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CKD Associated with T2D

Understanding Albuminuria

Understanding Albuminuria

Recognizing the Importance of Increased Albuminuria ​ in CKD Associated With T2D Recognizing the Importance of Increased Albuminuria ​ in CKD Associated With T2D

For many patients with T2D, albuminuria may be the earliest sign of CKD before eGFR declines and it is an important marker for the early diagnosis of CKD associated with T2D.1-3

​

Watch this 2 minute video to learn about the cardiorenal risks link to albuminuria and the impact albuminuria can have on patient outcomes.​

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    Early Diagnosis

    Albuminuria is a crucial component of early identification and diagnosis of CKD associated with T2D.3

    Clinical diagnosis of CKD in patients with T2D

    Persistent change in either or both of the following for ≥3 months4
    Elevated Albuminuria4

    UACR ≥30 mg/g 
    Marker of kidney damage5
    Reduced eGFR4

    <60 mL/min/1.73 m2
    Measure of kidney function5
     
    and/or 

    Clinical Diagnosis of CKD in a patient with T2D

    Persistent change in either or both of the following for ≥ 3 months1
    Elevated Albuminuria 1

    UACR ≥ 30mg/g 
    Marker of kidney damage2
    Reduced eGFR1

    < 60mL/min/1.73m2
    Measure of kidney function2
     
    and/or 
    For complete patient care, both UACR and eGFR are necessary​ For complete patient care, both UACR and eGFR are necessary​

    For complete patient care, both UACR and eGFR are necessary​ 3

    • Albuminuria is an early marker of kidney damage and cardiorenal risk3,6
    • Measuring eGFR alone may miss earlier stages of CKD3
    • Patients with normal eGFR are still at increased risk of CV events and CKD progression if albuminuria is present3

     

    Click to enlarge
    Cardiorenal Outcomes

    Albuminuria is associated with increased risk of CV events and CKD progression.​7-10

    Risk of CV outcomes are higher in patients with T2D and albuminuria, regardless of eGFR level Risk of CV outcomes are higher in patients with T2D and albuminuria, regardless of eGFR level

    Risk of CV outcomes are higher in patients with T2D and albuminuria, regardless of eGFR level 8

    In a study of 19,025 patients with T2D, incidence of CVD was lowest for patients without CKD and highest for patients with albuminuria and decreased eGFR.​

     

    However, even those patients with albuminuria and normal eGFR had higher incidence of CVD compared to patients without CKD. 

    Click to enlarge
    UACR is a predictor of CV mortality and ESKD UACR is a predictor of CV mortality and ESKD

    UACR is a predictor of CV mortality and ESKD 7,9

    Independent of eGFR and traditional risk factors, UACR ≥10 mg/g is significantly associated with an increased risk of CV mortality and UACR ≥30 mg/g is significantly associated with an increased risk of ESKD.

     

     

    Click to enlarge
    Albuminuria in patients with T2D is strongly associated ​ with CKD progression Albuminuria in patients with T2D is strongly associated ​ with CKD progression

    Albuminuria in patients with T2D is strongly associated with CKD progression 10

    This study of 31,931 patients with T2D showed that across all eGFR categories, risk of progression to the next higher category of eGFR was substantially increased with increasing albuminuria.

     

     

    Click to enlarge
    Click for information on HF outcomes associated with albuminuria​
    Testing and Guidelines

    Both UACR and eGFR should be used to guide CKD identification, monitoring, and appropriate management.4

    Guidelines recommend UACR to test for albuminuria in addition to eGFR at least annually in all patients with T2D starting at diagnosis 3-5,11

    Alt tag

     

    ADA, KDIGO, and AACE Guidelines

    Recommend using both eGFR and UACR to properly identify, stage, and monitor CKD
    in patients with T2D, as eGFR alone may miss the earlier stages of CKD3-5,11

    Risk of CV outcomes are higher in patients with T2D and albuminuria, regardless of eGFR level Risk of CV outcomes are higher in patients with T2D and albuminuria, regardless of eGFR level

    There are multiple tests to measure albuminuria, but UACR is the preferred test 3,12

    Testing for albuminuria can be most easily performed by UACR in a random spot urine collection.​

     

    Limitations exist when using methods other than UACR (such as AER, UPCR, and urine dipstick) for detection of CKD in patients with T2D.

