Albumin-creatinine Ratio Testing Research Articles

Abstract P337: Impact of a population health approach using smartphone-enabled home albuminuria testing to improve screening in patients with hypertension or diabetes

Background: Screening for albuminuria with urine albumin/creatinine ratio (ACR) testing among at risk patients is critical as guideline-based therapies can be used to decrease the risk of cardiovascular and kidney disease. However, adherence to testing remains very low, especially for hypertension. Here, we report the results from a prospective pilot study involving a smartphone-enabled home albuminuria testing quality improvement. Methods: We randomly selected 4000 adult individuals (50% with hypertension but no diabetes and 50% with diabetes +/- hypertension) receiving primary care at a large healthcare system in Central and Northeastern Pennsylvania who had not undergone ACR testing in the past 12 months to receive Minuteful Kidney, an FDA-cleared, smartphone-enabled home urine albuminuria screening kit using the vendor’s (Healthy.io) standard workflow. The home testing group was matched 1:1 to 4000 controls who received usual care using propensity score matching addressing imbalances in sociodemographics and comorbidities. The primary outcome was completion of ACR test (either laboratory based ACR or Minuteful Kidney) within 100 days of the index date. Results shown are as of May 1, 2024 (86 days after the index date). Results: Overall, completion of any ACR test was higher in the home testing group than matched controls (50.2% vs. 19.1%; p<0.001). The impact on ACR testing was higher for the hypertension subgroup (50.4% vs. 11.2%; p<0.001) than the diabetes subgroup (49.9% vs. 26.9%; p<0.001). Among the home testing group, 1542/4000 (38.7%) completed the smartphone ACR test, with a higher proportion of completions in non-diabetic hypertension (848/2000 [42.4%] than the diabetes subgroup (663/2000 [33.2%]). Adherence rates were similar across age groups and geographic location. Satisfaction was high among individuals in the home testing group (53+ Net Promoter Score; 94% rated the test as easy or very easy to complete; 88% stated preference for at home testing). Home-based albuminuria screening detected mild to moderate albuminuria (30-300 mg/g) in 33.2% and severe albuminuria (>300 mg/g) in 8.1%. Abnormal results were fairly similar for the diabetes subgroup (33.8% 30-300 mg/g, 10.8% >300 mg/g) and the hypertension subgroup (32.6% 30-300 mg/g, 5.9% >300 mg/g). Conclusions: A population health approach using smartphone-enabled home albuminuria testing is effective in increasing albuminuria screening among individuals with hypertension or diabetes.

Knowledge and Competence Regarding the Management of Chronic Kidney Disease among Family Medicine Professionals in the Eastern Province of Saudi Arabia: A Cross-Sectional Study.

Diabetes is a significant risk factor for chronic kidney disease (CKD) and a primary cause of global morbidity and mortality, resulting in significant costs to healthcare systems. The management of diabetic CKD in the primary care setting remains an ongoing challenge despite the current best practices in the quality of care. This study evaluated family medicine physicians' knowledge and confidence regarding managing CKD in the Eastern Province of Saudi Arabia. A self-administered online questionnaire was distributed to physicians through various social media sites and email lists. The largest number of participants reported a full confidence in knowing kidney disease stages, blood pressure targets and the importance of urine albumin-creatinine ratio testing. Overall, 71.8% of physicians reported a high confidence level, followed by 23.9% reporting average and 4.2% reporting low confidence. Being younger and working at PHC were identified as significant predictors of increased confidence. Although most of the physicians reported a high confidence in managing CKD patients, the need for improvement was evident. Age and workplace institutions were the greater contributors to physicians' confidence. Continuous education among healthcare practitioners is crucial to updating knowledge and providing optimum quality of care among this group of patients.

