Prevalence and Factors Associated with Albuminuria Screening Among High-Risk Adults in Saudi Arabia: A Retrospective Cross-Sectional Study

Introduction

Albuminuria represents a key clinical indicator of kidney damage and is well-established as an independent risk factor for cardiovascular events and adverse long-term outcomes.^1–3 The prevalence of albuminuria among individuals with diabetes and hypertension is high and estimated at 32.1% and 21.8%, respectively.⁴ According to the US Centers for Disease Control and Prevention (CDC), chronic kidney disease (CKD) frequently coexists with diabetes and hypertension, affecting approximately one in three individuals with diabetes and one in five with hypertension.⁵ The concurrence of type 2 diabetes, albuminuria, and reduced estimated glomerular filtration rate (eGFR) is associated with a ten-year cumulative mortality incidence of 47.0%.⁶ Given the prognostic significance of albuminuria, early identification and timely intervention are critical to reducing associated risks.^7,8 Several major international guidelines recognize the clinical importance of albuminuria.^8–13 Multiple guidelines (ADA, KDIGO, ESC/ESH, NICE, SDCPG) recommend at least annual albuminuria screening (ACR) in adults with diabetes and/or hypertension.^9–13 Despite some variation in testing frequency, most guidelines consistently identify diabetes and hypertension as significant risk factors for the development of albuminuria. However, real-world data suggest that testing for albuminuria remains suboptimal.^14,15 National laboratory data from the United States (2013–2019) indicate that only 21.0% of adults with diabetes and/or hypertension were tested for ACR.¹⁴ Early identification of CKD can significantly change the trajectory of kidney function decline.¹⁴ Moreover, effective management using pharmacotherapeutic agents such as renin angiotensin system (RAS) inhibitors, sodium glucose cotransporter 2 (SGLT-2) inhibitors, incretin therapies, and finerenone has been established to significantly reduce the risk of both cardiovascular and kidney adverse outcomes in individuals with albuminuria.^8,16,17 In Saudi Arabia, the burden of diabetic nephropathy is a leading cause of diabetes-related complications. A national registry-based study involving more than 54,000 adults with type 2 diabetes reported a diabetic nephropathy prevalence of 10.8%. The majority of these cases (8.1%) had albuminuria ≥300 mg/g, suggesting that many patients are not being screened at earlier stages of kidney involvement.¹⁸ Data on albuminuria testing among patients with diabetes, hypertension, or both without a prior diagnosis of CKD are limited in Saudi Arabia. Therefore, this study aimed to assess the real-world prevalence of albuminuria testing among high-risk individuals without a history of CKD. Additionally, the study sought to identify factors associated with suboptimal albuminuria testing practices at a tertiary care center in Saudi Arabia.

Methods

Study Design, Setting, and Population

This was a cross-sectional study conducted at King Abdulaziz Hospital, Ministry of National Guard – Health Affairs (MNGHA) in Al-Ahsa, Saudi Arabia, over the period from January 1 to December 31, 2023. Data were extracted from the hospital’s electronic medical records using the BESTCare 2.0 system. The required minimum sample size was calculated based on an expected prevalence of 50%, with a 95% confidence level and a 5% margin of error, resulting in a target of 384 patients.

Inclusion criteria were adults aged 18 years or older with a documented diagnosis of diabetes mellitus (identified using the following ICD-10 codes: E10, E11), hypertension (identified using the following ICD-10 codes: I10), or both conditions, who had attended at least two visits in primary care clinic during the study year. Exclusion criteria included a prior diagnosis of CKD at any stage, current kidney replacement therapy, pregnancy, history of kidney transplantation, active infection, or incomplete medical records. Data collected included demographic information (age, sex, body mass index), comorbidities (including heart failure, dyslipidemia, gout, cardiovascular disease, and stroke), laboratory parameters (serum creatinine, ACR, blood urea nitrogen, HbA1c, eGFR, mean arterial pressure), and medications use (angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), statins, and SGLT-2 inhibitors). Patients were required to have attended at least two outpatient visits within the study period (January 1 to December 31, 2023). Eligible patients were identified using an automated query of the BESTCare 2.0 electronic medical record system based on predefined ICD-10 diagnostic codes.

