Estimated Prevalence and Testing for Albuminuria in US Adults at Risk for Chronic Kidney Disease

Abstract

Importance: Albuminuria testing is crucial for guiding evidence-based treatments to mitigate chronic kidney disease (CKD) progression and cardiovascular morbidity, but it is widely underutilized among persons with or at risk for CKD.

Objective: To estimate the extent of albuminuria underdetection from lack of testing and evaluate its association with CKD treatment in a large US cohort of patients with hypertension or diabetes.

Design, setting, and participants: This cohort study examined adults with hypertension or diabetes, using data from the 2007 to 2018 National Health and Nutrition Examination Surveys (NHANES) and the Optum deidentified electronic health record (EHR) data set of diverse US health care organizations. Analyses were conducted from October 31, 2022, to May 19, 2023.

Main outcomes and measures: Using NHANES as a nationally representative sample, a logistic regression model was developed to estimate albuminuria (urine albumin-creatinine ratio ≥30 mg/g). This model was then applied to active outpatients in the EHR from January 1, 2017, to December 31, 2018. The prevalence of albuminuria among those with and without albuminuria testing during this period was estimated. A multivariable logistic regression was used to examine associations between having albuminuria testing and CKD therapies within the subsequent year (prescription for angiotensin-converting enzyme inhibitor [ACEi] or angiotensin II receptor blocker [ARB], prescription for sodium-glucose cotransporter 2 inhibitor [SGLT2i], and blood pressure control to less than 130/80 mm Hg or less than 140/90 mm Hg on the latest outpatient measure).

Results: The total EHR study population included 192 108 patients (mean [SD] age, 60.3 [15.1] years; 185 589 [96.6%] with hypertension; 50 507 [26.2%] with diabetes; mean [SD] eGFR, 84 [21] mL/min/1.73 m2). There were 33 629 patients (17.5%) who had albuminuria testing; of whom 11 525 (34.3%) had albuminuria. Among 158 479 patients who were untested, the estimated albuminuria prevalence rate was 13.4% (n = 21 231). Thus, only 35.2% (11 525 of 32 756) of the projected population with albuminuria had been tested. Albuminuria testing was associated with higher adjusted odds of receiving ACEi or ARB treatment (OR, 2.39 [95% CI, 2.32-2.46]), SGLT2i treatment (OR, 8.22 [95% CI, 7.56-8.94]), and having blood pressure controlled to less than 140/90 mm Hg (OR, 1.20 [95% CI, 1.16-1.23]).

Conclusions and relevance: In this cohort study of patients with hypertension or diabetes, it was estimated that approximately two-thirds of patients with albuminuria were undetected due to lack of testing. These results suggest that improving detection of CKD with albuminuria testing represents a substantial opportunity to optimize care delivery for reducing CKD progression and cardiovascular complications.

Figure 1.. Estimated Albuminuria Prevalence and Proportion Detected Among Patients With Hypertension and/or Diabetes (N = 192 108)

Detected albuminuria prevalence refers to tested patients having albuminuria ≥30 mg/g. Undetected albuminuria prevalence is the estimated prevalence of albuminuria ≥30 mg/g based on patient characteristics among the untested population. D indicates diabetes; eGFR, estimated glomerular filtration rate (measured in mL/min/1.73 m²); HTN, hypertension. ^aOther race and ethnicity includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander.

Figure 2.. Therapy Among Tested and Untested Patients by Quintile of Estimated Risk of Albuminuria (N = 149 554)

ACEi indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; SGLT2i, sodium-glucose cotransporter 2 inhibitor. ^aQuintile with a statistically significant difference between tested and untested groups. All comparisons of tested vs untested were significant to P < .001 except for the following: blood pressure less than 130/80 mm Hg for quintile 2 (P = .01), blood pressure less than 130/80 mm Hg for quintile 5 (P = .75), blood pressure less than 140/90 mm Hg for quintile 1 (P = .44), and blood pressure less than 140/90 mm Hg for quintile 2 (P = .02).