The International Diabetes Federation projects a global diabetes incidence of ~643 million by 2030.¹ Diabetic kidney disease (DKD) occurs in up to 40% of patients with diabetes.²

Although albumin-creatinine ratio (ACR) is known to be the earliest marker of kidney disease³, frequency of ACR testing remains low.^4-6 This article looks at how quantitative ACR point-of-care testing improves DKD diagnosis and is a game-changer for better overall patient management.¹ It has revolutionised medicine and saved millions of lives.¹

The global burden of kidney disease

Between 8 and 16% of the adult population have some form of kidney damage, and every year millions die prematurely of complications related to chronic kidney disease (CKD).⁷ Over time, worsening DKD is associated with increased risk of cardiovascular events, cerebrovascular events and renal morbidity and mortality.⁷

In developed countries, end-stage renal disease (ESRD) is a major cost driver for patients, their families and the taxpayers.⁸ Patients with ESRD require dialysis or kidney transplantation, which are highly costly and consume a sizeable portion of the health budget.⁸

In people with diabetes, cardiovascular and renal complications are the main cause of death, yet the majority of these patients are unaware of having diabetes complications.³

Kidney disease is often described as ‘silent’ because 90% of function can be lost before symptoms are experienced.⁸ Recent studies have found that one in ten adults could be affected, yet only one third of these will have had a diagnosis.⁹ The same study showed that mortality was substantial in this population, and that the leading cause of hospital visits and costs was CKD followed by heart failure.⁹ This is despite the fact that early detection and management of kidney disease can slow disease progression or even prevent it altogether.⁸

Early detection of cardiovascular and renal complications is key to initiating treatment and to halting progression of the disease.⁸

ACR is the earliest marker

ACR levels are associated with risk of cardiovascular disease, kidney disease progression and mortality.¹⁰ KDIGO recommends a comprehensive staging for CKD that incorporates albuminuria at all stages of estimated glomerular filtration rate (eGFR).^11,12 In patients with type 2 diabetes, diagnosis of DKD helps clinicians to adjust hypoglycaemic medication, such as glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2 (SGL-2) inhibitors, by avoiding contraindicated drugs and using others with caution to avoid potentially serious complications, such as hypoglycemias.^11,12

ACR is also known to be the earliest marker of kidney disease.³ A recent study found that routine measurement of ACR at the point-of-care in diabetes patients identified 8.6% with DKD and 9.9% with suspected DKD.¹³ In the group of patients with DKD, the medication was then adjusted in 46% of patients based on the ACR values.¹³

ACR can prove a useful screening tool for CKD and microvascular complications as well.^4,5 Despite all this, frequency of ACR measurement is still low in many countries around the world.^4-6  

Rapid point-of-care testing to improve patient outcomes

ACR measurement can be achieved with both laboratory testing and point-of-care testing (POCT).^13,14 POCT in primary care allows patients and their care providers to make management decisions at the time of the visit of a patient. Results are available within minutes and can be discussed with the patient immediately.^13-16

POCT has the potential to improve practice workflow, leading to operational and economic benefits.^18-20 For patients, this is more convenient and has been shown to increase understanding, motivation and patient satisfaction.^15-17  

In low- and middle-income countries, and in resource-limited or remote settings, POCT can offer further benefit over laboratory testing.^20-22 Several POC devices are now available which combine ACR measurement with other useful parameters (HbA1c, lipid profiles etc) and these have been shown to possess quantitative accuracy commensurate with laboratory testing.^21,22