Albuminuria, even in low levels within the “normal” range, is an independent predictor of cardiovascular and all-cause mortality, a new analysis of the PEACE trial shows.
Dr. Solomon states that, "We found that virtually any degree of albuminuria, even albumin below the level we call microalbuminuria, placed a patient at significantly higher risk of cardiovascular events. A number of other studies have been suggestive of this–HOPE in higher-risk vascular disease patients and LIFE in hypertension patients–but ours was a particularly low-risk population, so we’ve extended the findings to this low-risk group with stable CHD. We should stop thinking about cut-off values for microalbuminuria. If albumin is detectable in the urine, the patient is at increased risk."
Solomon explained that as such low levels of albumin cannot be detected with a dipstick test, they used a spot assay that measures the urinary albumin-to-creatinine ratio (ACR), which gives a more accurate measure of albumin status, as it takes into account the fact that the concentration of albumin in urine varies, depending on the amount of water consumed. "This is still a very easy, noninvasive, and cheap test. All you need is a urine sample. We do many far more invasive and expensive tests than this to risk-stratify patients. This test gives us a new window to the health of the vasculature that we should take advantage of," he added.
Noting that a previous analysis of the PEACE population had shown that a reduced glomerular filtration rate (GFR) was also associated with increased cardiovascular risk, Solomon said: "We have now shown that both measures of kidney function are markers of increased risk. If either one is compromised, then risk is increased, and if both are affected, then risk is very much increased. These two studies are telling us that we cardiologists need to pay more attention to kidney function in our patients and to understand that these are not patients who will ever come to dialysis or even necessarily see a nephrologist, but they do have mild kidney disease that puts them at increased risk for a cardiovascular event."
He pointed out that whether or not patients with minor renal dysfunction should be treated differently is open to debate but added: "There is a fair amount of evidence that inhibitors of the renin angiotensin system and ACE inhibitors in particular are of benefit to CHD patients with reduced renal function. So I would say that if you are undecided about whether to give an ACE inhibitor or not, this test could help you make that decision."
In the paper, the authors also note that microalbuminuria may represent an early marker of diffuse vascular endothelial dysfunction, and clinicians should consider serial quantification of ACR as a marker of risk, because its reduction may be a metric of treatment efficacy.
Solomon SD, Lin J, Solomon CG, et al. Influence of albuminuria on cardiovascular risk in patients with stable coronary artery disease. Circulation 2007; DOI: 10.1161/CIRCULATIONAHA.107.723270. Available at: http://circ.ahajournals.org.
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