#876 Albuminuria and the risk of dementia and different dementia subtypes: the Stockholm Creatinine Measurements (SCREAM) project

Abstract Background and Aims Studies investigating the association of chronic kidney disease and dementia predominantly focused on estimated glomerular filtration rate (eGFR) rather than albuminuria. The few studies focusing on albuminuria reported conflicting results, probably due to a lack of power, not taking into account the different dementia subtypes, not adjusting for eGFR, and the use of different albuminuria measurement techniques. This study therefore investigated the eGFR-independent risk of all-cause and type-specific dementia associated with albuminuria, quantified as urine albumin-creatinine ratio (ACR) and by dipstick, in a large population. Method We included subjects from the Stockholm Creatinine Measurements (SCREAM) project without a history of dementia and with age ≥65 years. The main analyses involved 138 688 subjects with at least one ACR test, and for sensitivity analyses, we involved 170 572 subjects with at least one dipstick proteinuria test. Albuminuria was quantified as KDIGO albuminuria A1-A3 stages. The primary outcome was incidence of all-cause dementia, and the key secondary outcomes were incidence of type-specific dementia. Dementia incidence was ascertained by record linkage with the national dementia registry (SveDem). ICD-10 coding was also used to classify subtypes only when there were no available dementia records in SveDem. Multivariable Cox regression models were used to calculate hazard ratios (HRs, 95% CIs) crude, and adjusted for confounders including baseline eGFR. Results During a median follow-up of 3.9 (IQR, 1.8-7.2) years, 9 970 subjects developed de novo dementia. After multivariable adjustment including baseline eGFR, subjects with an ACR of 30-299 mg/g or ≥300 mg/g had a 26% (HR, 1.26; 95% CI, 1.20-1.32) and 36% (HR, 1.36; 95% CI, 1.24-1.50) higher risk of developing all-cause dementia, respectively, when compared to subjects with an ACR <30 mg/g. Subjects with an ACR of 30-299 mg/g also presented a higher risk of developing several type-specific dementia, including Alzheimer's dementia (HR, 1.09, 95% CI, 1.01-1.17), vascular dementia (HR, 1.35, 95% CI, 1.22-1.48), and unspecified dementia (HR, 1.54, 95% CI, 1.41-1.69). No significant associations between albuminuria and the incidence of Lewy body dementia and Parkinson's Disease with dementia, frontotemporal dementia, as well as other types of dementia were observed. These results were generally robust in several sensitivity analyses, including replicating our main analyses in subjects with a dipstick proteinuria test instead of an ACR. Conclusion Increased albuminuria is associated with a higher risk of all-cause, Alzheimer's, and vascular dementia, independent of baseline eGFR and different albuminuria measurement techniques.

Fulfillment and Validity of the Kidney Health Evaluation Measure for People with Diabetes

ObjectiveTo evaluate the fulfillment and validity of the kidney health evaluation for people with diabetes (KED) Healthcare Effectiveness Data Information Set (HEDIS) measure. Patients and MethodsOptum Labs Data Warehouse (OLDW) was used to identify the nationally distributed US population aged 18 years and older, with diabetes, between January 1, 2017, and December 31, 2017. The OLDW includes deidentified medical, pharmacy, laboratory, and electronic health record (EHR) data. The KED fulfillment was defined in 2017 as both estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio testing within the measurement year. The KED validity was assessed using bivariate analyses of KED fulfillment with diabetes care measures in 2017 and chronic kidney disease (CKD) diagnosis and evidence-based kidney protective interventions in 2018. ResultsAmong eligible 5,635,619 Medicare fee-for-service beneficiaries, 736,875 Medicare advantage (MA) beneficiaries, and 660,987 commercial patients, KED fulfillment was 32.2%, 38.7%, and 37.7%, respectively. Albuminuria testing limited KED fulfillment with urinary albumin-creatinine ratio testing (<40%) and eGFR testing (>90%). The KED fulfillment was positively associated with receipt of diabetes care in 2017, CKD diagnosis in 2018, and evidence-based kidney protective interventions in 2018. The KED fulfillment trended lower for Black race, Medicare-Medicaid dual eligibility status, low neighborhood income, and low education status. ConclusionLess than 40% of adults with diabetes received guideline-recommended testing for CKD in 2017. Routine KED was associated with diabetes care and evidence-based CKD interventions. Increasing guideline-recommended testing for CKD among people with diabetes should lead to timely and equitable CKD detection and treatment.

Albuminuria screening in children with type 1 diabetes prior to and during the COVID-19 pandemic.

