A 9-year-old boy with known type 1 diabetes for 4 years presents with persistent microalbuminuria (urine albumin-to-creatinine ratio 45 mg/g) on two of three first-morning samples over 6 months. Blood pressure is normal. HbA1c is 8.8%. What is the most appropriate next step in management?

• A Intensify glycemic control alone and recheck in 3 months
• B Start a calcium channel blocker
• C Refer for renal biopsy
• D Initiate an ACE inhibitor (enalapril) ✓

Explanation

Persistent microalbuminuria in a child with type 1 diabetes (>3 years duration) is the earliest clinical marker of diabetic nephropathy. ADA and ISPAD guidelines recommend starting an ACE inhibitor (or ARB) once persistent microalbuminuria is confirmed on two of three samples, even with normal blood pressure, to reduce intraglomerular pressure and slow progression. Glycemic optimization is important but pharmacologic renoprotection is indicated at this stage. Renal biopsy is not needed when the clinical picture is consistent with diabetic nephropathy.

Reference: Nelson Textbook of Pediatrics, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.