Definitions

• CKD: It is defined as abnormalities of kidney structure or function, present for a minimum of 3 months, with implications for health. This includes an eGFR <60 mL/min/1.73 m² and/or markers of kidney damage such as albuminuria (ACR ≥30 mg/g).
• Diabetes Mellitus: It is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Diagnostic criteria include fasting plasma glucose ≥126 mg/dL, 2-hour plasma glucose ≥200 mg/dL during an OGTT, HbA1c ≥6.5%, or a random plasma glucose ≥200 mg/dL with classic symptoms.
• Hypertension: It is defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, based on an average of ≥2 properly measured readings at ≥2 visits.

Ethical Considerations

This study was approved by the Institutional Review Board (IRB) at King Abdullah International Medical Research Center in the Eastern Region (KAIMRC-ER) under approval number NRA23A/063/11, granted on February 11, 2024. All study procedures followed institutional and international ethical guidelines to ensure patient confidentiality and data protection. Access to patient information was limited to authorized investigators, and all data were handled in a secure and anonymized manner.

Statistical Analysis

Descriptive statistics were used to summarize sample characteristics and the prevalence of ACR testing among patients with hypertension, diabetes mellitus, or both conditions. Unadjusted associations between ACR testing and patient characteristics were assessed using unpaired t-tests for continuous variables and Chi-square or Fisher’s exact tests for categorical variables, as appropriate. A p-value of ≤ 0.05 was considered statistically significant. Variables included in the multivariable logistic regression model were selected based on clinical relevance, including age, sex, disease group, comorbidities, baseline laboratory values, and medication use. Collinearity among covariates was assessed prior to model fitting. All analyses were performed using IBM SPSS Statistics, Version 25.

Results

A total of 1000 outpatient medical records were initially screened, and 516 patients met the eligibility criteria. The mean age of study participants was 63.7 ± 7.6 years, and the mean eGFR was 89.0 ± 14.3 mL/min/1.73 m². More than half of the participants were female (53.3%). Regarding the chronic conditions, 16.1% had hypertension only, 11.4% had diabetes mellitus only, and 72.5% had both hypertension and diabetes mellitus. In addition, dyslipidemia and cardiovascular diseases were present in 96.5% and 12.0% of the study sample, respectively. In terms of medication use, 29.1% were receiving ACE inhibitors, 41.5% were on ARBs, 42.8% were on CCBs, 90.1% were on statins, and 13.2% were on SGLT-2 inhibitors. All sample characteristics are presented in Table 1.

Table 1 Baseline Characteristics of the Study Population According to Albumin-to-Creatinine Ratio (ACR) Testing Status (N = 516)

Among the 516 patients included in the study, 305 (59.1%) underwent at least one ACR test during the study period. The prevalence of ACR testing was 69.5% among patients with diabetes mellitus only, and 66.3% among those with both hypertension and diabetes mellitus. In contrast, the prevalence was substantially lower among patients with hypertension only, at 19.3% (see Figure 1).

Figure 1 Prevalence of albumin-to-creatinine ratio (ACR) testing among high-risk patients in Saudi Arabia (n = 516) during 2023.

Factors Associated with ACR Testing

Table 1 summarizes the results from chi-square tests of associations between ACR testing and patient characteristics. Statistically significant associations were observed between ACR testing and HbA1c levels, number of outpatient visits, type of chronic conditions, and the use of ARBs, CCBs, statins, and SGLT-2 inhibitors. Patients who underwent ACR testing had significantly higher HbA1c levels (mean = 7.5%) compared to those who did not (mean = 6.6%; p < 0.001). They also had a higher number of outpatient visits (mean = 4.5 vs 3.7; p < 0.001).

The proportion of patients who underwent ACR testing was significantly lower among those with hypertension alone (19.3%) compared to those with diabetes mellitus alone (69.5%) or with both hypertension and diabetes mellitus (66.3%) (p < 0.001).

Regarding medication use, ARB users had a significantly higher percentage of ACR testing compared to non-users (67.3% vs 53.3%, p = 0.001). Similarly, ACR testing was significantly more common among statin users compared to non-users (61.3% vs 39.2%, p = 0.002). Among patients who used SGLT-2 inhibitors, 82.4% underwent ACR testing compared to 55.6% of those who did not use SGLT-2 inhibitors. In contrast, a lower percentage of CCB users underwent ACR testing compared to non-users (53.8% vs 63.1%; p = 0.035).

