US Clinicians Missing the Mark for Albuminuria Testing, Preventing Optimal CKD Care

Michelle Estrella, MD, MHS
Credit: University of California San Francisco

More than 60% of patients with albuminuria in the US go undetected due to lack of testing, according to a new study.

An analysis of National Health and Nutrition Examination Surveys (NHANES) and the Optum deidentified electronic health record data from patients with hypertension or diabetes, results of the study suggest just 17.5% of the combined cohort undergoing urine albumin-creatinine ratio (UACR) testing, with investigators estimating just 35.2% of patients with albuminuria being tested.¹

“These results suggest that underutilization of UACR represents a major barrier to diagnosis of [chronic kidney disease] and deployment of therapies to prevent [chronic kidney disease] progression and the associated cardiovascular risk,” wrote investigators.¹

Like many chronic diseases, early detection of chronic kidney disease (CKD) stands to have a significant impact on long-term outcomes. The importance of early detection in CKD has only grown in recent years, with nephrology community seeing a recent boom in treatment options, particularly among people with diabetes, which has culminated in historic approvals in chronic kidney disease (CKD) for agents such as the nonsteroidal mineralocorticoid antagonist, finerenone, and multiple agents within the SGLT2 inhibitor class.^2,3

Citing the role of UACR testing, a team of investigators led by Michelle Estrella, MD, MHS, executive director of the Kidney Health Research Collaborative at the University of California San Francisco, designed the current study with the intent of estimating how the extent of albuminuria underdetection is influenced by a lack of testing and to better understand how this might affect CKD treatment in the US. Using NHANES as a nationally representative sample, investigators developed a logistic regression model to estimate albuminuria, which was defined as a UACR of 30 mg/g or greater. Following development, the model was applied to active outpatients in the Optum deidentified electronic health record data set.¹

The primary outcome of interest was the prevalence of albuminuria among those with and without testing within the electronic health record from January 1, 2017, through December 31, 2018. Investigators also expressed an interest in estimating associations between having albuminuria testing and use of CKD therapies in the subsequent year, which was performed using multivariable logistic regression model. CKD therapies of interest included ACE inhibitors or ARBs, SGLT2 inhibitors, and blood pressure control to less than 130/80 mmHg or less than 140/90 mmHg on the latest outpatient measure.¹

A total of 192,108 individuals from the Optum database were identified for inclusion in the study. Of these, 96.6% (n = 185,589) had hypertension and 26.2% (n = 50,507) had diabetes. Investigators pointed out the mean age of the overall study cohort was 60.3 (SD, 15.1) years and the mean eGFR was 84 (SD, 21) mL/min/1.73m2.¹

Upon analysis, results indicated 17.5% (n = 33,69 of patients underwent albuminuria testing, with 34.3% (n = 11,525) of these patients having confirmed albuminuria. Investigators pointed out UACR testing was more common among those with only diabetes (52.3%) than those with only hypertension (5.1%).¹

Based on results, investigators estimated the albuminuria prevalence rate was 13.4% among the 158,479 patients who were untested. Investigators noted the results suggested just 35.2% of the projected population with albuminuria had undergone testing. Further analysis purported undergoing albuminuria testing was associated with an increase in likelihood of receiving treatment with ACEi or ARBs (adjusted Odds ratio [aOR], 2.39; 95% Confidence Interval [CI], 2.32-2.46; P <.001), treatment with an SGLT2 inhibitor (aOR, 8.22; 95% CI, 7.56-8.94; P <.001), and of having achieved a blood pressure goal of less than 140/90 mmHg (aOR, 1.20; 95%CI, 1.16-1.23; P <.001).¹

“Early identification of albuminuria is increasingly crucial given the growing number of therapies, such as [SGLT2 inhibitors] and nonsteroidal mineralocorticoid antagonists, that have been shown to slow the progression of CKD and prevent cardiovascular complications," investigators wrote.¹ "More albuminuria testing is clearly needed among at-risk persons to ensure effective dissemination of these therapies and to fully realize their potential benefit.”

References:

1. Chu CD, Xia F, Du Y, et al. Estimated Prevalence and Testing for Albuminuria in US Adults at Risk for Chronic Kidney Disease. JAMA Netw Open. 2023;6(7):e2326230. doi:10.1001/jamanetworkopen.2023.26230
2. Campbell P. Finerenone (Kerendia) approved for chronic kidney disease associated with type 2 diabetes. HCP Live. July 9, 2021. Accessed July 27, 2023. https://www.hcplive.com/view/finerenone-kerendia-approved-chronic-kidney-disease-associated-with-type-2-diabetes.
3. Campbell P, Iapoce C. 10 years of SGLT2 inhibitors: A Decade of Redefining Cardiometabolic Care. HCP Live. March 29, 2023. Accessed July 27, 2023. https://www.hcplive.com/view/10-years-of-sglt2-inhibitors-a-decade-of-redefining-cardiometabolic-care.