NDT Advance Access originally published online on April 3, 2007
Nephrology Dialysis Transplantation 2007 22(8):2194-2200; doi:10.1093/ndt/gfm114
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Use of albumin creatinine ratio and urine albumin concentration as a screening test for albuminuria in an Indo-Asian population
1Section of Nephrology, Department of Medicine, 2Clinical Epidemiology Unit, Department of Community Health Sciences, The Aga Khan University, Karachi, Pakistan, 3Division of Nephrology, Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, MA, USA and 4National Heart Lung Institute, Imperial College, London, UK
Correspondence and offprint requests to: Dr Tazeen H. Jafar, Head, Section of Nephrology, Director, Clinical Epidemiology Unit, Associate Professor, Departments of Medicine and Community Health Sciences, Aga Khan University, PO Box 3500, Stadium Road, Karachi, Pakistan. Email: tazeen.jafar{at}aku.edu
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Abstract |
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Background. Albuminuria (>30 mg/day) based on 24 h urine albumin excretion is one of the criteria for chronic kidney disease (CKD) and a predictor of cardiovascular disease (CVD). Differences in urine albumin concentration and creatinine excretion rates between Indo-Asians and other populations may require different threshold values for detection of albuminuria. We compared the use of spot urine albumin concentration and urine albumin to creatinine excretion ratio for detection of albuminuria in this population.
Methods. A total of 577 subjects aged 
40 years, 54% of whom were women, were recruited from the general population in Karachi, Pakistan. Albumin concentration (mg/l) and albumin to creatinine ratio (mg/g of creatinine) were determined in a spot morning urine sample, and albuminuria (30 mg/day or greater) measured in a 24 h urine collected on the subsequent day.
Results. The median (25–75 percentile) of urine albumin excretion was 4.8 (3.6–10.3) mg/day: 5.4 (3.7–12.5) mg/day in men and 4.5 (3.8–8.9) mg/day in women. The overall prevalence (95% CI) of albuminuria was 11.8% (7.2–12.0%): 14.8% in men and 9.2% in women (P = 0.04). The areas under the receiver operator characteristic (ROC) curves for urine albumin concentration were 0.86 (0.82–0.90) and 0.88 (0.84–0.92), respectively, in women and men. The areas under the ROC curves for albumin to creatinine ratio were 0.86 (0.82–0.89) and 0.90 (0.86–0.93), respectively, in women and men. For urine albumin concentration, the sensitivity and specificity were 37 and 97%, respectively, in women and 69 and 94%, respectively, in men at the conventionally recommended value of 2 mg/dl. The discriminator value of urine albumin concentration identified in the analysis was 0.5 mg/dl in women (sensitivity of 87% and specificity of 75%) and 1.7 mg/dl in men (sensitivity of 74% and specificity of 93%). For the albumin to creatinine ratio, the sensitivity and specificity were 46 and 95%, respectively, in women and 60 and 97%, respectively, in men at cut-off value of 30 mg/g.
Conclusion. Both urine albumin concentration and albumin to creatinine ratio are acceptable tests for population screening for albuminuria in Indo-Asians. While sensitivities may be suboptimal, particularly in women, lowering the existing thresholds would compromise specificity. Those who screen positive need evaluation and management of CKD and prevention of CVD.
Keywords: Albuminuria; Asian; chronic kidney disease; proteinuria; population screening; urine albumin concentration; urine albumin to creatinine ratio
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Introduction |
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Albuminuria is one of the criteria for chronic kidney disease (CKD), and is a predictor of cardiovascular disease (CVD) in the general population [1–4]. Screening for albuminuria is recommended in patients at increased risk for CKD, including those with hypertension, diabetes, cardiovascular disease and a family history of CKD [5,6]. Treatment with ACE inhibitors and angiotensin receptor blockers in patients with albuminuria slows the progression of kidney disease and reduces the risk of CVD [7–10].
Diagnosis of albuminuria requires timed collection of urine over 24 h, which is cumbersome in routine clinical practice. An alternative method is the spot urine measurement of either albumin concentration or an albumin to creatinine ratio, which are relatively easy to obtain in the ambulatory setting. In general, albumin to creatinine ratio has been shown to have slightly better diagnostic accuracy than urine albumin concentration alone for detection of albuminuria in many populations [11].
