Diabetes and chronic
kidney disease: thediagnostic imperative

Supported by

About this article
This article, supported by Abbott and createdby Economist Impact, serves as an educational
resource to raise awareness of tests andinternational guidelines to be considered during
clinical consultations. It aims to empower patientsto engage in informed discussions with theirdoctors about diabetes.
The editorial team at Economist Impact would
like to thank the following individuals (listed
alphabetically) for generously contributing theirtime and insights, which have been critical to thecreation of this article.
• Professor Andrew Boulton, President of theWorldwide Initiative for Diabetes Education,
Chair of EURADIA (European Alliance for
Diabetes Research), and former President of theInternational Diabetes Federation (IDF)

The findings and views expressed in this article do
not necessarily reflect the views of the sponsor.
Economist Impact bears sole responsibility forthe contents of this article. While every effort
has been taken to verify the accuracy of thisinformation, Economist Impact cannot accept any
responsibility or liability for reliance by any personon this article or any of the information, opinions,or conclusions set out within.
This research was led by Alcir Santos Neto andconducted by Maria Clara Silva. This article wasauthored by Adam Green, edited by Alcir Santos
Neto and Maria Clara Silva, and copyedited by
Maria Ronald. Dr Rob Cook supervised anddirected the research program.

• Professor Vivian Fonseca, Professor of
Medicine, Assistant Dean for Clinical Research,
the Tullis-Tulane Alumni Chair in Diabetes, andChief of the Section of Endocrinology at Tulane
University Medical Center, and Past President(Medicine & Science) at the American Diabetes
Association (ADA)©Economist Impact 2024

2

Diabetes and chronic kidney disease: the diagnostic imperative

The diagnostic imperative
Diabetes mellitus (DM) or diabetes (hereafterused interchangeably), characterized by chronic
hyperglycemia, can, over time, lead to irreversible
damage to the heart, blood vessels, eyes, kidneys,
and nerves. As a result, diabetes – a silent
killer – is a leading cause of death and disability
worldwide, affecting patients across ethnicities,
age groups, and genders.1 In the United States,
more than 11% of the population (37m people)
have diabetes and 96m people have prediabetes.2
Prediabetes refers to the common and reversible
condition where blood glucose levels are elevatedbut not high enough for a diagnosis of T2DM.3
Similar trends are evident in Europe, where about
60m people have diabetes, equating to 10.3%of men and 9.6 % of women aged 25 years andabove.4
Diabetes has been recognized as a global healthchallenge, and, in 2006, was identified as a threat
to world health equivalent to that posed by
infectious diseases such as tuberculosis and HIV.5
Over half a billion people worldwide have DM,
a number that is expected to rise to more than
1.31bn by 2050.1 In 2004, it was estimated thatthe number of people with DM globally would
reach 382m by 2030, but this milestone wasbreached by 2013, suggesting an exponential
increase in incidence.6 An increase in prevalencein every region of the world is expected by 2045
(see Table 1).7

Over 0.5bn people
worldwide have diabetes,
a number that is
expected to rise toover 1.3bn people
by 2050.1
Worldwide, the mortality rate due to diabetes
increased by 3% between 2000 and 2019; thisincrease was particularly significant given that theprobability of dying from a disease like cancer orchronic respiratory diseases between the ages of
30 and 70 decreased by 22% in the same period.8
The DM burden is growing more rapidly in lowand middle-income countries (LMICs), driven inpart by a combination of population ageing, poor
nutrition, and sedentary lifestyles.9