BackgroundAlbuminuria is an important risk factor for adverse renal and cardiovascular outcomes in type 1 diabetes (T1D). We sought to describe: (1) adherence to albuminuria screening prior to and during the COVID-19 pandemic and (2) occurrence of abnormal urine albumin-creatinine ratio (ACR) tests in children with T1D.MethodsThis cohort study involved children aged 18 years or younger with T1D followed in the diabetes clinic at a pediatric tertiary center. Data was collected from 2016 to 2020. Adherence was defined by Diabetes Canada (DC) Guidelines for T1D in Children and Adolescents (2018).ResultsOf the 165 children who met DC criteria for screening; 88 (32%) were male and the median age at diagnosis was 5.8 years. Twenty-eight (17%) children had not completed a single ACR test, and 30 (18%) completed all eligible ACR tests. Test completion decreased from 66% in 2019 to 45% in 2020. Of the 345 ACR tests completed, 40 (11%) were abnormal (>2.5 mg/mmol) and 29 abnormal ACR tests (72%) were not repeated.ConclusionAdherence to albuminuria screening in this pediatric diabetes clinic is suboptimal with deterioration during the COVID-19 pandemic. Patient/physician and program-level strategies to improve adherence will play an important role in quality improvement.Impact Albuminuria screening is an important part of pediatric diabetes care.In our study, pediatric albuminuria screening adherence was suboptimal at 66% in 2019 and deteriorated during the pandemic to 45% in 2020.Program and patient-level adherence to clinical guidelines and barriers to accessing diabetes care during the pandemic merit further study.

Online clinical pathway for chronic kidney disease management in primary care: a retrospective cohort study

BackgroundClinical pathways aim to improve patient care. We sought to determine whether an online chronic kidney disease (CKD) clinical pathway was associated with improvements in CKD management.MethodsWe conducted a retrospective pre/post population-based cohort study using linked health data from Alberta, Canada. We included adults 18 years or older with mean estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m2. The primary outcome was measurement of an outpatient urine albumin creatinine ratio (ACR) in a 28-day period, among people without a test in the prior year. Secondary outcomes included use of guideline-recommended drug therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and statins).ResultsThe study period spanned October 2010 to March 2017. There were 84 independent 28-day periods (53 pre, 31 post pathway implementation) including 345,058 adults. The population was predominantly female (56%) with median age 77 years; most had category 3A CKD (67%) and hypertension (82%). In adjusted segmented regression models, the increase in the rate of change of ACR testing was greatest in Calgary zone (adjusted OR 1.19 per year, 95% CI 1.16–1.21), where dissemination of the pathway was strongest; this increase was more pronounced in those without diabetes (adjusted OR 1.25 per year, 95% CI 1.21–1.29). Small improvements in guideline-concordant medication use were also observed.ConclusionsFollowing implementation of an online CKD clinical pathway, improvements in ACR testing were evident in regions where the pathway was most actively used, particularly among individuals without diabetes.

Estimating Kidney Failure Risk Using Electronic Medical Records.

The four-variable kidney failure risk equation (KFRE) is a well-validated tool for patients with GFR <60 ml/min per 1.73 m2 and incorporates age, sex, GFR, and urine albumin-creatinine ratio (ACR) to forecast individual risk of kidney failure. Implementing the KFRE in electronic medical records is challenging, however, due to low ACR testing in clinical practice. The aim of this study was to determine, when ACR is missing, whether to impute ACR from protein-to-creatinine ratio (PCR) or dipstick protein for use in the four-variable KFRE, or to use the three-variable KFRE, which does not require ACR. Using electronic health records from OptumLabs Data Warehouse, patients with eGFR <60 ml/min per 1.73 m2 were categorized on the basis of the availability of ACR testing within the previous 3 years. For patients missing ACR, we extracted urine PCR and dipstick protein results, comparing the discrimination of the three-variable KFRE (age, sex, GFR) with the four-variable KFRE estimated using imputed ACR from PCR and dipstick protein levels. There were 976,299 patients in 39 health care organizations; 59% were women, the mean age was 72 years, and mean eGFR was 47 ml/min per 1.73 m2. The proportion with ACR testing was 19% within the previous 3 years. An additional 2% had an available PCR and 36% had a dipstick protein; the remaining 43% had no form of albuminuria testing. The four-variable KFRE had significantly better discrimination than the three-variable KFRE among patients with ACR testing, PCR testing, and urine dipstick protein levels, even with imputed ACR for the latter two groups. Calibration of the four-variable KFRE was acceptable in each group, but the three-variable equation showed systematic bias in the groups that lacked ACR or PCR testing. Implementation of the KFRE in electronic medical records should incorporate ACR, even if only imputed from PCR or urine dipstick protein levels.

