Is Screening for Microalbuminuria in Patients with Type 2 Diabetes Feasible in the Cape Town Public Sector Primary Care Context? A Cost and Consequence Study

Background: Type 2 diabetes contributes significantly to the burden of disease in South Africa. Proteinuria is a marker for chronic kidney and cardiovascular disease. All guidelines recommend testing for microalbuminuria because intervention at this stage can prevent or delay the onset of disease. Currently; none of the community health centres (CHCs) in Cape Town test for microalbuminuria; and there are concerns about its costs and feasibility. Objectives: The aim of this study was to assess the practicality; costs and consequences of introducing a screening test for microalbuminuria into primary care. Design: Chronic care teams were trained to screen and treat all patients with diabetes (n = 1 675) over a one-year period. The fidelity of screening; costs and consequences was evaluated. Setting and subjects: Patients with type 2 diabetes and chronic care teams at two community health centres in the Cape Town Metro district. Outcome measures: Data to evaluate screening were extracted from the records of 342 randomly selected patients. Data to evaluate treatment were taken from the records of all 140 patients diagnosed with microalbuminuria. Results: Of the patients with diabetes; 14.6 already had macroalbuminuria. Of the eligible patients; 69.9 completed the screening process which led to a diagnosis of microalbuminuria in another 11.7. Of those who were positively diagnosed; the opportunity to initiate angiotensin-converting enzyme (ACE) inhibitors was missed in 20; while 49.2 had ACE inhibitors initiated; or the dosage thereof increased. It would cost the health system an additional R1 463 to screen 100 patients and provide additional ACE inhibitor treatment for a year to the 12 that were diagnosed. Conclusion: The study demonstrated the feasibility of incorporating microalbuminuria testing into routine care. The costs involved were minimal; compared to the likely benefits of preventing end-stage renal failure and the costs of dialysis (estimated at R120 000 per year per patient)

Effects of the Sikle Cell (S) Gene on Serum Protein Profile

Total serum protein, albumin, total globulin levels, albumin/globulin ratio as well as the various globulin fractions were determined in 96 subjects, 39 are sickle cell (SS) disease subjects (steady state), and 30 are heterozygous sickle cell (AS) trait and 27 normal control subjects. The mean standard deviation of total protein was significantly higher (P< 0.05) in sickle cell disease when compared with heterozygous AS and normal controls. There was also significant difference (P<0.05) between AS and AA. The albumin level in sickle cell disease was significantly higher than in the other two groups. There was hyperglobuneamia observed in SS individuals with a mean ±SD of 32.6±10.0g/L when compared with AS and AA subjects with a mean ±SD of 30.8± 5.9g/L and 26.7±6.2g/L respectively. There also exist a significant difference between AS and AA (P <0.005). The Albumin/Globulin ratio is significantly lower (P <0.05) in SS than the other two groups but there was no significant difference (P>0.05) observed between AS and AA controls. The globulin fractions were observed to be higher in AS individuals except the gamma globulin which is higher in SS subjects. The hyperproteineamia as a result of the hyperglobulineamia is due to the globulin fraction present in the serum of SS individuals. The AS individuals are protected from various infectious disease conditions because of the high acute phase reactants and ß- globulin present in their serum as these has been observed to exert some immunioregulatory role