Table 1: Age-adjusted comparative prevalence of diabetes 7
Percentage, by year

Region

2000

2011

2021

2030*

2045*

Africa

1.2

4.5

5.3

5.5

5.6

Europe

4.9

6.7

7.0

8.0

8.7

Middle East and North Africa

7.7

11.0

18.1

19.6

20.4

North America and Caribbean

7.8

10.7

11.9

13.3

14.2

South and Central America

3.7

9.2

8.2

9.2

9.9

South-East Asia

5.3

9.2

10.0

10.9

11.3

Western Pacific

3.6

8.3

9.9

10.9

11.5

*Projections by the International Diabetes Federation©Economist Impact 2024

Diabetes and chronic kidney disease: the diagnostic imperative3

DM is broadly classified into three types basedon clinical presentation and etiology. These are
Type 1 diabetes (T1DM), Type 2 diabetes (T2DM),
and gestational diabetes (GDM). Monogenic andsecondary diabetes also exist, but they are farless common. The most common is T2DM, which
includes almost 90% of all diabetes cases.10 It
is most frequently seen in patients aged over45, but it is increasingly evident in younger age
groups due to rising levels of obesity, physicalinactivity, and poor diets. T1DM is more common
in children and adolescents but can develop at
any age. It accounts for 5-10% of DM and resultsfrom an insulin deficiency caused by the body
attacking and destroying the insulin-producing
cells of the pancreas.11 Unlike T2DM, which is alargely preventable lifestyle disease, T1DM is an
autoimmune disorder.12,13
Affordable treatment is critical for the survivalof patients living with diabetes. “Access to
medications is crucial; it is about equity andensuring that everyone has access to effective
treatments,” said Professor Andrew Boulton,
President of the Worldwide Initiative for Diabetes
Education, Chair of EURADIA (European Alliancefor Diabetes Research), and former President of
the International Diabetes Federation (IDF). Thosewith T1DM require daily doses of insulin, while
T2DM is treated with lifestyle changes, as well as
medicine and insulin, depending on the severityof the disease.14,15 Inadequately-controlled
diabetes, such as chronic hyperglycemia, canimpact several organ systems and potentially leadto fatal consequences.2,16-19 Continuous Glucose
Monitoring (CGM) can be an effective method tohelp patients increase awareness of their glucose
levels, thus improving their quality of life.20,21“The prevalence of diabetes is increasing rapidly,
and this is concerning, but it is preventable withearly screening and taking action early,” said Prof
Boulton. To combat the rise of diabetes, patient
education is critical to improve self-management
and monitoring, as well as treatmentcompliance.22-24©Economist Impact 2024

4Diabetes and chronic kidney disease: the diagnostic imperative

Associated costs of treating diabetes

Chronic kidney disease (CKD)

Care for people diagnosed with diabetes costs
1 in 4 healthcare system dollars (2022) in the
United States, and people diagnosed withdiabetes spend on average 2.6 times more on
their healthcare than people without diabetes.25
Glucose-lowering medicines and other diabetes
supplies contribute to direct medical costs, while
contributors to indirect costs include reduced
employment and lost productivity as a result ofpremature deaths that can impact the economy.25

The importance of protecting the body fromhyperglycemia (high levels of blood glucose)cannot be overstated; its effects are normallydivided into macrovascular and microvascularcomplications. Macrovascular complications
include “cardiovascular, cerebrovascular, andperipheral vascular disease,” while microvascularcomplications include “retinopathy, neuropathy
and nephropathy”.29

In England and Wales, the National Health Service(NHS) spends 10% of its budget on diabetes,
equivalent to over $3.2m every hour.27,B Thatis nearly $30.3bn spent annually on treating
diabetes and its complications.27,28,B The NHS
spends $373m on supplies such as blood glucose
meters, test strips, and needles for insulin
pens.27,28,B According to the IDF’s Global Diabetes
Atlas, cost is expected to rise in almost every
region of the world by 2045 (see Table 2).26

Kidney diseases rank as the ninth leading causeof death in the United States, and researchsuggests that T2DM is the leading cause of CKD
and end-stage kidney disease globally.30-32 About
30-40% of those with T1DM will develop CKD
with a high risk of cardiovascular events, renal
insufficiency and kidney failure, whereas thosewith T2DM are at a major risk for end-stage renal
disease.33,34 Diabetic nephropathy is a significant
cause of CKD, which often develops slowly and isasymptomatic until it is advanced.