Behavior-based diabetes management: impact on care, hospitalizations, and costs

To (1) examine the impact of the Diabetes Care Rewards (DCR) program on adherence to care standards and (2) evaluate the economic impact of adherence to care standards. A retrospective observational cohort study design with propensity matching. Additional covariates adjustment was used to minimize residual imbalance. Utilization and cost data were compared between individuals enrolled vs individuals eligible for but not enrolled in the DCR program using a standard mean difference. Individuals were employees or their dependents from self-insured companies throughout the United States. Outcomes included adherence to the care standards, service utilization, and costs. A total of 3318 propensity-matched participants were included. Primary analysis revealed that enrolled members increased adherence to semiannual glycated hemoglobin, annual lipid, and annual urine albumin-creatinine ratio testing. Additionally, enrolled members experienced less utilization of high-acuity services and increased rates of physician visits. In a secondary analysis, the enrolled group was associated with greater pharmaceutical costs but lower medical costs. A behavioral science- and incentive-based diabetes management program was associated with greater rates of adherence to recommended diabetes monitoring care standards, increased routine clinic visits, decreased hospital admissions, and decreased inpatient days. Anticipated increases in pharmaceutical expenditures were offset by overall lower medical expenditures. Results indicate the economic benefits of adherence to evidence-based standards for diabetes care.

Can a semi-quantitative method replace the current quantitative method for the annual screening of microalbuminuria in patients with diabetes? Diagnostic accuracy and cost-saving analysis considering the potential health burden.

ObjectivesDiabetes is a global epidemic, and the high cost of annually and quantitatively measuring urine albumin excretion using the turbidimetric immunoassay is challenging. We aimed to determine whether a semi-quantitative urinary albumin-creatinine ratio test could be used as a screening tool for microalbuminuria in diabetic patients.MethodsWe assessed the diagnostic accuracy of the semi-quantitative method. The costs of false results in the semi-quantitative method were calculated based on the annual probability of disease progression analyzed through a systematic literature review and meta-analysis. The pooled long-term cost-saving effect of the semi-quantitative method compared with the quantitative test was assessed using a Markov model simulating a long-term clinical setting. Diagnostic accuracy and the cost-saving effect were also validated in an independent external cohort.ResultsCompared with the quantitative test, the semi-quantitative method had sensitivities of 93.5% and 81.3% and specificities of 61.4% and 63.1% in the overall sample of diabetic patients (n = 1,881) and in diabetic patients with eGFR ≥60 ml/min/1.73 m2 and a negative dipstick test (n = 1,110), respectively. After adjusting for direct and indirect medical costs, including the risk of disease progression, which was adjusted by the meta-analyzed hazard ratio for clinical outcomes, it was determined that using the semi-quantitative method could save 439.4 USD per person for 10 years. Even after adjusting the result to the external validation cohort, 339.6 USD could be saved for one diabetic patient for 10 years.ConclusionsThe semi-quantitative method could be an appropriate screening tool for albuminuria in diabetic patients. Moreover, it can minimize the testing time and inconvenience and significantly reduce national health costs.

Quality of diabetes care in breast, colorectal, and prostate cancer

PurposeOverlooking other medical conditions during cancer treatment and follow-up could result in excess morbidity and mortality, thereby undermining gains associated with early detection and improved treatment of cancer. We compared the quality of care for diabetes patients subsequently diagnosed with breast, colorectal, or prostate cancer to matched, diabetic non-cancer controls.MethodsLongitudinal cohort study using primary care records from the Clinical Practice Research Datalink, United Kingdom. Patients with pre-existing diabetes were followed for up to 5 years after cancer diagnosis, or after an assigned index date (non-cancer controls). Quality of diabetes care was estimated based on Quality and Outcomes Framework indicators. Mixed effects logistic regression analyses were used to compare the unadjusted and adjusted odds of meeting quality measures between cancer patients and controls, overall and stratified by type of cancer.Results3382 cancer patients and 11,135 controls contributed 44,507 person-years of follow-up. In adjusted analyses, cancer patients were less likely to meet five of 14 quality measures, including: total cholesterol ≤ 5 mmol/L (odds ratio [OR] = 0.82; 95% confidence interval [CI], 0.75–0.90); glycosylated hemoglobin ≤ 59 mmol/mol (adjusted OR = 0.77; 95% CI, 0.70–0.85); and albumin creatinine ratio testing (adjusted OR = 0.83; 95% CI, 0.75–0.91). However, cancer patients were as likely as their matched controls to meet quality measures for other diabetes services, including retinal screening, foot examination, and dietary review.ConclusionsAlthough in the short-term, cancer patients were less likely to achieve target thresholds for cholesterol and HbA1c, they continued to receive high-quality diabetes primary care throughout 5 years post diagnosis.Implications for Cancer SurvivorsThese findings are important for cancer survivors with pre-existing diabetes because they indicate that high-quality diabetes care is maintained throughout the continuum of cancer diagnosis, treatment, and follow-up.

