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Integrating albuminuria and GFR in the assessment of diabetic nephropathy

Nature Reviews Nephrology volume 5, pages 397–406 (2009)Cite this article

Abstract

The evaluation of diabetic nephropathy from research and clinical viewpoints depends on the assessment of two continuous variables, albumin excretion rate (AER) and glomerular filtration rate (GFR). These two parameters form the basis of both the European classification of five stages of diabetic nephropathy, assessed according to changes in AER and GFR (hyperfiltration, normoalbuminuria, microalbuminuria, macroalbuminuria and end-stage renal disease), and the National Kidney Foundation classification of five stages of chronic kidney disease based on categories of estimated GFR. Although increases in AER generally precede a decline in GFR, some patients follow a non-albuminuric pathway to renal impairment. In addition, studies indicate that GFR decreases in a linear fashion from normal or above-normal levels. Whether hyperfiltration is part of the pathogenetic process leading to diabetic nephropathy remains unclear. Ideally, both AER and GFR should be assessed at an early stage in patients being evaluated for diabetic nephropathy. New methods such as the use of cystatin-C-based equations for estimating GFR should be considered because current creatinine-based estimates are inaccurate at normal or high GFRs. Serial assessments of both AER and GFR might allow diabetic nephropathy to be diagnosed at early stages of the disease process that are selectively responsive to new interventions. The successful integration of AER categories with the recently defined stages of GFR represents a new challenge in the management of diabetic nephropathy.

Key Points

  • Both albumin excretion rate (AER) and glomerular filtration rate (GFR) should be assessed at an early stage in evaluating patients for diabetic nephropathy

  • In the assessment of diabetic nephropathy, the roles of AER and GFR are complementary rather than competitive

  • Changes in AER are dynamic whereas changes in GFR are usually progressive

  • Although increases in AER generally precede a decline in GFR, some patients follow a non-albuminuric pathway to renal impairment

  • The course of renal abnormalities in type 1 and type 2 diabetes is similar, but more heterogeneous in type 2 diabetes

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Figure 1: The distribution of 301 patients with type 2 diabetes attending a single tertiary referral clinic divided according to GFR and AER.

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  1. Endocrine Center, Austin Health and University of Melbourne, Victoria, Australia

    George Jerums, Sianna Panagiotopoulos, Erosha Premaratne & Richard J. MacIsaac

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Jerums, G., Panagiotopoulos, S., Premaratne, E. et al. Integrating albuminuria and GFR in the assessment of diabetic nephropathy. Nat Rev Nephrol 5, 397–406 (2009). https://doi.org/10.1038/nrneph.2009.91

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