Table 2: Diabetes-related health expenditure per person 26, A
US$, by year

Region

2011

2021

2030*

2045*

Africa

883

633

2,183

1,661

Europe

1,493

3,573

6,373

6,521

Middle East and North Africa

684

539

1,882

1,467

North America and Caribbean

2,232

9,503

2,047

1,965

South and Central America

1,080

2,535

3,100

2,834

South-East Asia

No data

130

26,414

20,611

Western Pacific

1,354

1,394

35,78636,926*Projections by the International Diabetes Federation

Adapted from the International Diabetes Federation, with costs rounded to the nearest US$ and transposed from the publication year of 2021 to 2024 US$ with an average inflation rate of 5.03%
and cumulative inflation of 15.76%.
B
Costs transposed from 2012, the year the date was reported, with an average exchange rate of 1 US$ to 0.78 Pounds£, and an average inflation rate of 2.65% and cumulative inflation of 36.63%.
A©Economist Impact 2024

5Diabetes and chronic kidney disease: the diagnostic imperative

CKD is clinically defined as a low estimatedglomerular filtration rate (eGFR) or other signs ofkidney damage and persistently elevated urinary
albumin excretion present for three months
or more.C,35 The National Kidney Foundation
reported that nearly 90% of adults living withCKD in the United States are unaware that they
have it.36 Of all the long-term complications ofdiabetes, CKD is the most expensive to treat
and has a severe impact on daily life. “CKD canbe a very expensive disorder if people don’t get
diagnosed early and treated appropriately toprevent the need for dialysis,” explained Professor
Vivian Fonseca, Professor of Medicine, Assistant
Dean for Clinical Research, the Tullis-Tulane
Alumni Chair in Diabetes, and Chief of the Sectionof Endocrinology at Tulane University Medical
Center, and Past President (Medicine & Science) at
the American Diabetes Association (ADA).

“Chronic kidney disease can be a very
expensive disorder if people don’t get
diagnosed early and treated appropriately toprevent the need for dialysis. ”
Vivian Fonseca, Professor of Medicine, Tulane University Medical Center.

Treating CKD patients with dialysis in the UnitedStates can cost nearly three times as much as
non-dialysis CKD Medicare patients.37
Dialysis or a kidney transplant may be requiredfor patients with kidney failure. Diabetic dialysis
patients are challenging to manage as theyexperience higher rates of cardiovascular eventsand mortality in comparison to non-diabetic
patients on dialysis, although mortality rates havedeclined over the last century.38 Despite this,reports suggest that excess mortality associatedwith both T1DM and T2DM is restricted topatients with CKD, making prevention andeffective management key aims for managing
these patients.39

C

Nearly 90% of adults livingwith chronic kidney diseasein the United States areunaware that they have it.36

Detecting diabetes earlyPrevention of diabetes is the most effective
way to minimize the impact of diabetic kidneydisease.40 “There needs to be an awareness about
early recognition and the importance of it. This
allows for early treatment to prevent diseaseprogression,” said Prof Fonseca. Screening forprediabetes and T2DM is effective in preventing
the progression from prediabetes to diabetes to
CKD.
Prevention and effective management strategies
for diabetes represent good value in terms ofcosts per quality-adjusted life year or QALY
gained. Public health interventions, for example,
are widely accepted as cost-effective prevention
measures and cost less than $50,000 per QALY.2
Lifestyle modifications to prevent T2DM in
those at high risk cost $12,500 per QALY whencompared to no such modifications.2 “It is
economically viable to screen high-risk groups
but not the whole population,” explained Prof
Boulton. “All complications of diabetes can besilent until it is too late. Screening picks them up
before that,” he continued.
Aggressive interventions and regular follow-ups
are important for those at very high risk basedon their test results. Vigilance is key in primarycare, where relevant patients are contacted
annually about their screenings. Some countries
perform better at this phase, Prof Boulton
explained. “Scotland is a good example of acountry that has trained primary-level care toensure things [diabetes] are detected early.
The Netherlands has done very well with its
programs, and the Scandinavians are very good.