After adjusting for patient characteristics in multivariable logistic regression, the number of outpatient visits, type of chronic conditions, ARB use, and SGLT-2 inhibitor use remained statistically significant predictors of ACR testing. Patients with frequent outpatient visits were significantly more likely to undergo ACR testing compared to those with fewer visits. Specifically, for each additional outpatient visit, the odds of undergoing ACR testing increased by 28% (Adjusted Odds Ratio (AOR) = 1.28, 95% CI =1.12, 1.46). We also observed that patients with hypertension only were 86% less likely to undergo ACR testing (AOR = 0.14, 95% CI = 0.07, 0.31) compared to those with both hypertension and diabetes mellitus. In terms of medication use, patients using ARBs were 3.17 (95% CI = 1.69, 5.93) times more likely to undergo ACR testing compared to those not using ARBs. Similarly, patients using SGLT-2 inhibitors were three times more likely to undergo ACR testing (AOR = 3.00, 95% CI = 1.31, 6.90) than those not using SGLT-2 inhibitors (see Table 2).

Table 2 Logistic Regression of Characteristics and Predictors of Albumin-to-Creatinine Ratio (ACR) Testing

ACR Test Results and Albuminuria Classification

Figure 2 displays the ACR results among patients who underwent testing. Of the 305 patients tested, 60.0% were classified as having normal to mildly increased albuminuria (A1), 33.1% as having moderately increased albuminuria (A2), and 6.9% as having severely increased albuminuria (A3).

Figure 2 Distribution of albumin-to-creatinine ratio (ACR) results among high-risk patients who underwent testing in 2023 (n = 305).

Discussion

In this cross-sectional study of high-risk adults with diabetes mellitus, hypertension, or both conditions, we identified substantial gaps in adherence to guideline-recommended albuminuria testing. The overall prevalence of ACR testing was suboptimal (59.1%), despite the cohort’s high-risk profile, including a mean age of 63.7 years. Testing rates were highest among patients with diabetes mellitus-only subgroup (69.5%) and lowest among those with the hypertension-only subgroup (19.3%). The markedly low rate of ACR testing among patients with hypertension alone warrants particular attention. In routine clinical practice, hypertension management is often centered on blood pressure control and cardiovascular risk reduction, while kidney disease prevention may receive less emphasis in the absence of diabetes. In contrast to diabetes care, which is frequently supported by structured follow-up protocols, performance indicators, and laboratory order sets, hypertension-only care pathways may lack systematic prompts for albuminuria screening. As a result, despite clear guideline recommendations, opportunities for early CKD detection in this high-risk group may be missed. The observed association between ACR testing and the use of ARBs and SGLT-2 inhibitors further highlights the influence of clinical context and prescribing behavior on screening practices. These medications are commonly prescribed with renal protection in mind and are often initiated within structured diabetes or CKD management frameworks. Their use may therefore reflect greater clinician awareness of kidney-related risk, closer monitoring, or specialist involvement, all of which may prompt albuminuria testing. This “renal-protective prescribing mindset” may partially explain why patients receiving ARBs or SGLT-2 inhibitors were more likely to undergo ACR testing in our cohort. Among those tested, approximately 40% exhibited albuminuria (A2 or A3), highlighting the clinical importance of routine screening in identifying early kidney injury. Consistent with prior literature, we observed significant associations between ACR testing and factors such as higher HbA1c levels, a greater number of outpatient visits, and the use of ARBs, statins, SGLT2 inhibitors, and CCBs.^15,19 After adjusting for patient characteristics, the number of outpatient visits, type of chronic condition, and the use of ARBs and SGLT2 inhibitors remained independently associated with higher odds of undergoing ACR testing. These findings are aligned with previous studies that have reported higher screening rates among more medically complex patients.¹⁹