Quality indicators for the detection and management of chronic kidney disease in primary care in Canada derived from a modified Delphi panel approach.

The detection and management of chronic kidney disease lies within primary care; however, performance measures applicable in the Canadian context are lacking. We sought to develop a set of primary care quality indicators for chronic kidney disease in the Canadian setting and to assess the current state of the disease's detection and management in primary care. We used a modified Delphi panel approach, involving 20 panel members from across Canada (10 family physicians, 7 nephrologists, 1 patient, 1 primary care nurse and 1 pharmacist). Indicators identified from peer-reviewed and grey literature sources were subjected to 3 rounds of voting to develop a set of quality indicators for the detection and management of chronic kidney disease in the primary care setting. The final indicators were applied to primary care electronic medical records in the Electronic Medical Record Administrative data Linked Database (EMRALD) to assess the current state of primary care detection and management of chronic kidney disease in Ontario. Seventeen indicators made up the final list, with 1 under the category Prevalence, Incidence and Mortality; 4 under Screening, Diagnosis and Risk Factors; 11 under Management; and 1 under Referral to a Specialist. In a sample of 139 993 adult patients not on dialysis, 6848 (4.9%) had stage 3 or higher chronic kidney disease, with the average age of patients being 76.1 years (standard deviation [SD] 11.0); 62.9% of patients were female. Diagnosis and screening for chronic kidney disease were poorly performed. Only 27.1% of patients with stage 3 or higher disease had their diagnosis documented in their cumulative patient profile. Albumin-creatinine ratio testing was only performed for 16.3% of patients with a low estimated glomerular filtration rate (eGFR) and for 28.5% of patients with risk factors for chronic kidney disease. Family physicians performed relatively better with the management of chronic kidney disease, with 90.4% of patients with stage 3 or higher disease having an eGFR performed in the previous 18 months and 83.1% having a blood pressure recorded in the previous 9 months. We propose a set of measurable indicators to evaluate the quality of the management of chronic kidney disease in primary care. These indicators may be used to identify opportunities to improve current practice in Canada.

Where now for proteinuria testing in chronic kidney disease?: Good evidence can clarify a potentially confusing message.

Although the value of testing for proteinuria may be undisputed and understood by nephrologists and diabetologists, the lack of clarity about the rationale for testing and the optimal way of doing so in primary care has caused confusion for many practitioners.1 Issues such as variation in proteinuria definition, laboratory measurement, and reporting methods, along with conflicting messages about who, how, and when to test, have led to uncertainty and under-testing.1,2 There have been long-standing debates about the use of various dipsticks, the role of proteinuria in urinary tract infection, the use of urinary protein:creatinine ratio (PCR) versus albumin:creatinine ratio (ACR), and the number of tests needed for identification versus quantification of proteinuria. Reporting variations include some laboratories using non-numeric results such as ‘ratio too low to calculate’ making visualisation of results and accurate audit of ACR testing challenging for busy practitioners. Urinary dipsticks have important limitations in terms of their accuracy in detecting and quantifying albuminuria.3 In this context, GPs and other clinicians could be forgiven for being uncertain about the clinical utility of its identification. Chronic kidney disease (CKD) has been included in the Quality and Outcomes Framework (QOF) since 2006–2007, and, from 2009–2010, included a proteinuria indicator (‘The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio [or protein:creatinine ratio] test in the preceding 12 months’). Currently, several CKD indicators are in the process of being ‘retired’, including the one relating to proteinuria testing. This increases the potential for uncertainty about the role of proteinuria testing and is likely to lead to a fall in ACR tests in England, particularly in people without diabetes, unless it is seen as valuable in its own right. It may also serve to reinforce the suggestion that labelling people …

Control of type 2 diabetes in King Abdulaziz Housing City (Iskan) population, Saudi Arabia.

