Microalbumin and heart disease

Cardiovascular disease is the biggest cause of morbidity and mortality in the western world and despite all the advances in medical practice, the burden continues to increase. As a doctor, I have realized that there are several problems with the way we do things which probably contributes to the increasing prevalence of cardiovascular complications.

Firstly a lot of the emphasis on management of a condition is based on treating the condition and a lot less emphasis is placed on preventing the condition from developing in the first place.Unfortunately once the condition has developed, more often than not, it is impossible to reverse it and you spend all your time managing its complications. This is the equivalent of covering a problem with a sticking plaster and hoping that the problem will go away rather than examining and addressing the root cause of the problem.

Secondly the markers we use to diagnose a condition are late markers or may be even the wrong markers altogether. For example in diabetes, we use blood sugar or HbA1c as the test for diagnosing diabetes. Unfortunately however there are several studies which show that upto 26% of newly diagnosed diabetics have already got evidence of kidney disease, 24% have lower extremity disease, 12% have eye disease and 17% have cardiovascular disease. If you are using a marker to diagnose a condition because you want prevent complications but by the time that the marker has helped you make the diagnosis, a quarter of the patients have already developed the complications of the condition and many of these complications develop over a number of years then clearly we are relying on a very unsophisticated or even a wrong marker. Surely a better marker would be that which picks up the condition before the complications develop. So why do we continue to persevere with using HbA1c as a test to diagnose diabetes? The answer is because we are told to. This is what the guidelines say and we are protocol-bound doctors and many of us have lost the ability to think for ourselves any more. Unfortunately the guidelines are based around managing populations and always have a cost-effectiveness agenda. So doctors have assumed a number as the be-all and end-all determinant of whether you have a harmful process or not when it is so obvious that the number does not pick up the harmful process just as it is beginning but instead rises somewhere in the middle of the course of that harmful process. What this means is that there may be a number of people out there who have a harmful process going on in their bodies without knowing and they are falsely assured by their doctors that they don’t have the condition because the number has not risen above a certain man-defined threshold. It is also bemusing to note that that man-made threshold and those goal posts are shifted every few years.

Finally, even though the number is a poor guide to the process, we spend all our time treating the number or making the number looking prettier without really seeing whether our treatment is reversing the process. In diabetes, a lot of our management is about making the HbAic numbers appear nicer but actually this strategy has not been shown to actually prevent some of the macrovascular complications such as heart attacks and strokes. So we use the wrong marker and we spend our time treating this wrong marke so is it really a surprise then when the burden of complications continues to increase.

As the whole of the medical fraternity becomes more protocol–centered and less patient-centered, it becomes important that patients take matters thin their own hands and try and educate themselves so that they can advocate for themselves and asks for those tests which may allow us to look for harmful processes within our body rather than relying on the crude that medical professionals are advocate.

Today i wanted to talk about a really interesting test that we should be using more often but we don't and this is called Microalbuminura.



If you measure the amount of albumin in a 24h urine collection of a healthy person, the levels are generally less than 15mg/24h. Anything between 15 to 30 is considered high normal and anywhere between 30-300mg is considered in a range known as microalbuminuria. Anything above 300 is considered macroalbuminuria. Unfortunately a lot of doctors rely on the a dipstick of the urine to look for protein in the urine but the dipstick will not detect microalbuminuria because the amount of protein in microalbuminuria is less than the threshold for the urine dipstick test and this is why you have to have a specific test for microalbuminuria. This is usually a 24hour urine collection specifically for measuring urine microalbumin levels.

It is actually a very simple and inexpensive test and in an ideal world should certainly be offered and checked .