Glomerular filtration rate (eGFR) less than 60 ml/min per 1.73 square meters.
©Economist Impact 2024

6Diabetes and chronic kidney disease: the diagnostic imperative

It’s about having the system to recall and review
patients regularly,” he said. In Europe, screening is
recommended annually for patients with kidneydisease and less frequently for non-diabetics,
while the United States’ recommendations are
testing regularly, annually for cystic fibrosisrelated diabetes and at least every three years if
levels are normal.41,42

Regular review of patients includes checking
average blood sugar levels, which can be used tomonitor seemingly healthy individuals, those athigh risk of developing diabetes, and those who
already have diabetes. There are three recognizeddiagnostic tests for diabetes, but the test with thebest diagnostic accuracy is rarely straightforward
as each has its advantages and disadvantages.43“...(early detection is) about having the system
to recall and review patients regularly...”Andrew Boulton, President of the Worldwide Initiative for Diabetes Education.

“Vigilance is key in primary care, where
relevant patients are contacted annually
about their screenings. Some countries
perform better at this phase. ”
Andrew Boulton, President of the 					Worldwide Initiative for Diabetes Education.

©Economist Impact 2024

7

Diabetes and chronic kidney disease: the diagnostic imperative

Diagnostic tests
Diabetes and prediabetes are detected bymeasuring fasting plasma glucose (FPG) levels,
HbA1c (glycated hemoglobin), or with an oral
glucose tolerance test (OGTT), including a 2-hour
plasma glucose measurement during the oral
glucose tolerance test. This section assesses thediagnostic options recommended by current
guidelines in the United States and Europe (seeTable 3).

and is more convenient to use than OGTT.43,45
However, FPG is not failure-proof; it is vulnerable
to pre-analytical variables such as recent foodintake, how well the sample is stored, acute stressand diurnal variations, and common drugs suchas corticosteroids, which can influence glucose
metabolism.46,47

Fasting plasma glucose (FPG)

HbA1c has several advantages compared toother screening and diagnostic tests. It is moreconvenient as fasting is not required, and it has
better pre-analytical stability as it is not affectedby day-to-day fluctuations in plasma glucose
levels due to illness or nutrition. The advantagesof the HbA1c test may be offset by its higher
cost, lower sensitivity, limited availability insome developing countries, and poor correlation
between its value and average glucose levels insome patients.42

FPG is the fastest and simplest way to diagnose
diabetes; it is inexpensive and sensitive. In
patients presenting with classic symptoms such as
hyperglycemia, the plasma glucose level is enoughto diagnose diabetes, although some physicians
may still test for HbA1c to determine how chronic
the elevated glucose levels are. Studies comparing
OGTT, FPG, and HbA1c and concluded thatFPG has a higher level of accuracy than HbA1c

HbA1c

Table 3: Guidelines for diabetes testing 41,42,44
United States
Guidelines

Europe
Tests

Tests

Guideline

HbA1c
Standards of Carein Diabetes—2023
Abridged for Primary
Care Providers

Fasting Plasma Glucose(FPG)
2-hour plasma glucose
during 75-g (OGTT)
Random plasma glucose
(RPG)
HbA1c

Classification andDiagnosis of Diabetes:
Standards of Care in
Diabetes—2023

FPG
OGTT
RPG

HbA1c

FPG

OGTT

2019 European
Society of Cardiology(ESC) Guidelines on
diabetes, pre-diabetes,and cardiovasculardiseases, developed incollaboration with theEuropean Association
for the Study ofDiabetes (EASD)RPG