The population residing in Indo-Asian countries has been shown to have one of the highest prevalence of diabetes, hypertension (20 and 40%, respectively, in those aged 40 years or over in urban cities) and [12,13] a rapidly escalating burden of cardiovascular and chronic kidney disease [14]. The guidelines by the Kidney Disease Initiative for Global Outcomes (KDIGO) of the National Kidney Foundation, the American Diabetic Association and the seventh report of the Joint National Committee (JNC-VII) recommend that patients with hypertension and/or diabetes should be screened for the presence of albuminuria with use of urine albumin concentration or albumin to creatinine ratio on spot urine sample [6,15–18]. However, differences in urine concentration or creatinine excretion rates may lead to inaccurate diagnosis of albuminuria. Yet there are no data to validate these alternative measures of albuminuria in Indo-Asians [13].
We conducted this study to test the diagnostic performance of albumin concentration and albumin to creatinine ratio, measured in a spot morning urine sample, in predicting a urinary albumin excretion (UAE) of 30 mg or greater in subsequent 24 h urine (albuminuria) in Indo-Asians.
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Methods |
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Sampling details
This is a substudy of a cohort study of Population Based Strategies for Effective Control of High Blood Pressure. The sample was drawn using cluster sampling from four randomly selected communities (clusters of households) in the metropolitan city of Karachi, after obtaining approval from the Ethical Review Committee at the Aga Khan University. A total of 1000 residential households were numbered and mapped in the four randomly selected study clusters. The total number of subjects recorded as residing in these households was 7229, from which 1177 individuals were aged 40 years or over, and constituted our target population.
Pregnant women, those who had exercised heavily (more than 1 h of vigorous exercise on a day of the collection period) as exercise may lead to transient elevation in urine albumin and bed-ridden or mentally incompetent subjects were excluded.
Instructions on 24 h urine collection were given, and bottles were provided. All subjects were evaluated at the community clinic in their areas by rigorously trained community health workers. The evaluation included the following: (i) administration of a questionnaire which details smoking status, food-frequency questionnaire and other life-style factors, (ii) assessment of three consecutive readings of blood pressure with a calibrated automated device (Omron HEM-737 Blood Pressure Monitor) in the sitting position after 5 min of rest, (iii) anthropometry (height, weight), (iv) laboratory tests including fasting blood glucose (Synchron Cx-7/Delta, Beckman, US), serum and 24 h urine creatinine (Jaffe method, Beckman DU), and urine albumin (measured using nephelometry using Array Systems method on Beckman Coulter) and (v) an ECG. In addition, morning spot urine samples were collected on all subjects within 2 days of timed urine collections. On the spot urine sample, specific gravity (Multistix 8 SG), urine albumin and creatinine concentration were measured within 8 h of specimen collection. Measurements on 24 h urine were performed on the same day as collections were completed. All assessments were performed to a standard protocol that conformed to the international standards for definitions and measurements, and external quality control on albumin measurements were performed by the Bio-Rad Laboratories Inc, Irvine, CA. The study was conducted over one year (from 2005 to 2006).
Variable definitions
Albuminuria was defined as UAE 30 mg in a 24 h urine collection.
High urine albumin concentration (mg/dl) was defined as urine albumin concentration of 2 mg/dl or greater (as recommended by the KDIGO guidelines) in a single spot urine sample [15].
High albumin to creatinine ratio (mg/g) was defined as albumin to creatinine ratio of 30 mg/g or greater in a single spot urine sample. These thresholds are recommended by KDIGO for detection of albuminuria [15].
Hypertension was defined as mean systolic BP >140 mmHg or mean diastolic BP >90 mmHg measured 20 min apart, on two separate occasions, or taking antihypertensive medications.
Diabetes was defined as fasting blood sugar >7.0 mmol/l (126 mg/dl), or taking antidiabetic medications [19].
Statistical analysis
SAS version 9.1 and MedcalcTM were used for analyses. Data were presented as median and inter-quartile range (IQR), or mean and standard deviation (SD) as specified. Medians were compared using the Mann–Whitney test for unpaired data.
