31 However, the cost-effectiveness of screening for albuminuria was not compared to that of screening for proteinuria. Moreover, the proposed sensitivity and specificity of 1+ dip-stick proteinuria for detecting albuminuria or proteinuria was too optimistic in light of two recent studies.11,22 In contrast, several studies have found

that screening for albuminuria or proteinuria followed by treatment with ARB is cost-effective for preventing ESRD or death in diabetics.32 Moreover, a few studies have found that ACEI or ARB treatment in microalbuminuric diabetics is more cost-effective than that in proteinuric diabetics, including an Asian study.32,33 However, these studies made this comparison based on indirect comparisons between two separate RCT. Moreover, they did not account for the cost of screening Pembrolizumab for albuminuria click here or proteinuria. Thus, the relative cost-effectiveness

of screening for albuminuria or proteinuria in diabetics is not known. Due to a lack of a direct comparison, CKD guidelines differ in their opinions regarding the choice between ACR and PCR.2 For example, the UK CKD guidelines, Scottish Intercollegiate Guidelines Network and Caring for Australians with Renal Impairment Guidelines recommend that ACR should be used for diabetic patients, whereas PCR should be used for non-diabetic CKD.2 In contrast, the Kidney Disease Quality Outcomes Initiative Guidelines recommend ACR but

PCR is regarded as acceptable if the ACR is high (>0.5–1 g/g creatinine).2 For PAK5 diabetics, albuminuria should be used because it is a surrogate end-point for early diabetic nephropathy.3 In fact, screening for albuminuria is even more important for diabetic Asians because they have the highest prevalence of albuminuria (55%) in the world.34 Moreover, albuminuria is more sensitive than proteinuria in detecting CKD. For example, a direct comparison study found that 67.5% of albuminuria subjects were found to have no proteinuria whereas 8% of proteinuric subjects had no albuminuria (especially non-diabetics) in a cross-sectional study of the general population.35 Thus, measuring proteinuria misses 67.5% of albuminuric subjects for whom treatment with ARB is cost-effective. In contrast, there is no reason to measure albuminuria for patients with known proteinuria. For non-diabetics, proteinuria should be used because of the following reasons. First, the measurement of proteinuria is cheaper than that of albuminuria.9 Second, most renoprotective RCT in non-diabetics and the only renoprotective RCT with proteinuria as a treatment target (also in non-diabetics) measured proteinuria instead of albuminuria.2,28 Third, ACEI is efficacious in slowing progression of renal disease only in patients with proteinuria of more than 0.5 g/day.