See Appendix A for ranges and frequency©Economist Impact 2024

8

Diabetes and chronic kidney disease: the diagnostic imperative

Anything affecting red blood cell turnover
can also interfere with HbA1c results. Factors
increasing HbA1c include vitamin B12 deficiency,
decreased erythropoiesis and/or a splenectomy;on the other hand, chronic liver disease, somemedicines, and rheumatoid arthritis can reduce
HbA1c values.48 Despite this, studies have showna strong correlation between HbA1c and diabetes
complications and lower HbA1c levels areassociated with an increased risk of hypoglycemia
in patients with both T1DM and T2DM.49
Alternative markers of glycemia
Clinical guidelines strongly base diagnostic
strategies on FPG and HbA1c. However, thesetests are not always appropriate. Glycatedalbumin and fructosamine have evolved asalternative markers of glucose control, and can beused as an adjunct test to HbA1c or as a reliablemeasure when HbA1c is unsuitable. Despite
this, no guideline currently supports the useof glycated albumin and fructosamine for the
diagnosis of diabetes or prediabetes.50
The NHS Trust in England recommends thatfructosamine testing be used for monitoring
diabetes patients when HbA1c results are notavailable, as there is no established diagnostic
threshold based on evidence.51
Fructosamine is made by the glycation of serum
proteins, including albumin. Since albumin isabundant in plasma, fructosamine is principallyglycated albumin.52 Glycated albumin andfructosamine reflect short-term glycemic levels
and are not influenced by conditions that affect
HbA1c. HbA1c measures glycated hemoglobin
over three months, while glycated albumin
and fructosamine measure a shorter period of
approximately two weeks, thus bridging the
gap between HbA1c and continuous glucose
monitoring and allowing for more effective
monitoring of changes in blood glucose levels.53,54
Testing for glycated albumin is more affordable
than HbA1c, and can even be automated.

Prof Fonseca shared some insight into thevarious diagnostic methods used: “HbA1c is very
important, but testing glucose is less important.
Fructosamine (FRA) and glycated albumin (GA)are useful in certain situations, and while GA is abetter test than FRA, FRA testing is done more,”he explained. He affirms that GA is a new test
that is not widely available, so FRA is often used.
Indeed, the diagnostic efficiency of glycatedalbumin is superior to that of fructosamine dueto the changes that can occur in glycated serum
proteins in response to systemic disorders.
Glycated albumin can be reported as a ratio tototal albumin, minimizing any interference fromthe presence of non-glycated albumin. Methods
for measuring glycated albumin are also better
standardized than those for fructosamine.47
Oral glucose tolerance test (OGTT)The OGTT was the gold standard for diagnosing
diabetes and prediabetes but is now usedinfrequently due to several limitations.55 The
OGTT encounters issues with reproducibility, issensitive to time of testing, and there are more
acceptable alternatives in clinical settings.55 Thereis also uncertainty about how well patients adhere
to the preparation requirements.56 The World
Health Organization (WHO) has recommended
using HbA1c to diagnose T2DM in the community,
meaning the OGTT is now only performed on
patients for whom HbA1c measurement would
be inappropriate. Additionally, research suggeststhat the OGTT, which requires ingesting a syrupy
solution and waiting two hours for testing, may
be an inconvenient approach that is not entirely
accepted by patients.57,58 One study reported thatapproximately half of women experienced stressand nausea during the OGTT.59©Economist Impact 2024

9Diabetes and chronic kidney disease: the diagnostic imperative

Preventing kidney disease in diabetes
Uncontrolled diabetes is well-known for its ability
to cause damage to various tissues in the body,particularly the kidneys. This close relationshipemphasizes the importance of not only regularly
testing for diabetes but also for regular screening
for CKD. It is crucial to note that approximately
one in three adults with diabetes also has CKD,
highlighting the direct connection between these
conditions.31 If diabetes progresses to CKD, thefinancial impact is significant as patients with CKD
face nearly triple the medical expenses comparedto those without CKD.37 This underscores theurgent need for integrated monitoring of bothdiabetes and CKD to reduce risks and effectively
manage costs.
For those living with diabetes, avoiding
complications is extremely important. Daily
self-monitoring of blood sugar levels, regular
HbA1c tests, and attending annual screenings
for renal complications are effective measures.
Self-monitoring is often done with capillary blood
glucose tests, which involve blood drop samples
usually collected from a finger prick.60

