































 

 Epidemiology and Society Health Review| ESHR 
Vol. 6, No. 2, 2024, pp. 74-86 ISSN 2656-6052 (online) | 2656-1107 (print) 
      http://journal2.uad.ac.id/index.php/eshr/index                                                   eshr@ikm.uad.ac.id 

 

 

      10.26555/eshr.v6i2.8982  

 
 

74 

 
 

  

 
Review Article  
 
The Importance of UACR (Urinary Albumin Creatinine Ratio) 
Examination in Patients with Diabetes Mellitus Type 2: A 
Systematic Review 
 
Tetrina Purtaria1*, Sulistyawati Sulistyawati1  
1 Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia 
 
* Correspondence: tetrina.p@gmail.com. Phone: +6281-2158-5959 
 
Received 07 Sept 2023; Accepted 01 Dec 2024; Published 19 Dec 2024 
 

ABSTRACT 

Background: Diabetes mellitus is a chronic metabolic condition causing elevated blood glucose 
levels, leading to microvascular and macrovascular consequences. It is a leading cause of end-stage 
kidney disease (ESKD) and end-stage renal disease (ESRD). Diabetes causes diabetic nephropathy, 
which is the leading cause of end-stage renal disease. The urinary albumin-to-creatinine ratio 
(UACR) is a clinically used tool to evaluate albuminuria and prevent the progression of diabetic 
nephropathy. ACR measurements are predictive markers for renal outcomes, cardiovascular 
outcomes, and mortality in diabetics. Microalbuminuria, a condition characterized by 30 to 300 mg/g 
in spot urine, is an independent predictor of coronary artery disease, cardiovascular disease, and all-
cause mortality. This systematic review aimed to understand the role of ACR (albumin creatinine 
ratio) urine in patients with type 2 diabetes mellitus based on the published article. 
Method: The systematic review followed Preferred Reporting Items for Systematic Reviews and 
Meta-Analyses (PRISMA) guidelines and used databases ScienceDirect, PubMed, and Sage Journal 
to search for articles on urinary albumin creatinine ratio in type 2 diabetes mellitus. The search used 
keyword, inclusion and exclusion criteria to screen the article. 10 articles met our criteria and were 
included in this research. 
Results: ACR (albumin creatinine ratio) levels are linked to cardiovascular risk in patients with 
diabetes mellitus (DM), and high UACR (urinary albumin creatinine ratio levels are linked to an 
increased risk of CKD (chronic kidney diseases). The patient's diabetes duration also impacts ACR 
levels. The KDI is a composite of eGFR (estimated glomerular filtration rate) and ACR risk variables 
with a clear linear relationship with all three outcomes. It may aid in the identification of high-risk 
individuals who will benefit the most from prophylactic medications. 
Conclusion: Patients should be taught how better blood glucose and albuminuria control might help 
delay the progression of CKD. The male sex is protective; however, most female patients were 
postmenopausal with low estrogen levels, eliminating any potential renoprotective advantage. 
Dipsticks may be used for UACR testing, making it more convenient. 

Keywords: DM 1; ESRD 2; ACR 3; diabetic nephropathy 4; UACR 5; Microalbuminuria 6 

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INTRODUCTION 

Diabetes mellitus is a chronic metabolic condition that causes elevated blood glucose levels 
over time. This tissue damage can result in both microvascular and macrovascular 
consequences. Small blood vessels are damaged by microvascular problems, causing 
retinopathy, nephropathy, and neuropathy. Large blood arteries are damaged by 
macrovascular problems, which raises the risk of hypertension, heart attacks, strokes, 
decreased blood flow (particularly in the legs), and postponed wound healing.1 

Diabetes mellitus is becoming more common all over the world. According to the Diabetes 
Atlas 2021, People with diabetes mellitus worldwide reach more than 500 million. Meanwhile, 
in Indonesia, there are more than 19 million people with diabetes.2 Diabetes mellitus is a 
leading cause of end-stage kidney disease (ESKD). Many multiethnic studies have found a 
higher prevalence of kidney problems in Asian individuals with type 2 diabetes mellitus.3 
Patients with type 2 diabetes (T2D) are more likely to be diagnosed with end-stage renal 
disease (ESRD). Diabetes causes diabetic nephropathy, which is the leading cause of end-
stage renal disease.4 Microvascular complications caused by chronic hyperglycemia are the 
leading cause of diabetes mellitus. Albumin excretion of more than 30 mg per day is known 
as microalbuminuria, which plays a vital role in the onset of diabetic nephropathy, which 
uncontrollably develops into clinical proteinuria and ends with a decrease in glomerular 
filtration rate and kidney failure.5 

One of the most common complications of diabetes is diabetic nephropathy. While metabolic 
syndrome is an established risk factor for albuminuria and cardiovascular disease, it certainly 
is not the only risk factor. Furthermore, in prediabetes patients, a high glomerular filtration rate 
is related to impaired arterial stiffness and cardiovascular disease. The urinary albumin-to-
creatinine ratio (ACR) is used clinically to evaluate albuminuria while also serving as a regular 
practice for diabetes management and intervention to detect and prevent the progression of 
diabetic nephropathy. Albuminuria is a warning sign of diabetes and shows the existence of 
diabetic microvascular damage. Previous research has shown that ACR is independently 
related to all-cause and cardiovascular disease mortality in diabetics.6 The detection of UACR 
(urinary albumin creatinine ratio) in diabetic individuals is a standard approach for clinical 
screening of kidney damage in these patients.7 Albumin-to-creatinine ratio (ACR) 
measurements of albuminuria are common in diabetics and are recognized as predictive 
markers for renal outcomes, cardiovascular outcomes, and mortality.8 