Individual values of urine albumin concentration and albumin to creatinine ratio were compared with UAE using Spearman rank correlation analysis. The values of urine albumin concentration were divided by urine specific gravity and correlation analyses were repeated. Since the urine albumin to creatinine ratio already adjusts for urine concentration by way of dividing urine albumin by creatinine, the correlation analysis for this test was not repeated after further division by urine specific gravity. The associations between measured UAE and urine albumin concentration and urine to creatinine ratio were assessed by Passing and Bablok regression analyses. In addition, comparison between urine albumin to creatinine ratio and UAE was also assessed by measuring the accuracy (proportion of estimates within 20, 30 and 50% of UAE values).
Diagnostic performances of urine albumin concentration and albumin to creatinine ratio for albuminuria are expressed in terms of specificity, sensitivity and areas under receiver operating characteristic (ROC) curves. The ROC curve analysis was also used to determine the best discriminator values for the non-reference indicators. The value lying nearest to the point of intersection of the ROC curve and the 100%-to-100% diagonal was chosen as the best discriminator value.
The sensitivity and specificity for detecting albuminuria were also assessed at the cut-off levels of urine albumin concentration and urine albumin to creatinine ratio as recommended by KDIGO (2 mg/dl and 30 mg/g, respectively) and NKF (17 mg/g in men and 25 mg/g in women for urine albumin to creatinine ratio).
A P-value of <0.05 was regarded to indicate statistical significance.
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Results |
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General characteristics of the study population
Out of the 1177 target population aged 40 years or above, a total of 577 were included in the study. None of the patients had to be excluded due to heavy exercise during the collection period. Figure 1 illustrates a flow diagram of subjects included and excluded from the study. The characteristics of subjects included in the final sample (n = 577) are shown in Table 1.
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Comparison of characteristics between those who gave urine samples (n = 632) vs those did not (n = 545) revealed that responders vs non-responders were more likely to be women (55% vs 49%, P = 0.03); to have known hypertension (41% vs 27%, P < 0.001), but less likely (albeit non-significantly) to have known diabetes (14% vs 17%, P = 0.15), respectively. However, mean age was not different between the two.
UAE
The median (IQR) of urine albumin excretion was 4.8 (3.6–10.3) mg/day: 5.4 (3.7–12.5) mg/day in men and 4.5 (3.8–8.9) mg/day in women (P < 0.001). The overall prevalence (95% CI) of albuminuria was 11.8% (7.2–12.0%): 14.8% in men and 9.2% in women (P = 0.04).
Urine albumin concentration
The median (IQR) urine albumin concentration was 0.37 (0.21–0.85) mg/dl: 0.48 (0.23–0.10) mg/dl in men and 0.31 (0.20–0.62) mg/dl in women (P 
0.001). The overall prevalence of high urine albumin concentration was 10.5%: 14.5% in men and 7.3% in women (P = 0.006).
The positive predictive value for albuminuria in those with high urine albumin concentration (2 mg/dl or greater) was 69% (71% in men and 65% in women), and negative predictive value was 95%.
Albumin to creatinine ratio
The median albumin to creatinine ratio (IQR) was 5.0 (4.0–10.0) mg/g: 5.0 (4.0–13.0) mg/g in men and 5.0 (3.0–8.0) mg/g in women (P = 0.02). The overall prevalence of high albumin to creatinine ratio was 10.6%: 12.2% in men and 9.2% in women (P = 0.25).
The positive predictive value for albuminuria in those with high albumin to creatinine ratio (30 mg/g or greater) was 72% (81% in men and 62% in women), and negative predictive value was 95%.
Correlation analysis
Individual values of urine albumin concentration and albumin to creatinine ratio were significantly correlated with UAE in men and women (P < 0.001 for each). For urine albumin concentration, the rank correlations were r = 0.29 in men and improved to r = 0.40 after adjusting for urine specific gravity. In women, it was r = 0.25 and improved to r = 0.38 after adjusting for urine specific gravity.
For urine albumin to creatinine ratio, the rank correlations were r = 0.58 and 0.44 in men and women, respectively.
The proportion of estimates of albumin to creatinine ratio within 20, 30 and 50% of UAE were 22, 33 and 56%, respectively.