Only 47% of people livingwith diabetes in Englandreceived all their required
checks in 2021-2022 (thisstatistic is likely linked to
the Covid-19 pandemic).63

Adherence to these finger prick tests is known to
be poor; on the other hand, minimally invasive
continuous glucose monitors (CGMs) are fast
growing in popularity. CGMs measure real-time
interstitial glucose values, providing information
on variability in blood glucose levels.61,62 “Thegeneral availability of continuous glucose
monitoring has been a very significant change,”
said Prof Fonseca concerning increased usage of
CGMs. This is particularly important in diabetics
with advanced kidney disease, where fluctuations
in blood glucose are very common, and HbA1c is
not a reliable test.
Prof Fonseca affirms that HbA1c and urine
microalbuminuria tests are not only very
important in the early detection of CKD, but they
are not being done often enough. “We are nottesting HbA1c enough,” he said. A recent reportfrom England suggests that less than half (47%)
of people living with diabetes received all theirrequired checks in 2021-2022, a statistic likely
linked to the Covid-19 pandemic.63
To prevent progression to kidney disease,pharmacologic interventions such as metformintherapy should be considered for adults at highrisk of T2DM, including those with FPG levels≥110 mg/dL.44 The diagnosis of prediabetes or
T2DM should be confirmed with repeat testing
before starting interventions.64
Understanding the risk factors for kidneydisease in diabetes patients can help with early
identification and intervention. Prof Boulton
explained that screening and early detection canreverse the incidence of CKD. “You can reverse it if
you catch it early, it requires good blood pressure
control with ACEi [angiotensin-converting enzyme
inhibitors], ARBs [angiotensin receptor blockers],©Economist Impact 2024

10Diabetes and chronic kidney disease: the diagnostic imperativeand SGLT2 [sodium-glucose cotransporter-2]
inhibitors,” he said. Kidney protective medicines,
including ARBs and ACEi, that also lower bloodpressure can be used to slow the decline in renal
function.65,66 Randomized controlled trials (RCTs)
have shown that if microvascular complications
are treated effectively from the point of
diagnosis, it can reduce major cardiovascularcomplications.67
The ADA recommends that the urinary
albumin-to-creatinine ratio (UACR) and eGFR
should be assessed (at least) annually in patientswith T1DM for more than five years, for all
people with T2DM, and for all patients who
have comorbid hypertension to check for kidneydisease (see Table 4). The European Society ofCardiology (ESC)/European Association for the
Study of Diabetes (EASD) guidelines further
suggest that the serum creatinine test is alsodone annually, along with tight glucose and bloodpressure control, while American guidelines

recommend periodic monitoring of serum
creatinine.68,69
Measurement of eGFR is challenging as it depends
on measurement of serum creatinine, which has
limitations in terms of accuracy and sensitivity.70
Cystatin C, however, is a protein that has emerged
as an alternative marker for kidney function.
Unlike creatinine, it is unaffected by muscle massand has a stronger association with cardiovasculardisease and mortality than creatinine.71 In its
2012 guidelines, Kidney Disease Improving Global
Outcomes (KDIGO) recommended using cystatin
C to confirm diagnosis of CKD determinedusing creatinine-based GFR, as cystatin C is amore accurate marker of kidney function to
inform clinical decision-making.72 Cystatin C also
removes race from the GFR equation, making
CKD diagnosis more equitable.73

Table 4: Guidelines for chronic kidney disease (CKD) testing 41,42,44
United States
Guidelines

Standards of Carein Diabetes—2023
Abridged for Primary
Care Providers

Chronic Kidney Disease
and Risk Management:
Standards of Care in
Diabetes—2023

Europe
Tests

Tests

Urinary Albumin
Measurement(Spot UACR)

Urine Albumin-toCreatinine Ratio (UACR)

