Underutilization of albuminuria screening in adults with diabetes mellitus or hypertension: a systematic review and meta-analysis

BACKGROUND: Guidelines recommend routine urine albumin-to-creatinine ratio (uACR) screening in patients with diabetes (annual) and hypertension (at least once, with follow-up annually if CKD is found). However, real-world adherence remains uncertain and appears suboptimal. This study aimed to quantify the global prevalence of albuminuria testing in high-risk adults with hypertension and/or diabetes. METHODS: We conducted a systematic review and meta-analysis of observational studies reporting the proportion of adults with diabetes mellitus, hypertension, or both who underwent albuminuria testing in routine care. Multiple databases were searched through Web of Science, PubMed, Google Scholar, and Scopus. Pooled uACR testing prevalence was calculated using random-effects meta-analysis of proportions, with heterogeneity assessed by Cochran's Q and I² statistics. Subgroup analyses examined differences by patient group, test modality, and country income level. RESULTS: Thirty studies (from diverse countries and settings) met the inclusion criteria, involving over 29 million patients. Albuminuria testing rates were low in most settings. Overall, only about one in five high-risk patients underwent a uACR test in routine clinical practice. Pooled uACR testing prevalence was approximately 22% (fixed-effect model dominated by a large U.S. dataset), and 49% (95% CI: 7-93%) in a random-effects model accounting for extreme between-study variability (I² ~100%). Testing uptake ranged from < 5% in some systems to nearly 100% in protocolized programs. Subgroup comparisons showed higher rates in diabetes-focused and screening-driven studies, whereas hypertension cohorts had particularly low uptake. CONCLUSIONS: uACR testing remains underutilized among patients with hypertension or diabetes. This gap between guidelines and practice leads to delayed CKD detection and timely initiation of appropriate treatment. CLINICAL TRIAL NUMBER: Not applicable.