of the disease; monitor serum insulin levels|
|Nutrition (Related to excessive dietary intake more than body requirements, insulin deficiency, stress; anxiety; depression; cultural lifestyle; unhealthy food sources; financial restrictions)||Increased thirst, increased urination, weight loss; fatigue; elevated blood glucose levels; inadequate glucose management; increased hunger||Monitor blood glucose results, refer to dietician for evaluation, administer insulin or oral agent; assess the cultural aspects of diet selection; correlate dietary intake with blood glucose and monitor trends; collaborate with a dietician to develop a cultural- and age-appropriate diet plan; correlate nutritional intake and exercise; ensure that the patient understands the relationship between caloric intake and medication (insulin, oral agent); provide social services, dietary referrals if necessary|
|Renal impairment (Related to elevated blood glucose levels over time; decreased renal perfusion; prolonged hypotension; heart disease with altered cardiac output)||Altered fluid, electrolyte, and acid base balance; decreasing urinary output; elevated blood glucose||Review and trend diagnostic tests (BUN, Cr, urine osmolality, creatinine clearance, microalbumin, blood glucose); teach accurate self-administration of medication to control blood pressure and blood glucose; teach accurate monitoring of blood glucose; ensure compliance with recommended dietary and exercise regimes; monitor and trend glomerular filtration rate|
|Health management (Related to complexity of health-care system; complexity of therapeutic management; altered metabolic process resulting in increased or decreased potassium; knowledge deficit; conflicted decision making; cultural family health patterns; barriers to healthy decisions; mistrust of HCP)||Health choices are ineffective in making a difference on outcomes; increasing symptoms of illness; verbalizes that therapeutic regime is too difficult; patient and family do not support HCP’s suggestions for health improvement; refusal to follow recommended therapeutic regime||Assess effort to follow recommended regime; assess family or cultural factors that impact the success of the therapeutic regime; assess the patient’s self-assessment of his or her health status; include the patient and family in designing the plan of care; tailor the plan of care to the patient’s lifestyle; collaborate with the patient and family to develop a system of managing own health; focus on behaviors that will make the biggest positive impact on improved health|
- Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
- Patient Teaching: Inform the patient this test can assist in evaluating for early kidney disease.
- Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
- Obtain a history of the patient’s endocrine and genitourinary systems, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
- Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
- Review the procedure with the patient. Provide a nonmetallic urinal, bedpan, or toilet-mounted collection device. Address concerns about pain and explain that there should be no discomfort during the procedure.
- Usually a 24-hr time frame for urine collection is ordered. Inform the patient that all urine must be saved during that 24-hr period. Instruct the patient not to void directly into the laboratory collection container. Instruct the patient to avoid defecating in the collection device and to keep toilet tissue out of the collection device to prevent contamination of the specimen. Place a sign in the bathroom to remind the patient to save all urine.
- Instruct the patient to void all urine into the collection device and then to pour the urine into the laboratory collection container. Alternatively, the specimen can be left in the collection device for a health-care staff member to add to the laboratory collection container.
- Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
- Instruct the patient to avoid excessive exercise and stress during the 24-hr collection of urine.
- Note that there are no food, fluid, or medication restrictions unless by medical direction.
- Potential complications: N/A
- Ensure that the patient has complied with activity restrictions during the procedure.
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Instruct the patient to cooperate fully and to follow directions.
- Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
- Clean-Catch Specimen
- Instruct the male patient to (1) thoroughly wash his hands, (2) cleanse the meatus, (3) void a small amount into the toilet, and (4) void directly into the specimen container.
- Instruct the female patient to (1) thoroughly wash her hands; (2) cleanse the labia from front to back; (3) while keeping the labia separated, void a small amount into the toilet; and (4) without interrupting the urine stream, void directly into the specimen container.
- Put on gloves. Empty drainage tube of urine. It may be necessary to clamp off the catheter for 15 to 30 min before specimen collection. Cleanse specimen port with antiseptic swab, and then aspirate 5 mL of urine with a 21- to 25-gauge needle and syringe. Transfer urine to a sterile container.
- Obtain a clean 3-L urine specimen container, toilet-mounted collection device, and plastic bag (for transport of the specimen container). The specimen must be refrigerated or kept on ice throughout the entire collection period. If an indwelling urinary catheter is in place, the drainage bag must be kept on ice.