Estimated Glomerular
Filtration Rate (eGFR)

Estimated Glomerular
Filtration Rate (eGFR)

Serum Creatinine

Urine Protein Test

UACR

UACR

eGFR

eGFR

Serum Creatinine

Serum Creatinine

Serum Potassium

HbA1c

Urinary Sediment Analysis

Urine Protein Test

Guideline

2019 ESC Guidelines on
diabetes, pre-diabetes,and cardiovasculardiseases developedin collaboration with
the EASD

See Appendix B for ranges and frequency©Economist Impact 2024

Diabetes and chronic kidney disease: the diagnostic imperative

11

Conclusion
Diabetes is a global challenge that causes
significant morbidity and mortality. Prediabetes
is a risk as it can progress to diabetes and its
complications, including CKD, which affects
approximately one-third of diabetes patients.
Early detection and treatment of diabetes can also
prevent or delay the development of CKD, which
often leads to significant morbidity and mortality.
Outcomes can be significantly improved if bothdiabetes and CKD are caught early. Screening
and diagnostic tests are recommended alongsideinterventions such as lifestyle changes to prevent
progression. Screening is particularly importantsince diabetes and its complications can be silent
until it is too late to treat effectively. Lifestylemodifications and public health interventions
are cost-effective interventions when comparedto the cost of inaction. Examples include
community-based education programs, changing
daily diets, and exercising, among others.74
Guidelines recommend tests for screening,
diagnosis, and monitoring to prevent the
progression of diabetes. These include regulartesting of glycemia, blood pressure, and kidney
function, alongside medication as required.
There is a part for both patients and doctors
to play. Research indicates that less than halfof patients engage effectively with monitoring
appointments. Patients need to be educatedon the importance of attending screening andtreatment appointments, as well as performing
self-monitoring and care. Doctors need to remain
vigilant and monitor patients who are at highrisk of developing diabetes and its long-term
complications. It is important that these very
preventable diseases, T2DM and CKD, are caught
early and managed effectively.

©Economist Impact 2024

12Diabetes and chronic kidney disease: the diagnostic imperative

Appendix A: Guidelines for diabetes 41,42,44
United States
Guideline

Tests

Pre-diabetes

Diabetes

Frequency

Standards of Care HbA1c
in Diabetes—2023
Abridged for
Fasting Plasma
Primary Care
Glucose (FPG)
Providers

5.7–6.4%≥6.5%(39–47 mmol/mol) (48 mmol/mol)

At least annually for prediabetes; more
frequently based on risk factors and initial results

100–125 mg/dL(5.6–6.9 mmol/L)

Annually for screening

2-hour plasma
glucose during
75-g (OGTT)

140–199 mg/dL≥200 mg/dL(7.8–11.0 mmol/L) (11.1 mmol/L)

Random plasma
glucose (RPG)-≥126 mg/dL(7.0 mmol/L)≥200 mg/dL(11.1 mmol/L)

As needed based on risk factors or abnormal
FPG/A1C results
As needed, especially if symptoms of diabetes
are present

Classification
HbA1c
and Diagnosis
of Diabetes:
Standards of Care FPG
in Diabetes—2023

5.7–6.4%≥6.5%(39–47 mmol/mol) (48 mmol/mol)

At least every 3 years if normal; annually forprediabetes

100–125 mg/dL(5.6–6.9 mmol/L)

Annually for prediabetes; every 3 years if normal

OGTT

2-h PG level of≥200 mg/dL
140–199 mg/dL(11.1 mmol/L)(7.8–11.0 mmol/L)RPG-≥126 mg/dL(7.0 mmol/L)

As recommended by healthcare provider≥200 mg/dL
As needed(11.1 mmol/L) in patientswith classic symptomsof hyperglycemia or
hyperglycemic crisis

EuropeGuideline

Tests

Pre-diabetes

2019 ESC
Guidelines
on diabetes,
pre-diabetes, andcardiovasculardiseasesdeveloped incollaboration with
the EASD

HbA1c

5.7–6.4%≥6.5%(39-47 mmol/mol) (48 mmol/mol)

