How often should eGFR (estimated Glomerular Filtration Rate) and UACR (urine Albumin-to-Creatinine Ratio) testing be completed in patients with diabetes, according to the American Diabetes Association guidelines?

eGFR and UACR Testing Frequency in Patients with Diabetes

According to the American Diabetes Association, eGFR and UACR should be assessed at least annually in patients with type 1 diabetes who have had the disease for ≥5 years and in all patients with type 2 diabetes regardless of treatment. 1

Baseline Screening Recommendations

The annual screening requirement applies to:

• Type 1 diabetes: Begin testing after 5 years of disease duration 1
• Type 2 diabetes: Begin testing at diagnosis, regardless of treatment status 1
• Both tests must be performed together to adequately assess kidney disease risk, as they provide complementary information about kidney function and damage 1

Increased Monitoring Frequency for Established Kidney Disease

For patients with established diabetic kidney disease, testing frequency should increase to 1-4 times per year based on disease severity. 1 The specific frequency depends on the stage of chronic kidney disease:

Risk-Stratified Monitoring Schedule

• Normal to mildly increased albuminuria (UACR <30 mg/g) with normal eGFR: Annual monitoring 2
• Moderately increased albuminuria (UACR 30-299 mg/g): 1-2 times per year 2
• Severely increased albuminuria (UACR ≥300 mg/g): 3-4 times per year 2
• eGFR <60 mL/min/1.73 m²: More frequent monitoring required, with specific frequency determined by both eGFR and albuminuria categories 1

Clinical Context and Implementation

The Reality of Current Practice

While these are the guideline recommendations, real-world data reveals significant gaps in implementation. A large U.S. study of over 500,000 patients found that while eGFR testing rates reached 89.5% annually, uACR testing rates were only 52.9% annually, falling far short of guideline recommendations 3. This gap is problematic because:

• Albuminuria testing identifies different at-risk populations than eGFR alone 3
• The prevalence of detected elevated albuminuria increases linearly with testing rates, suggesting substantial underdiagnosis when testing is omitted 3
• Combined changes in both UACR and eGFR predict advanced kidney disease better than either marker alone 4

Why Both Tests Matter

The combination of increasing UACR and decreasing eGFR carries a hazard ratio of 15.15 for progression to advanced CKD, compared to 1.78 for UACR increase alone and 7.53 for eGFR decrease alone 4. This multiplicative effect underscores why both tests must be performed together rather than relying on eGFR alone, despite the latter's higher implementation rate.

Common Pitfalls to Avoid

• Do not skip uACR testing simply because eGFR is normal—albuminuria can be the earliest marker of diabetic kidney disease, particularly in type 1 diabetes 1
• Do not rely on a single abnormal uACR result—confirm with repeat testing due to variability in albumin excretion 2
• Do not delay monitoring intensification in patients with declining kidney function—those with macroalbuminuria experience eGFR decline at 5.7% per annum compared to only 0.3% in those without albuminuria 5