Screen urine albumin-to-creatinine ratio (uACR) and serum creatinine annually if diagnosed with diabetes or hypertension: catch chronic kidney disease early

Only 10% of adults in China with chronic kidney disease (CKD) know they have it. Annual blood and urine testing in patients with diabetes and hypertension detects silent nephropathy years before irreversible kidney failure. For individuals identified with elevated urinary albumin, starting an SGLT2 inhibitor like dapagliflozin reduces composite risk of renal failure, end-stage kidney disease, and renal/cardiovascular death by ~39%, and all-cause mortality by ~31%.

Low cost. Simply collect a random urine sample for uACR and have blood drawn for serum creatinine (eGFR) during routine clinical follow-ups. The difficulty is remembering to request kidney screening when feeling completely asymptomatic.

The 6th China Chronic Disease and Risk Factor Surveillance (176,874 adults undergoing blood and urine testing) revealed an overall CKD prevalence of 8.2% (~82 million adults), with 73.3% residing in early stages 1 and 2; overall awareness of CKD was only 10.0%. A cross-sectional survey across 45 Chinese tertiary hospitals revealed that 31% of 9,672 type 2 diabetes patients had CKD, yet among these 2,997 affected patients, only 27% had ever undergone prior renal screening. The KDIGO 2024 Clinical Practice Guideline mandates testing both urine albumin (uACR) and estimated glomerular filtration rate (eGFR) in at-risk populations, prioritizing individuals with diabetes, hypertension, and cardiovascular disease. The American Diabetes Association (ADA 2026) Standards of Care mandate annual uACR and eGFR screening for all type 2 diabetes patients and type 1 patients with >=5 years' disease duration. In diabetic patients with hypertension and microalbuminuria (uACR 30–299 mg/g), guidelines recommend ACE inhibitors or ARBs. In the landmark DAPA-CKD randomized trial (4,304 CKD patients with eGFR 25–75 and uACR 200–5000), over a median of 2.4 years, the primary composite outcome (>=50% sustained eGFR decline, end-stage kidney disease, or renal/CV death) occurred in 9.2% of the dapagliflozin group vs. 14.5% of placebo (HR 0.61, 95% CI: 0.51–0.72, a 39% relative reduction). All-cause mortality was 4.7% vs. 6.8% (HR 0.69, 95% CI: 0.53–0.88, a 31% relative reduction), with equivalent efficacy regardless of diabetes status.

Graded Evidence Grade B because no randomized trial has compared mortality between "annual screening" vs. "no screening" directly; mortality reductions stem from pharmacological interventions initiated after microalbuminuria is diagnosed. Benefit magnitude is categorized as Moderate. A single elevated uACR does not establish CKD: KDIGO guidelines require repeat confirmation across 2 of 3 specimens within 3 to 6 months. Antihypertensive drug selection must be individualized by physicians. Annual diabetic retinopathy and diabetic foot screening are covered in Chapter 16, Rule 7.

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