The regression analysis between levels of UAE and urine albumin concentration, and albumin to creatinine ratio, each, revealed no significant deviation from linearity.
ROC curve analysis
Urine albumin concentration
For urine albumin concentration, the areas under the ROC curves for detection of albuminuria were 0.88 (0.84–0.92) and 0.86 (0.82–0.90) in men and women, respectively (Figure 2). The differences among the curves for albumin to creatinine ratio and urine albumin concentration were not statistically significant (P = 0.68 in men and P = 0.98 in women).
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Based on the ROC curve, the sensitivity and specificity were 81 and 95%, respectively, in men, and 43 and 97%, respectively, in women, at the conventionally recommended value of 2 mg/dl (Figure 1).
The discriminator value identified in the ROC analyses for urine albumin concentration was gender specific (Figure 1). These values were 1.7 mg/dl for men (sensitivity of 74% and specificity of 93%) and 0.5 mg/dl for women (sensitivity of 87% and specificity of 75%).
Urine albumin to creatinine ratio
The areas under the ROC curves of albumin to creatinine ratio for detection of albuminuria were 0.90 (0.86–0.93) and 0.86 (0.82–0.89) in men and women, respectively (Figure 1).
Based on the ROC curve, the sensitivity and specificity were 60 and 97%, respectively, in men, and 46 and 95%, respectively, in women, at cut-off value of 30 mg/g (Figure 1).
The sensitivity and specificity were 66 and 93%, respectively, for a gender-specific cut-off value of 17 mg/g in men, and 52 and 95%, respectively, for women at a cut-off value of 25 mg/g (Figure 1).
The discriminator value identified in the ROC analyses for albumin to creatinine ratio was gender-specific (Figure 1). These values were 6.7 mg/g for men and 9.3 mg/g for women.
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Discussion |
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The Indo-Asian population accounts for one-sixth of the World's inhabitants. This is the first report on the performance of spot urine albumin concentration, and albumin to creatinine ratio as a screening test for the detection of albuminuria in a population-based sample from Indo-Asia. Our findings suggest that both these tests are appropriate for application in the Indo-Asian population. Our results also indicate that while the conventionally recommended cut-off values of these tests as suggested by KDIGO (2 mg/l for urine albumin concentration and of 30 mg/g for albumin to creatinine ratio) were associated with high specificity, the sensitivity for detection of albuminuria at these levels was suboptimal in women. However, lowering these thresholds would compromise the specificity of the test.
It is interesting to note that the threshold of urine albumin concentration for detection of albuminuria in men (1.7 mg/dl) in our study approximates that proposed by the KDIGO. However, a lower threshold was found in our study for women (0.6 mg/dl). There could be many potential reasons for this difference. First, a lower threshold (
1.0 mg/dl) of urine albumin concentration has also been suggested in other studies including the PREVEND study [11,20]. Furthermore, the lower threshold in women could be explained in part by the significantly lower urine specific gravity (SD) [1.018 (0.006)] in women vs men [1.021 (0.007)] (P < 0.001) reflecting more dilute urine in the former. This is supported by the fact that adjusting for urine specific gravity significantly improved the correlation between urine albumin concentration and UAE, which was more pronounced in women. A lower urine specific gravity has been shown to lower the urine albumin concentration threshold for detection of albuminuria in other studies as well [21]. Our findings suggest the use of a lower urine albumin concentration threshold in women (0.6 mg/dl).
Urine albumin to creatinine ratio has been criticized as a screening test for albuminuria in subjects with low muscle mass, and a high ratio has been shown to have weak correlation with 24 h urine albumin excretion in patients with low muscle mass [22]. This is mainly because lower urine creatinine excretion would tend to increase the albumin to creatinine ratio without increasing the absolute albumin excretion. Racial differences in creatinine excretion have been reported [23]. Previously we showed that Indo-Asians have lower creatinine excretion than estimated values for Caucasians [24]. The mean urine creatinine excretion was even lower (by about 2 mg/kg/day) in this study. However, we found that the area under the ROC curve for albumin to creatinine ratio was consistent with those published reports in other Caucasian populations [25]. These findings suggest that albumin to creatinine ratio can be used reliably to detect albuminuria in Indo-Asian population.
