Let's Keep Kidneys Happy! Targeting urine albumin as a treatment goal in diabetes

Diabetes is the leading cause of kidney failure in Canada and around the world. One of our goals in treating diabetes is to protect the kidneys from damage.

There are two ways that kidney health must be routinely assessed:

a blood test to measure kidney function (called glomerular filtration rate or GFR, which is calculated from a blood test called creatinine)
a urine test to check for protein (called urine albumin:creatinine ratio or ACR).

Chronic kidney disease can be defined as having either a persistently low GFR, a persistent elevation in urine ACR, or both. While the GFR is usually included on routine blood work, the urine ACR is not checked often enough. In diabetic kidney disease, the ACR is usually elevated for years before the GFR starts to fall, so the ACR is an important alert that the kidneys are starting to sustain damage. As blogged previously, because ACR often goes unchecked, and because low kidney function (GFR) is usually without symptoms until very late stage, kidney disease often goes undetected until very advanced stages.

The good news is, there are a number of treatment strategies to reduce urine ACR, including:

good diabetes control
good blood pressure control
weight management
ACE inhibitors/ARBs (medications that reduce blood pressure and protect kidneys)
SGLT2 inhibitors (medications that treat type 2 diabetes, and protect kidneys in people with or without type 2 diabetes)
finerenone (a mineralocorticoid receptor antagonist, approved in USA, not yet approved in Canada)

In the 2022 American Diabetes Association Guidelines update, there is now a target of ACR treatment, which is a reduction of at at least 30% in ACR, to slow progression of chronic kidney disease. In clinical trials of ACE inhibitors or ARBs in type 2 diabetes, reducing albuminuria by 30% has been associated with improved kidney and cardiovascular outcomes. But that doesn’t mean we should stop there – the lower the ACR, the better!

BOTTOM LINE: The urine ACR is an important marker of kidney disease, and reducing ACR is an important treatment goal. If you have diabetes, ask your doctor to have urine ACR included in your routine lab testing. If you are a health care provider, do everything you can to reduce ACR in your patients!

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