Albuminuria Testing Falling Short in Patients at Risk for CKD

Many cases of albuminuria may be missed in the U.S. due to lack of testing among patients at risk for chronic kidney disease (CKD), a cohort study suggested.

Examining electronic health records for nearly 200,000 patients with hypertension or diabetes, only 17.5% underwent albuminuria testing, reported Chi D. Chu, MD, MAS, of the University of California San Francisco, and colleagues in JAMA Network Open.

Notably, of the 33,629 high-risk patients who had testing, 34.4% had albuminuria, defined as a urine albumin-creatinine ratio (UACR) of 30 mg/g or greater.

Of the 158,479 patients who went untested, Chu’s group estimated there was a 13.4% albuminuria prevalence rate. This would translate to 21,231 patients who may have albuminuria but weren’t screened for it.

Taken together, the authors explained that this meant only 35.2% of the projected population with albuminuria received necessary testing.

“This sizable underdetection of individuals with albuminuria was consistently observed across all demographic and comorbidity subgroups,” they noted, adding that only 10.4% of patients with hypertension and no diabetes were screened, even though 70.4% of patients with undetected albuminuria fell into this category.

When patients were stratified by estimated level of risk for albuminuria, those falling into the highest-risk categories were more likely to undergo testing. However, even those patients who fell into the highest quintile for estimated albuminuria risk, only 36% were tested (7.1% without diabetes and 47.9% with diabetes).

Those who underwent testing had significantly higher odds of receiving subsequent treatment. For example, albuminuria testing was tied to higher odds of treatment with SGLT2 inhibitors (OR 8.22, 95% CI 7.56-8.94), in addition to treatment with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB; OR 2.39, 95% CI 2.32-2.46).

Testing was also associated with having blood pressure controlled to less than 140/90 mm Hg (OR 1.20, 95% CI 1.16-1.23).

“Early detection of CKD among individuals at risk for CKD, such as those with hypertension or diabetes, is necessary to ensure optimal dissemination of disease-modifying CKD therapies,” Chu and team wrote.

Even though annual albuminuria testing “has long been guideline-recommended” for people with diabetes, they pointed out that testing rates consistently fall under the 50% mark. Rates are even lower for people without diabetes but with hypertension, who only get tested around 10% of the time. Putting this into perspective, estimated glomerular filtration rate (eGFR) testing is conducted in about 90% of patients with hypertension or diabetes.

“Improving uptake of guideline-directed therapies, including ACE [inhibitors] or ARB, SGLT2 [inhibitors], and nonsteroidal mineralocorticoid antagonists among individuals with CKD and albuminuria represents a critical opportunity to curb CKD progression and related kidney and cardiovascular complications,” they noted.

Data for the study came from a random sample of the U.S.-based Optum de-identified electronic health record dataset. This included adults with at least two outpatient visits from January 2017 through December 2018 with either diabetes or hypertension.

Of the 192,108 patients included in the analysis, 55% were women, 10.9% were Black, 96.6% had hypertension, and 26.2% had diabetes. Mean age was 60.3, and mean eGFR was 84 mL/min/1.73 m². More than half had commercial insurance, and about a third were on Medicare.

Chu’s group noted that they didn’t take alternative measures of albuminuria other than the standard UACR testing into account, like urine protein-creatinine ratio, 24-hour urine albumin or protein quantification, or urine dipstick protein, which they considered a limitation to their study.

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