Objective:To assess the level of control and prevalence of type 2 diabetes in King Abdulaziz Housing City (Iskan) population of Saudi Arabia.Materials and Methods:Retrospective cross-sectional study conducted in a primary-care setting. All Type 2 diabetics referred to our diabetes center between January 2011 and January 2015 were identified, and their computerized records reviewed. Glycated hemoglobin levels (HbA1c), low-density lipoprotein (LDL), blood pressure (BP), and the albumin-creatinine ratio (ACR) were noted and the patients categorized accordingly. Demographic data (age and gender) were also documented. Inactive patients (not seen for more than 2 years) were excluded.Results:The overall prevalence of type 2 diabetes for all age groups in ISKAN population was 3.25%. About 56% of the diabetics were female and 70% were aged between 18 and 59 years. The rate of uncontrolled diabetes was 59.3%. Males were more likely to have uncontrolled diabetes (odds ratio: 1.44, CI: 1.17–1.76, P = 0.0004). Forty percent of the diabetics had an LDL above target (≥2.6 mmol/l) while 25.9% had uncontrolled hypertension (BP ≥ 140/90). Of those who had an ACR test done within the last year (59.3%), the rate of micro- and macro-albuminuria was 8.8% and 2.5%, respectively.Conclusions:The overall prevalence of type 2 diabetes in our community seems lower than the previously reported national figures. An alarming number of diabetics in our population have an uncontrolled disease. More stringent diabetes annual review and recall program is needed to control diabetes and reduce complications.

Primary care detection of chronic kidney disease in adults with type-2 diabetes: the ADD-CKD Study (awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease).

This US, multicenter, observational study assessed the CKD prevalence in adult patients with type-2 diabetes mellitus (T2DM) and characterized the proportion of detected and undiagnosed CKD in the primary care setting using the following: a clinician survey; a patient physical exam and medical history; a single blood draw for estimated glomerular filtration rate (eGFR) and glycosolated hemoglobin (HbA1c); urine dipstick for protein; urine albumin-creatinine ratio (ACR); two patient quality of life questionnaires; and a 15-month medical record review. The study consisted of 9339 adults with T2DM and 466 investigator sites. Of the 9339 enrolled, 9307 had complete data collection for analysis. The 15-month retrospective review showed urine protein, urine ACR, and eGFR testing were not performed in 51.4%, 52.9% and 15.2% of individuals, respectively. Of the 9307 patients, 5036 (54.1%) had Stage 1–5 CKD based on eGFR and albuminuria; however, only 607 (12.1%) of those patients were identified as having CKD by their clinicians. Clinicians were more successful in diagnosing patients with Stage 3–5 CKD than Stages 1 and 2. There were no differences in clinicians’ likelihood of identification of CKD based on practice setting, number of years in practice, or self-reported patients seen per week. Awareness or patient self-reported CKD was 81.1% with practitioner detection versus 2.6% in the absence of diagnosis. Primary care of T2DM demonstrates recommended urine CKD testing is underutilized, and CKD is significantly under-diagnosed. This is the first study to show CKD detection is associated with awareness.

PMM.43 The Predictive Value of Urinary Albumin: Creatinine Ratio In Pregnancy

IntroductionCurrent risk assessment guidelines for pre-eclampsia are unable to reliably predict adverse outcomes and thus inform management. This study investigated the association and predictive value of urinary albumin: creatinine ratio...

Microalbuminuria could improve risk prediction of stroke in patients with transient ischaemic attacks and minor strokes