Although our findings show that both urine albumin concentration and albumin to creatinine ratio are good screening tests, the correlation of their levels with UAE, and the agreement among the individual values of urine albumin to creatinine ratio with UAE remains suboptimal. This suggests that these tests have good accuracies to detect the presence or absence of albuminuria, but may be limited in their ability to quantify the magnitude of albuminuria in Indo-Asian populations. The latter needs further study in Indo-Asian patients with CKD.
Our study has limitations. Those who participated in the study were more likely to be women, and have known hypertension compared to those who did not. Moreover, only subjects aged 40 years or over were recruited, potentially increasing the representation of those with CKD (including those due to glomerulonephritis), which increases with advancing age. However, screening for albuminuria is also recommended in high-risk subjects including those with hypertension, and generally among adults aged 50 years or over. Thus, application of the screening test is also expected to be greater in this subgroup. Undercollection of 24 h urine samples can lead to underestimation of measured UAE, thus, inaccurately lowering the thresholds of urine albumin concentration as well as urine to creatinine ratio for detecting albuminuria. For a number of reasons, we believe that this is not the likely explanation. In our study, trained community research workers emphasized adequacy of urine collection to the participants and advised appropriate recollection in cases of doubt. Furthermore, we deleted samples containing values of 24 h urine volume of <500 ml/day. Moreover, the relationship between urine albumin concentration and urine to creatinine ratio and measured UAE did not seem to vary significantly according to the level of measured UAE.
The major strength of our study is that our sample was drawn from the general population, and so our findings are generalizable to the same. However, like all screening tests, its validity may vary in subsets of patients with varying risk factor profiles. For example, the positive predictive power of these tests is likely to be greater in a subgroup of patients with diabetes, as well as others at high risk of kidney disease. These Bayesian principles of assigning pre-test probability need to be considered during clinical decision-making for cost-effective management, which are perhaps even more important for resource-scarce developing countries [26]. However, these tests are usually performed in clinical settings where pre-test probability is generally better.
In conclusion, our findings endorse the recommendations of KDIGO that, both, urine albumin concentration and albumin to creatinine ratio are acceptable tests for population screening for albuminuria in Indo-Asians. Moreover, the existing recommended cut-off values for these tests for identification of albuminuria seem reasonable for application in the Indo-Asian population. However, sensitivity is low among women. Those who screen positive with either test need further evaluation and management of CKD and prevention of CVD. Since implementation of screening via urine albumin concentration using albumin dipstick with sensitivities in the desired range is likely to be more practical and cost effective, we recommend inclusion of this strategy in CKD prevention programs in Indo-Asian countries.
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Supported by grant from the Wellcome Trust, UK (Drs Jafar/Chaturvedi/Hatcher).
Conflict of interest statement. None declared.
(See related article by Gansevoort et al. Methodology of screening for albuminuria. Nephrol Dial Transplant 2007; 22: 2109–2111.)
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- Roest M, Banga JD, Janssen WM, et al. Excessive urinary albumin levels are associated with future cardiovascular mortality in postmenopausal women. Circulation (2001) 103:3057–3061.
[Abstract/Free Full Text] - Hillege HL, Fidler V, Diercks GF, et al. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Circulation (2002) 106:1777–1782.
[Abstract/Free Full Text] - Sarnak MJ, Levey AS, Schoolwerth AC, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension (2003) 42:1050–1065.
[Free Full Text] - Yuyun MF, Khaw KT, Luben R, et al. Microalbuminuria independently predicts all-cause and cardiovascular mortality in a British population: the European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) population study. Int J Epidemiol (2004) 33:189–198.
[Abstract/Free Full Text] - Bakris GL. Microalbuminuria: what is it? Why is it important? What should be done about it? J Clin Hypertens (Greenwich) (2001) 3:99–102.[Medline]
- Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med (2003) 139:137–147.
[Abstract/Free Full Text] - Asselbergs FW, Diercks GF, Hillege HL, et al. Effects of fosinopril and pravastatin on cardiovascular events in subjects with microalbuminuria. Circulation (2004) 110:2809–2816.