At least twice a year for diabetics; less frequently
for non-diabetics

FPG

5.6-6.9 mmol/L(100-125 mg/dL)

Annually for those with pre-diabetes or more
frequently based on medical advice

OGTT

7.8 to <11.1 mmol/L ≥11.1 mmol/L(140-199 mg/dL)(≥200 mg/dL)

RPG-

Diabetes≥7.0 mmol/L(126 mg/dL)

Measures blood sugarat any time of day,regardless of when
you last ate. Levelsof ≥11.1 mmol/L(200 mg/dL), along withsymptoms of diabetes,
indicate diabetes

Frequency

As needed
As needed©Economist Impact 2024

13

Diabetes and chronic kidney disease: the diagnostic imperative

Appendix B: Guidelines for chronic kidney disease (CKD) 41,42,44
United States
Guideline

Tests

Range

Frequency

Standards of Carein Diabetes—2023
Abridged forPrimary Care
Providers

UrinaryAlbumin
Measurement(Spot UACR)

Normal:<30 mg/g creatinine
Moderately Elevated: 30–300 mg/g
creatinine
Severely Elevated: ≥300 mg/g creatinine

At least annually for people with T1DM (≥5 years ofduration)
At least annually for all people with T2DM. Morefrequent monitoring (1–4 times per year) for people withestablished diabetic kidney disease depending on the
disease stage

Estimated
Glomerular
Filtration Rate(eGFR)

Varies based on the CKD stage

Regular monitoring for people with CKD; typically part ofroutine lab work

Serum
Creatinine

Normal reference range varies bylaboratory

Regular monitoring for people on medications affecting
kidney function

UACR

Normal:<30 mg/g creatinine
Moderately Elevated: 30–300 mg/g
creatinine
Severely Elevated: ≥300 mg/g creatinine

Annually for people with T1DM (≥5 years duration) and all
people with T2DM
1-4 times per year for established diabetic kidney disease,depending on disease stageeGFR

Normal: >60 mL/min/1.73 m2
Abnormal: <60 mL/min/1.73 m2

Annually or more frequently depending on CKD stage andpatient status

Serum
Creatinine

Varies based on age, sex, muscle mass

Periodically monitor in patients on ACE inhibitors, ARBs,
or MRAs; or when eGFR <60 mL/min/1.73 m2

Serum
Potassium

Normal range typically 3.5-5.0 mq/L

Periodically in patients on diuretics, ACE inhibitors, ARBs,
MRAs

Urinary
Sediment
AnalysisPresence or absence of red/white blood
cells, casts

As indicated in cases of rapidly changing kidney function
or to differentiate CKD causes

Guideline

Tests

Range

Frequency

2019 ESC
Guidelines
on diabetes,
pre-diabetes, andcardiovasculardiseasesdeveloped incollaboration with
the EASD

Serum
Creatinine
Measurement

Varies based on age, sex, and muscle
mass; normal range: 0.7-1.3 mg/dL formen, 0.6-1.1 mg/dL for women

Annually for patients with diabetes

eGFR

Normal: ≥90 mL/min/1.73m2;
CKD: <60 mL/min/1.73m2

Annually for DM patients; more frequently if CKD ispresent

UACR

Normal:<30 mg/g;
Microalbuminuria: 30-300 mg/g;
Macroalbuminuria: >300 mg/g

AnnualUrine Protein
Test

Normal <150 mg/day; persistent
proteinuria indicated by higher values

Based on clinical suspicion or existing CKD

HbA1c

Goal for DM patients <7%;individualized goals in CKD

At least twice a year in stable patients; quarterly inpatients with treatment changes or not meeting glycemic
goals

Chronic Kidney
Disease and Risk
Management:
Standards of Carein Diabetes—2023

Europe©Economist Impact 2024

14

Diabetes and chronic kidney disease: the diagnostic imperative

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