Screening for kidney disease in adults with diabetes and prediabetes

Abstract

Worldwide, we are facing an increasing prevalence of diabetes mellitus, the number one cause of end-stage renal disease. It is imperative that chronic kidney disease among adults with diabetes mellitus be detected early when interventions are most effective in preventing end-stage renal disease. Screening tools work best when health care providers have a clear understanding of the natural history of the disease process. The use of urine albumin measurement as a screening tool for diabetic nephropathy is based on the well characterized evolution of nephropathy in type 1 diabetes mellitus. However, the evolution of chronic kidney disease among adults with type 2 diabetes mellitus appears to be more heterogeneous. In contrast to type 1 diabetes mellitus, a substantial percentage of adults with type 2 diabetes mellitus have decreased glomerular filtration rate in the absence of increased urine albumin excretion. Focusing solely on urine albumin excretion to screen for chronic kidney disease may miss a substantial number of cases in adults with diabetes mellitus. In addition, up to one-third of adults with newly diagnosed diabetes mellitus already have chronic kidney disease, which may have first developed during the prediabetic state. Screening for chronic kidney disease only after an adult develops diabetes mellitus may miss that 'early' window of opportunity in many patients. To maximize the effectiveness of our screening programs, we must not only use tests with adequate sensitivity but also implement screening tests early in the disease process to prevent the progression of chronic kidney disease to end-stage renal disease.