[Abstract/Free Full Text] - Gaede P, Tarnow L, Vedel P, Parving HH, Pedersen O. Remission to normoalbuminuria during multifactorial treatment preserves kidney function in patients with type 2 diabetes and microalbuminuria. Nephrol Dial Transplant (2004) 19:2784–2788.
[Abstract/Free Full Text] - Ravera M, Ratto E, Vettoretti S, Parodi D, Deferrari G. Prevention and treatment of diabetic nephropathy: the program for irbesartan mortality and morbidity evaluation. J Am Soc Nephrol (2005) 16(Suppl 1):S48–S52.
[Abstract/Free Full Text] - Strippoli GF, Craig MC, Schena FP, Craig JC. Role of blood pressure targets and specific antihypertensive agents used to prevent diabetic nephropathy and delay its progression. J Am Soc Nephrol (2006) 17:S153–S155.
[Abstract/Free Full Text] - Bakker AJ. Detection of microalbuminuria. Receiver operating characteristic curve analysis favors albumin-to-creatinine ratio over albumin concentration. Diabetes Care (1999) 22:307–313.
[Abstract/Free Full Text] - Jafar TH, Levey AS, Jafary FH, et al. Ethnic subgroup differences in hypertension in Pakistan. J Hypertens (2003) 21:905–912.[CrossRef][Web of Science][Medline]
- Jafar TH, Jafary FH, Jessani S, Chaturvedi N. Heart disease epidemic in Pakistan: women and men at equal risk. Am Heart J (2005) 150:221–226.[CrossRef][Web of Science][Medline]
- Reddy KS. Cardiovascular disease in non-Western countries. N Engl J Med (2004) 350:2438–2440.
[Free Full Text] - Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int (2005) 67:2089–2100.[CrossRef][Web of Science][Medline]
- Johnson CA, Levey AS, Coresh J, Levin A, Lau J, Eknoyan G. Clinical practice guidelines for chronic kidney disease in adults: Part I. Definition, disease stages, evaluation, treatment, and risk factors. Am Fam Physician (2004) 70:869–876.[Web of Science][Medline]
- Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension (2003) 42:1206–1252.
[Abstract/Free Full Text] - Molitch ME, DeFronzo RA, Franz MJ, et al. Nephropathy in diabetes. Diabetes Care (2004) 27(Suppl 1):S79–S83.[CrossRef][Medline]
- Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care (1997) 20:1183–1197.[Web of Science][Medline]
- Gansevoort RT, Verhave JC, Hillege HL, et al. The validity of screening based on spot morning urine samples to detect subjects with microalbuminuria in the general population. Kidney Int Suppl (2005) S28–S35.
- Parikh CR, Fischer MJ, Estacio R, Schrier RW. Rapid microalbuminuria screening in type 2 diabetes mellitus: simplified approach with Micral test strips and specific gravity. Nephrol Dial Transplant (2004) 19:1881–1885.
[Abstract/Free Full Text] - Cirillo M, Laurenzi M, Mancini M, Zanchetti A, De Santo NG. Low muscular mass and overestimation of microalbuminuria by urinary albumin/creatinine ratio. Hypertension (2006) 47:56–61.
[Abstract/Free Full Text] - Mattix HJ, Hsu CY, Shaykevich S, Curhan G. Use of the albumin/creatinine ratio to detect microalbuminuria: implications of sex and race. J Am Soc Nephrol (2002) 13:1034–1039.
[Abstract/Free Full Text] - Jafar TH, Schmid CH, Levey AS. Serum creatinine as marker of kidney function in South Asians: a study of reduced GFR in adults in Pakistan. J Am Soc Nephrol (2005) 16:1413–1419.
[Abstract/Free Full Text] - Derhaschnig U, Kittler H, Woisetschlager C, Bur A, Herkner H, Hirschl MM. Microalbumin measurement alone or calculation of the albumin/creatinine ratio for the screening of hypertension patients? Nephrol Dial Transplant (2002) 17:81–85.
[Abstract/Free Full Text] - Winkler RL, Smith JE. On uncertainty in medical testing. Med Decis Making (2004) 24:654–658.
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Accepted in revised form: 9. 2.07
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