Normoalbuminuric Renal-Insufficient Diabetic Patients

Abstract

OBJECTIVE -About 20% of diabetic patients with chronic kidney disease (CKD) detected from the new American Diabetes Association recommendations (albumin excretion rate Ͼ30 mg/24 h or estimated glomerular filtration rate [GFR] Ͻ60 ml/min per 1.73 m 2 ) may be normoalbuminuric. Do the characteristics and outcome differ for subjects with and without albuminuria?RESEARCH DESIGN AND METHODS -A total of 89 patients with diabetes and a modification of diet in renal disease (MDRD) estimated GFR (e-GFR) Ͻ60 ml/min per 1.73 m 2 underwent a 51Cr-EDTA B-isotopic GFR determination and were followed up for 38 Ϯ 11 months.RESULTS -The mean MDRD e-GFR (41.3 Ϯ 13.1 ml/min per 1.73 m 2 ) did not significantly differ from the i-GFR (45.6 Ϯ 29.7). Of the subjects, 15 (17%) were normoalbuminuric. Their i-GFR did not differ from the albuminuric rate and from their MDRD e-GFR, although their serum creatinine was lower (122 Ϯ 27 vs. 160 Ϯ 71 mol/l, P Ͻ 0.05): 71% would not have been detected by measuring serum creatinine (sCr) alone. They were less affected by diabetic retinopathy, and their HDL cholesterol and hemoglobin were higher (P Ͻ 0.05 vs. albuminuric). None of the CKD normoalbuminuric subjects started dialysis (microalbuminuric: 2/36, macroalbuminuric: 10/38) or died (microalbuminuric: 3/36, macroalbuminuric: 7/38) during the follow-up period (log-rank test: P Ͻ 0.005 for death or dialysis), and their albumin excretion rate and sCr values were stable after 38 months, whereas the AER increased in the microalbuminuric patients (P Ͻ 0.05), and the sCr increased in the macroalbuminuric patients (P Ͻ 0.01).CONCLUSIONS -Although their sCr is usually normal, most of the normoalbuminuric diabetic subjects with CKD according to an MDRD e-GFR below 60 ml/min per 1.73 m 2 do really have a GFR below 60 ml/min per 1.73 m 2 . However, as expected, because of normoalbuminuria and other favorable characteristics, their risk for CKD progression or death is lower. Diabetes Care 30:2034-2039, 2007T wenty-five to forty percent of patients with diabetes have kidney damage (1), and diabetes is the first cause of end-stage renal disease in most countries (2). The early detection of chronic kidney disease (CKD) in diabetic patients is therefore of critical importance. The conventional approach for screening is the determination of the albumin excretion rate (AER). However, a substantial proportion of normoalbuminuric diabetic patients may present with a reduced glomerular filtration rate (GFR): their rates have been reported to be ϳ20% based on GFR Ͻ60 ml/min per 1.73 m 2 in type 2 diabetes (3) and in type 1 diabetes based on GFR Ͻ90 ml/min per 1.73 m 2 with more advanced glomerular lesions (4). In accordance with the National Kidney Foundation guidelines (5), this has led the American Diabetes Association to recommend the screening of CKD in diabetic patients based both on the AER (threshold: 30 mg/24 h) and the Cockcroft and Gault equation or modification of diet in renal disease (MDRD) equation estimated GFR (threshold: 60 ml/min per 1.73 m 2 ) (6...

Clinical impact of albuminuria and glomerular filtration rate on renal and cardiovascular events, and all-cause mortality in Japanese patients with type 2 diabetes

“…In this aspect, Yokoyama et al [17] described that the proportion of subjects with low eGFR (\60 ml/min per 1.73 m 2 ) and normoalbuminuria was 11.4 % of type 2 diabetic patients examined (262/2,298). Supporting our notion, Rigalleau et al [18] reported that risk for renal progression in such patients with type 1 or type 2 diabetes is lower. On the contrary, allcause mortality, not cardiovascular events, was strongly associated with reduced eGFR \30 ml/min per 1.73 m 2 in normoalbuminuric diabetic patients in this present study.…”

Blood pressure level and risk of major cardiovascular events and all-cause of mortality in patients with type 2 diabetes and renal impairment: an observational study from the Swedish National Diabetes Register

“…Albuminuria was found only in 30% of patients with RI at baseline, in line with previous studies in which the majority of patients with type 2 diabetes and RI were found to be normoalbuminuric [40][41][42]. Both albuminuria and RI are independent risk factors for CVEs and all-cause mortality in type 2 diabetes, with albuminuria being the strongest risk factor and relevant at all levels of renal function.…”

A Cross-sectional Survey of Chronic Kidney Disease and Diabetic Kidney Disease in Japanese Type 2 Diabetic Patients at Four Urban Diabetes Clinics

“…A previous report from the UK (2) revealed that 30% of diabetic patients had CKD stage 3, which was similar to our result indicating a higher prevalence of CKD in diabetic patients than the general population. Our survey also demonstrated that 64% of diabetic patients with CKD stage 3 were normoalbuminuric, in contrast to the results which showed that normoalbuminuric patients were about 20 to 30% in CKD stage 3 patients (11,12). ACEIs and ARBs might have modified both ACR and eGFR, although the absolute number of patients on these drugs in our study were fewer than in the previous studies (11,12 (11,12 …”