- Begin the test between 6 and 8 a.m. if possible. Collect first voiding and discard. Record the time the specimen was discarded as the beginning of the timed collection period. The next morning, ask the patient to void at the same time the collection was started and add this last voiding to the container. Urinary output should be recorded throughout the collection time.
- If an indwelling catheter is in place, replace the tubing and container system at the start of the collection time. Keep the container system on ice during the collection period, or empty the urine into a larger container periodically during the collection period; monitor to ensure continued drainage, and conclude the test the next morning at the same hour the collection was begun.
- At the conclusion of the test, compare the quantity of urine with the urinary output record for the collection; if the specimen contains less than what was recorded as output, some urine may have been discarded, invalidating the test.
- Include on the collection container’s label the amount of urine and test start and stop times.
- Promptly transport the specimen to the laboratory for processing and analysis.
Random Specimen (Collect in Early Morning)
- Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
- Nutritional Considerations: Increased levels of microalbumin may be associated with diabetes. There is no “diabetic diet”; however, many meal-planning approaches with nutritional goals are endorsed by the American Dietetic Association (ADA). Patients who adhere to dietary recommendations report a better general feeling of health, better weight management, greater control of glucose and lipid values, and improved use of insulin. Instruct the patient, as appropriate, in nutritional management of diabetes. The 2013 Guideline on Lifestyle Management to Reduce Cardiovascular Risk published by the American College of Cardiology (ACC) and the American Heart Association (AHA) in conjunction with the National Heart, Lung, and Blood Institute (NHLBI) recommends a “Mediterranean”-style diet rather than a low-fat diet. The new guideline emphasizes inclusion of vegetables, whole grains, fruits, low-fat dairy, nuts, legumes, and nontropical vegetable oils (e.g., olive, canola, peanut, sunflower, flaxseed) along with fish and lean poultry. A similar dietary pattern known as the Dietary Approaches to Stop Hypertension (DASH) diet makes additional recommendations for the reduction of dietary sodium. Both dietary styles emphasize a reduction in consumption of red meats, which are high in saturated fats and cholesterol, and other foods containing sugar, saturated fats, trans fats, and sodium. If triglycerides also are elevated, the patient should be advised to eliminate or reduce alcohol. The nutritional needs of each diabetic patient need to be determined individually (especially during pregnancy) with the appropriate health-care professionals, particularly professionals trained in nutrition.
- Recognize anxiety related to test results, and be supportive of perceived loss of independence and fear of shortened life expectancy.
- Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. The ADA recommends A1c testing four times a year for patients whose treatment plan has changed or who are not meeting treatment goals and twice a year for patients who are meeting treatment goals and have stable, good glycemic control. Testing for microalbumin is recommended annually upon diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Instruct the patient to resume usual activity, as directed by the HCP.
- Instruct the patient and caregiver to report signs and symptoms of hypoglycemia or hyperglycemia.
- Discuss the implications of abnormal test results on the patient’s lifestyle.
- Provide teaching and information regarding the clinical implications of the test results, as appropriate.
- Emphasize, if indicated, that good glycemic control delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy.
- Educate the patient regarding access to counseling services, as appropriate. Provide contact information, if desired, for the American Diabetes Association (www.diabetes.org) or the AHA (www.americanheart.org).
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
- Answer any questions or address any concerns voiced by the patient or family.
- Teach the patient that diabetes that is not controlled can cause multiple health issues including renal failure resulting in necessary dialysis to support life.
Expected Patient Outcomes
- States understanding that a urine test can assess for early renal failure associated with diabetes
- States understanding that renal failure can lead to death
- Demonstrates proficiency in the ability to perform a self-check glucose accurately
- Demonstrates proficiency in the ability to perform insulin self-administration correctly or to take oral agent
- Complies with the HCP-recommended therapeutic regime to manage diabetes
- Complies with the recommendation to attend support groups to learn how to manage disease process
- Related tests include A/G ratio, angiography renal, blood pool imaging, BUN, CBC, cortisol, creatinine, creatinine clearance, culture urine, cystometry, cystoscopy, cytology urine, echocardiography, echocardiography transesophageal, EPO, fluorescein angiography, fundus photography, glucose, GTT, glycated hemoglobin, gonioscopy, Holter monitor, insulin, insulin antibodies, magnesium, protein total and fractions, renogram, UA, visual fields test, and voiding cystourethrography.
- Refer to the Endocrine and Genitourinary systems tables at the end of the book for related tests by body system.