A recent cohort study conducted by researchers at the University of California San Francisco reveals a serious problem in the detection of albuminuria among patients at risk for chronic kidney disease (CKD) in the United States. The study, published in JAMA Network Open, analyzed electronic health records of nearly 200,000 patients with hypertension or diabetes. The findings indicate that only 17.5% of these high-risk patients underwent albuminuria testing, resulting in a significant percentage of cases being missed. This lack of testing is a cause for concern as albuminuria is a key indicator of CKD and its early detection is crucial for effective disease management and treatment.
Underdiagnosis among High-Risk Patients
Among the 33,629 high-risk patients who underwent testing, 34.4% were found to have albuminuria, which is defined as a urine albumin-creatinine ratio (UACR) of 30 mg/g or greater. However, of the 158,479 patients who were not tested, the researchers estimate that there was a 13.4% prevalence rate of albuminuria. This suggests that approximately 21,231 patients may have albuminuria but were not screened for it, leading to a significant underdetection of the condition. This trend was observed across all demographic and comorbidity subgroups, indicating a systemic issue that needs to be addressed.
Inequalities in Testing Rates
The study also highlights the disparities in testing rates based on the estimated level of risk for albuminuria. Even among high-risk patients, only 36% received testing, with rates dropping further for patients without diabetes but with hypertension. Only 10.4% of patients in this category were screened, despite the fact that 70.4% of undetected albuminuria cases fell into this group. This suggests that there is a widespread failure to adhere to guideline-recommended testing practices, particularly in the case of patients without diabetes.
The researchers found that patients who underwent albuminuria testing had significantly higher odds of receiving subsequent treatment. These treatments included the use of SGLT2 inhibitors and ACE inhibitors or ARBs, which are known to be effective in managing CKD. Additionally, testing was associated with better blood pressure control. These findings emphasize the importance of early detection in ensuring optimal dissemination of disease-modifying CKD therapies, which can help slow down the progression of CKD and reduce the risk of kidney and cardiovascular complications.
The study highlights the need for improved uptake of testing and guideline-directed therapies among at-risk individuals. Annual albuminuria testing is recommended for people with diabetes, yet the testing rates consistently fall below 50%. For those without diabetes but with hypertension, testing is even less common, occurring only around 10% of the time. The researchers stress the importance of increasing awareness and adherence to testing guidelines, as well as providing education to healthcare professionals and patients about the significance of albuminuria in CKD detection and management.
It is important to note that the study has certain limitations. The researchers only considered the standard UACR testing for albuminuria and did not take alternative measures into account. This includes urine protein-creatinine ratio, 24-hour urine albumin or protein quantification, or urine dipstick protein. Considering these alternative measures could have provided a more comprehensive assessment of albuminuria and CKD prevalence.
The underdetection of albuminuria among high-risk patients with hypertension or diabetes is a significant concern. Improving testing rates and adherence to guidelines is crucial for the early detection and management of CKD. Increased awareness, education, and access to albuminuria testing are needed to ensure that at-risk individuals receive appropriate care and prevent the worsening of their condition. By addressing this issue, healthcare providers can make a positive impact on CKD outcomes and reduce the burden of kidney disease on patients and the healthcare system as a whole.
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