A woman has urinary ketones, a urine microalbumin/creatinine ratio of 67 mg/g (micro‑albuminuria) and dipstick protein 2+. What is the likely diagnosis and what immediate work‑up and management are recommended?

Likely Diagnosis and Immediate Management

This patient most likely has diabetic ketoacidosis (DKA) with underlying diabetic kidney disease, and requires immediate assessment of blood glucose, serum electrolytes, arterial blood gas, and serum creatinine to confirm DKA and evaluate renal function.

Immediate Diagnostic Work-Up

Confirm Diabetic Ketoacidosis

• Measure capillary or venous blood glucose immediately; DKA typically presents with glucose >250 mg/dL 1
• Obtain arterial or venous blood gas to document metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L) 1
• Check serum or urine ketones (already positive on dipstick, but quantification guides management) 1
• Measure serum electrolytes including sodium, potassium, chloride, and calculate anion gap 1

Assess Renal Function and Confirm Albuminuria

• Measure serum creatinine and calculate eGFR using the CKD-EPI equation to determine baseline kidney function 1, 2
• The urine microalbumin/creatinine ratio of 67 mg/g confirms moderately increased albuminuria (formerly microalbuminuria, 30–299 mg/g range) 1, 2
• The dipstick protein 2+ suggests the albumin excretion may be higher than the spot ratio indicates, or reflects concentrated urine 3
• Repeat the albumin-to-creatinine ratio on two additional first-morning urine samples over 3–6 months after DKA resolves to confirm persistent albuminuria, as marked hyperglycemia and ketoacidosis are transient causes of elevated albumin excretion 1, 2

Exclude Other Causes of Proteinuria

• Rule out urinary tract infection with urinalysis and culture, as infection causes transient albuminuria 1, 2
• Assess for congestive heart failure clinically and with chest X-ray if indicated, as volume overload elevates albumin excretion 2
• Document whether the patient exercised vigorously within 24 hours, as this transiently raises urinary albumin 1, 2

Immediate Management Priorities

Treat Diabetic Ketoacidosis First

• Initiate intravenous fluid resuscitation with 0.9% normal saline 1
• Start continuous intravenous insulin infusion once potassium is >3.3 mEq/L 1
• Replace potassium aggressively as insulin drives potassium intracellularly 1
• Monitor glucose hourly and add dextrose to fluids when glucose falls below 200–250 mg/dL 1
• Continue insulin infusion until ketones clear and anion gap normalizes 1

Address Albuminuria After DKA Resolves

Confirm Persistent Albuminuria

• Do not diagnose chronic kidney disease based on a single measurement during acute illness; DKA itself causes transient albuminuria 1, 2
• Obtain two additional first-morning urine samples over 3–6 months after metabolic stabilization 1, 2
• Persistent albuminuria is confirmed when ≥2 of 3 samples show ACR ≥30 mg/g 1, 2

Initiate Renoprotective Therapy

• Start an ACE inhibitor or ARB immediately once persistent albuminuria (ACR ≥30 mg/g) is confirmed, regardless of baseline blood pressure 1, 4, 5
• This recommendation applies even in normotensive patients, as these agents reduce progression to macroalbuminuria and lower cardiovascular event rates 1, 4, 5
• Target blood pressure <130/80 mmHg in all patients with confirmed albuminuria 1, 5
• Monitor serum creatinine and potassium 1–2 weeks after starting ACE inhibitor or ARB therapy 1

Optimize Glycemic Control

• Target HbA1c <7% to reduce the risk and slow progression of diabetic kidney disease 1, 4, 5
• Consider adding an SGLT2 inhibitor or GLP-1 receptor agonist, as these classes reduce chronic kidney disease progression and cardiovascular events in type 2 diabetes 1

Lifestyle Modifications

• Provide intensive smoking-cessation counseling if applicable, as smoking accelerates kidney damage 1
• Advise dietary protein restriction to approximately 0.8 g/kg/day (the recommended daily allowance) 1

Monitoring Schedule After Stabilization

• Re-measure ACR at 6 months after initiating ACE inhibitor or ARB therapy to assess response 1
• If a significant reduction is observed, transition to annual ACR testing 1
• Perform annual eGFR assessment when treatment goals are met and eGFR ≥60 mL/min/1.73 m² 1
• Conduct annual dilated retinal examination to screen for diabetic retinopathy, which frequently coexists with diabetic kidney disease 1

Nephrology Referral Criteria

• Refer when eGFR falls below 30 mL/min/1.73 m² for evaluation of renal replacement therapy 1
• Refer for rapidly increasing albuminuria or progression to ACR ≥300 mg/g despite optimal therapy 1
• Refer for rapid decline in eGFR or uncertain etiology of kidney disease 1

Common Pitfalls to Avoid

• Do not diagnose chronic albuminuria during acute metabolic derangement; marked hyperglycemia and ketoacidosis transiently elevate urinary albumin excretion 1, 2
• Do not delay ACE inhibitor or ARB therapy once persistent albuminuria is confirmed; these agents are indicated even with normal blood pressure 1, 4, 5
• Do not rely on dipstick protein alone to quantify albuminuria; standard dipsticks detect protein only above 300 mg/g creatinine, missing the microalbuminuric range 6, 7
• Do not combine an ACE inhibitor with an ARB, as dual therapy raises the risk of hyperkalemia and acute kidney injury without added renal benefit 1