The underutilization of ACR testing represents a missed clinical opportunity for early CKD diagnosis and the implementation of comprehensive cardiovascular–kidney risk reduction strategies, including both non-pharmacological interventions and evidence-based pharmacotherapies.⁴ High systolic blood pressure and high fasting plasma glucose are modifiable risk factors that have been consistently reported as leading global contributors to the burden of cardiovascular disease.²⁰ In 2025, these conditions accounted for 2377.1 (95% CI: 2340.8–2413.3) and 796.4 (95% CI: 776.2–816.7) age-standardized disability-adjusted life years (DALYs) per 100,000 population, respectively.²⁰ Both risk factors are projected to remain major contributors through 2050, indicating the potential for substantial health care challenges and increased economic burden.²⁰ Nevertheless, global data on albuminuria testing reflect patterns similar to those observed in our study, with persistently low testing rates despite clear guideline recommendations and the recognized clinical value of the test.^4,15,19 A multinational analysis of over 3 million adults found that ACR screening rates ranged from 35% in diabetes to just 4% in hypertension, revealing that regular testing is often not tailored to patient risk levels.⁴

Several barriers likely contribute to the underutilization of ACR testing. Previous studies have several contributing factors, including low adherence to screening guideline recommendations, inadequate follow-up after abnormal ACR results, and provider-related factors.¹⁹ Additionally, system-level barriers, including workflow inefficiencies, lack of automated reminders, and patient non-adherence, may further hinder optimal screening practices.¹⁹ Locally, a prior Saudi study also revealed low awareness of albuminuria among patients with diabetes and hypertension, suggesting a combination of patient- and provider-level barriers.²¹ Implementing systematic outreach strategies, such as home-based or proactively scheduled ACR screening for high-risk individuals, may help overcome the limitations of testing and improve early detection of kidney disease in primary care settings.²² In the SALINE study, a total of 6380 patients were invited, including 3802 through general practices and 2578 through community pharmacies. Among those with confirmed albuminuria who completed further evaluation, more than 85% were identified as having either newly diagnosed or insufficiently managed chronic kidney disease or cardiovascular risk factors.²² A recent large-scale implementation study in the Netherlands (THOMAS) found that home-based screening using a urine collection device achieved a 59.4% participation rate and 96.6% sensitivity for detecting albuminuria, suggesting that community-based approaches can successfully enhance early detection efforts.²³ Additionally, community pharmacy services may serve as accessible settings for the early identification of individuals with hypertension and diabetes mellitus.^24,25

This study provides several strengths, including being the first to specifically assess the prevalence of albuminuria testing in a high-risk population in Saudi Arabia. The use of detailed electronic health record data and multivariable modeling strengthens the validity of our findings. However, limitations should be acknowledged. First, the single-center design limits the generalizability of results to broader populations. Second, the cross-sectional nature of the study prevents the establishment of causal relationships. Third, reliance on electronic health record data may have introduced documentation biases. In addition, residual confounding cannot be excluded, as several potentially influential factors were not captured, including socioeconomic status, physician specialty, clinic type, health insurance coverage, and patient health literacy or education level. Lastly, the study did not explore provider- or system-level barriers in depth, limiting the ability to fully understand the drivers of underutilization. Future research should prioritize multicenter studies to capture national testing patterns and explore regional variability. Longitudinal cohort studies assessing the impact of ACR testing on CKD progression and cardiovascular outcomes are warranted. Additionally, qualitative research investigating healthcare provider attitudes and systemic barriers would be valuable in designing targeted interventions to enhance screening rates. This study identifies a substantial gap in albuminuria testing among high-risk Saudi adults, particularly among those with hypertension alone. Enhancing adherence to ACR testing guidelines in primary care represents a key opportunity to improve early CKD detection and optimize long-term clinical outcomes in this vulnerable population.

Conclusion

Our study demonstrated that a substantial proportion of high-risk patients in Saudi Arabia, particularly those in the hypertension subgroup, are not receiving recommended ACR testing. This underutilization is concerning, as early detection of albuminuria is critical for initiating timely interventions that preserve kidney function. Increasing testing rates within primary care settings can facilitate earlier identification of kidney disease and reduce the risk of long-term complications. Targeted efforts are warranted to address this gap and to improve adherence to guideline-recommended screening in routine clinical practice. Potential implementation strategies include electronic medical record–based alerts or standardized order sets during hypertension-related visits, integration of albuminuria screening into primary care pathways, pharmacist-led screening initiatives, and regular audit-and-feedback mechanisms to support guideline adherence. Future multicenter studies are needed to confirm these findings across different healthcare settings and to evaluate the effectiveness of targeted interventions aimed at improving ACR testing, particularly among patients with hypertension alone.