The recommendations for prevention and treatment of diabetic nephropathy include: Hemoglobin A1C <6.5, BP <130/80 mm Hg, use of an ACE inhibitor or angiotensin II receptor blocker (ARB), and referral to a nephrologist for glomerular filtration rate <60 mL. Given that these are recommendations for any diabetic irrespective of a diagnosis of diabetic nephropathy, how does screening for microalbuminuria change the management of these patients?—MICHAEL TOPPE, PA-C, Newport, N.C.

I agree that most diabetics are on an ACE inhibitor or ARB for the hypertensive component of metabolic syndrome. (These drugs are chosen to offer renal protection.) However, diabetic patients whose untreated BP is <130/80 mm Hg and who have normal estimated glomerular filtration rate (eGFR) do not have to be put on an ACE inhibitor or ARB unless they develop proteinuria (or their BP or eGFR become abnormal). Clinical guidelines from the Joslin Diabetes Center recommend that urine albumin be measured annually and an ACE inhibitor or ARB initiated once proteinuria is confirmed. Moving forward, the albumin/creatinine (A/C) ratio should be monitored every six months. If the A/C ratio is >300 μg/mL, consider keeping the BP <125/75 mm Hg and reducing protein in the diet.—JoAnn Deasy, PA-C, MPH (142-2)

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