BackgroundTransient ischaemic attacks (TIA) and minor strokes are important risk factors for recurrent strokes; they precede 23% of strokes within 90 days. Identification of patients at high risk of developing further strokes is essential to allow early intervention and avoid the catastrophic outcome of strokes. Elevated urinary albumin excretion rate (AER) is a risk factor and predicts cardiovascular disease, stroke, and mortality. Elevated AER can be detected with a point-of-care bedside test. MethodsPatient demographics and the ABCD2 score were obtained for 150 consecutive patients with TIA who presented to the daily stroke clinic and the stroke unit. The ABCD2 score composite for age, blood pressure, clinical features, duration, and diabetes is the risk score presently used for stratifying patients with TIA. All patients had their albumin:creatinine ratio (ACR) measured from a urine sample obtained during their visit to the clinic or the stroke unit at Royal Devon & Exeter Hospital. Patients were followed up for any events, cardiovascular events, stroke, or death at day 7, 30, and 90. FindingsNine patients had recurrent strokes or TIAs by day 7 and 13 by day 9. Patients who had a recurrent stroke or TIA at day 7 and day 90 had a significantly higher ACR than those who did not have an event (4·00 mg/mmol [95% CI 1·89–8·40] vs 1·89 [95% CI 1·58–2·25]; p=0·03 and 3·73 [95% CI 2·12–6·56] vs 1·85 [95% CI 1·55–2·22]; p=0·02, respectively). After adjustment for sex and ABCD2 score, the 90-day predictive role of ACR persisted for those with versus those without subsequent events (adjusted ACR 3·48 mg/mmol [95% CI 1·96–6·19] vs 1·87 [95% CI 1·56–2·24], p=0·04). Stratification of the population at an ACR of 3.0 mg/mmol identified 39 patients at higher risk. Cox proportional hazards of progressing to stroke by day 90 if ACR was more than 3·0 mg/mmol was 3·2 (95% CI 1·07–9·45, p<0·04). InterpretationIncreased urinary albumin excretion, as detected by urinary ACR, is significantly elevated in patients who present with TIA or minor strokes and go on to have further strokes. The use of clinic urinary ACR test could improve the risk prediction of currently available stroke risk scores such as the ABCD2 score. FundingNational Institute for Health Research and Stroke Research Network.

Monitoring young people with type 1 diabetes for diabetic nephropathy: Potential errors of annual ACR testing

AimType 1 diabetes guidelines recommend annual monitoring of albumin-creatinine ratio (ACR) to detect nephropathy. Annual monitoring for conditions such as dyslipidemia leads to high rates of false-positive diagnoses. We estimated rates of false-positive and false-negative diagnoses under annual, biennial and triennial monitoring. MethodsUsing Oxford Regional Prospective Study (ORPS) data we modelled ACR over time. Using simulation we estimated numbers of positive and negative diagnoses and the proportion that are false, over 6 years of monitoring, when assessment intervals are 1, 2 or 3 years. ResultsAverage increase per year (95%C.I.) in ACR was 3,5% (2,0–5,0%) for males and 4,8% (3,2–6,5%) for females. By 6 years, annual monitoring would lead to 56 (49–63) false-positive diagnoses for every 100 positive diagnoses of micro-albuminuria, biennial to 49 (42–57) false-positives and triennial to 46 (39–53). For every 100 negative diagnoses, annual monitoring would lead to 1,2 (0,8–1,5) false-negatives, biennial to 2,3 (1,7–3,0) and triennial to 3,0 (2,2–3,8). ConclusionLess frequent monitoring would result in fewer false-positive diagnoses, but increased false negatives, or missed diagnoses. The clinical implications of these scenarios need further investigation through cost-benefit analysis.

The Diagnostic Accuracy of a Urine Albumin-Creatinine Ratio Point-of-Care Test for Detection of Albuminuria in Primary Care

Albuminuria is an important sign of chronic kidney disease and is detected routinely by measurement of urinary albumin-creatinine ratio (ACR). A Siemens CLINITEK test designed for use at the point of care is available that can semiquantitatively measure ACR. Diagnostic accuracy study evaluating a urinary ACR point-of-care test. The semiquantitative ACR test was evaluated at the point of care in a representative primary care population (those with or at increased risk of chronic kidney disease) of 642 patients under standard operational conditions and compared with the reference standard of ACR measurement in the clinical laboratory. The point-of-care CLINITEK semiquantitative ACR test. This test uses dye-binding and catalytic assays for albumin and creatinine, respectively, on a Microalbumin 9 strip, which is read by the CLINITEK Status Analyzer, and ACR is calculated automatically. Laboratory measurement of albumin and creatinine on an Abbott Architect analyzer by immunoturbidimetric and enzymatic assays, respectively, and calculation of ACR. The prevalence of albuminuria (laboratory ACR≥30 mg/g) in the study population was 20.2%. Sensitivity and specificity of the point-of-care test for detecting albuminuria were 83.2% and 80.0%, respectively. Positive and negative predictive values were 51.2% and 95.0%, respectively; positive and negative likelihood ratios were 4.16 and 0.21, respectively. Twenty-three (3.6%) samples measured at the point of care were not analyzed in the central laboratory for a variety of reasons, including laboratory reception data entry errors. Our sensitivity calculation is accurate to an approximately 8% CI. The instrument-read reagent strip test was a poor rule-in test for albuminuria at the point of care, as evidenced by the low positive predictive value, but was a reasonable rule-out test. Observed sensitivity was lower than reported in earlier laboratory-based studies. This decreased diagnostic accuracy needs to be balanced against the potential advantages of a point-of-care testing approach.