     

    Click to enlarge
    UACR is a predictor of CV mortality and ESKD UACR is a predictor of CV mortality and ESKD

    Albuminuria and eGFR are independent predictors of CKD progression and risk for CV events and both should be used to guide appropriate CKD management 4

    The heat map shown recommends comprehensive CKD staging that ​uses both eGFR and albuminuria to determine cardiorenal risk, provide the recommended frequency of screening and monitoring, and guide treatment decisions.

     

    Click to enlarge
    Albuminuria in patients with T2D is strongly associated ​ with CKD progression Albuminuria in patients with T2D is strongly associated ​ with CKD progression

    ADA 2024 guidelines recommend reducing albuminuria levels to slow CKD progression 3

    ADA 2024 Treatment Recommendation 11.6:​

    In people with CKD who have ≥300 mg/g urinary albumin, a reduction of 30% or greater in mg/g urinary albumin is recommended to slow CKD progression (C)​

     

    Click to view ADA 2024 Guidelines
    Click for more information on impact ​of albuminuria reduction on outcomes​
    Burden

    Increased albuminuria in patients with T2D burdens both the patient and the healthcare system.14,15

    Comparison Comparison

    Patients with T2D and albuminuria have a high burden of disease and healthcare resource use 14

    Compared to patients with T2D and normal albuminuria, patients with moderately to severely increased albuminuria experience significantly higher rates of ER and inpatient admissions and significantly higher risks of receiving dialysis.

     

     

    Click to enlarge

    ~2-3x

    higher costs for patients with UACR ≥30 mg/g
    compared to patients with UACR <30 mg/g15

    Click for more information on the burden of albuminuria

    Abbreviations

    AACE, American Association of Clinical Endocrinology; ADA, American Diabetes Association; AER, albumin excretion rate; CI, confidence interval; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; DKD, diabetic kidney disease; DP, dipstick proteinuria; eGFR, estimated glomerular filtration rate; ER, emergency room; ESKD, end-stage kidney disease; GFR, glomerular filtration rate; HF, heart failure; HR, hazard ratio; KDIGO, Kidney Disease Improving Global Outcomes; T2D, type 2 diabetes; UACR, urine albumin-to-creatinine ratio; UAE, urine albumin excretion; UPCR, urine protein-to-creatinine ratio.

    References

    1. Afkarian M. Pediatr Nephrol. 2015;30(1):65-74.
    2. Pugliese G. Acta Diabetol. 2014;51(6):905-915.
    3. American Diabetes Association. Section 11. Diabetes Care. 2024;47(Suppl 1):S219-S230.
    4. de Boer IH, et al. Consensus report. Diabetes Care. 2022;45(12):3075-3090.
    5. Kidney Disease Improving Global Outcomes. Kidney International. 2024;105(Suppl 4S):S117-S314.
    6. Looker HC, et al. J Am Soc Nephrol. 2019;30(6):1049-1059.
    7. Matsushita K, et al. Lancet. 2010;375(9731):2073-2081.
    8. Jin Q, et al. Am J Kidney Dis. 2022;80(2):196-206.
    9. Gansevoort RT, et al. Kidney International. 2011;80(1):93-104.
    10. Nichols GA, et al. BMC Nephrology. 2020;21(1):167.
    11. Blonde L, et al. Endocr Pract. 2022;28(10):923-1049.
    12. Kidney Disease Improving Global Outcomes. Kidney Int Suppl. 2013;3(1):1-150.
    13. Shlipak MG, et al. Kidney Int. 2021;99(1):34-47.
    14. Zhou Z et al. Diabetes Ther. 2017;8(3):555-571.
    15. Vassalotti JA, et al. Am J Manag Care. 2019;25(11):e326-e333.

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