Identifying additional patients with diabetic nephropathy using the UK primary care initiative

The aim of this study was to use general practice data to estimate the prevalence of diabetic nephropathy within the registered diabetes patients and examine variation in practice prevalence and management performance since introduction of this initiative. Reported quality indicators from the Northern Ireland General Practice Quality and Outcomes Framework were analysed for diabetes and diabetic nephropathy prevalence and management in the period 2004-2008. Variation in prevalence at practice level was assessed using multiple linear regression adjusting for age, practice size, deprivation and glycaemic control. In 2006-2007, 57,454 (4.1%) adult diabetic patients were registered in the denominator population of 1.4 million compared with 51,923 (3.8%) in 2004-2005 (mean practice range 0.5-7.7%). Diabetic nephropathy prevalence was 15.1 and 11.5%, respectively (8688 and 5955 patients). Documented diabetic nephropathy prevalence showed marked variation across practices (range 0-100%) and was significantly negatively correlated with diabetes list size, albumin creatinine ratio testing rates and renin-angiotensin-aldosterone system blockade use and positively correlated with exception reporting rates. Specifically, for every increase in 100 diabetic patients to a register, documented diabetic nephropathy prevalence reduced by 40% (P=0.003). On the positive side, median albumin-creatinine ratio testing rates doubled to 82% compared with figures in the pre-Framework era. Implementation of the Northern Ireland General Practice Quality and Outcomes Framework has positively benefitted testing for diabetic nephropathy and increased numbers of detected patients in a short space of time. Large variation in diabetic nephropathy prevalence remains and is associated with diabetes registry size, screening and treatment practices, suggesting that understanding this variation may help detect and better manage diabetic nephropathy.

The Kidney Evaluation and Awareness Program in Sheffield (KEAPS): A Community-Based Screening for Microalbuminuria in a British Population

Background/Objectives: Microalbuminuria (MA) detects subjects at risk for cardiovascular disease (CVD) and chronic kidney disease (CKD) among diabetics, hypertensives and the general population. There is still a paucity of data on prevalence and risk factors for MA in the UK. We examined in a cross-sectional study, the prevalence and risk factors for MA in the general population of Sheffield, UK. Methods: The study was conducted among participants of the Kidney Evaluation and Awareness Program in Sheffield (KEAPS), a population-based screening program for MA. The screening tools included a questionnaire collating information on demographics, lifestyle, medical and family history of diabetes mellitus, hypertension and CKD. MA measurements were obtained by immunonephelometry, and MA thresholds were defined using the albumin-creatinine ratio. Results: The prevalence of MA was 7.1% in a random sample of a Sheffield-based population screened only once. The prevalence was 6.2% in the non-diabetic and non-hypertensive subjects. The prevalence of MA was only 1.3% in the subjects without any known risk factor, such as old age, diabetes, hypertension, obesity or CVD. The prevalence of MA could be overestimated as it was based on a single albumin-creatinine ratio testing. The independent predictor variables associated with the presence of MA in a mutually adjusted logistic regression model were: age (OR = 1.012, 95% CI: 1.00–1.02), diabetes (OR = 3.25, 95% CI: 1.30–8.13), obesity (OR = 4.09, 95% CI: 1.71–9.80) and family history of hypertension (OR = 1.87, 95% CI: 1.00–3.47). Conclusions: The main determinants of MA were increased age, diabetes, obesity and family history of hypertension. On the population level, obesity as a risk factor for MA is less well documented; in this study obesity had greater odds for MA than diabetes and hypertension.