The average concentration of UACR in spot urine samples is less than 30 mg/g. Men's 
average UACR values range from less than or equal to 17 mg/g, but women's levels are often 
higher, about 25 mg/g. Microalbuminuria occurs when the spot pee contains 30 to 300 mg/g. 
In the general population, microalbuminuria is an independent predictor of coronary artery 
disease, cardiovascular disease, and all-cause mortality. There is conflicting evidence from 
several observational studies that there is a link between incident hypertension and a slight 
increase in UACR within the normal range.9 A systematic review is done to determine the role 
of ACR urine in patients with DM type 2. 

 

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METHOD 

The systematic review followed recommendations of the Preferred Reporting Items for 
Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The research articles used in 
this systematic review were obtained from some databases such as ScienceDirect, PubMed 
and Sage. The search used keywords: 'urinary albumin creatinine ratio in type 2 diabetes 
mellitus’. The next stage was analysis and synthesis, in which the article adjusted to the 
inclusion and exclusion criteria previously defined. Criteria for Inclusion in this systematic 
review are (1) an article in English, (2) free full text, (3) discuss diabetes mellitus type 2, (4) 
published from 2018 to May 2023, and (5) based on experiment or research data. Exclusion 
criteria for a systematic review are (1) full text not available, (2) the title of the article needs to 
be more relevant to the topic (3) it does not discuss the role of ACR Urine.  

RESULTS 

The search process conducted is described in Figure 1. Based on the search results from 
several databases using predefined keywords, in total 22,629 articles were obtained. After the 
screening according to our criteria, 10 articles were met the criteria and included to the 
analysis. 

 

 Figure 1. Diagram of Preferred Reporting Items for Systematic Review and Meta-Analysis 
(PRISMA) 

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Ten articles were included in the analysis, we synthesized each article by looking at the 
design, sample, variables, instruments and analysis used (Table 1) 

Table 1. Summary of findings from articles included 

NO Author Year Title Methods (design, samples, 
variables, instrument, 

analysis) 

Results 

1 Hertzel C. Gerstein 
et al. 

2022 A novel kidney 
disease index 
reflecting both 
the albumin-to-
creatinine ratio 
and estimated 
glomerular 
filtration rate 
predicted 
cardiovascular 
and kidney 
outcomes in type 
2 diabetes. 8 

D comparative design study The kidney 
disease index 
combines the 
baseline eGFR 
and ACR into a 
novel composite 
risk factor that has 
a simple linear 
relationship with 
incident serious 
outcomes in 
people with 
diabetes and 
additional 
cardiovascular risk 
factors. 

S purposive sampling;  
V people aged 50 or older 

with either newly 
diagnosed or established 
type 2 diabetes whose 
body mass index was≥23 
kg/m2 and whose HbA1c 
was 9.5% or less (with no 
lower limit) on stable 
doses of up to 2 oral 
glucose-lowering drugs 
with or without basal 
insulin between August 
2011 and 2013 

I Annual laboratory 
assessments (measured 
urine albumin-to-
creatinine ratio (ACR) 
and estimated glomerular 
filtration rate  

A Chi-square 

2 Wilailuck 
Tuntayothin et al.  

2020 Development and 
Validation of a 
Chronic Kidney 
Disease 
Prediction Model 
for Type 2 
Diabetes Mellitus 
in Thailand.10 

D retrospective cohort 
study 

Older age, female 
sex, lower eGFR, 
higher UACR, and 
higher HbA1c 
were associated 
with an increased 
risk of developing 
stage-3 CKD in 
Thai patients with 
type 2 DM. Higher 
UACR at baseline 
reflects 
preexisting kidney 
damage. 

S purposive sampling;  
V V = patients with type 2 

DM treated at the 
Diabetics Clinic Centre at 
Taksin Hospital in 
Bangkok, Thailand 

I medical record 
A Baseline characteristics 

of training and validation 
data sets were compared 
using Student's t-test or 
Mann-Whitney. Wilcoxon 
test for continuous 
variables and chi-square 
test for categorical 
variables 

3 Austin G. Stack et 
al. 

2021 Effect of 
Intensive Urate 
Lowering with 
Combined 

D multicenter, prospective, 
randomized, double-
blinded, parallel-group, 
placebo-controlled trial 

The study met the 
primary objective 
with a reduction in 
UACR from 
baseline at 12 S purposive sampling;  

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NO Author Year Title Methods (design, samples, 
variables, instrument, 

analysis) 

Results 

Verinurad and 
Febuxostat on 
Albuminuria in 
Patients 
With Type 2 
Diabetes: A 
Randomized 
Trial.11 

V Adults 18 years or older 
with T2DM 

weeks for 
verinurad plus 
febuxostat versus 
placebo 

I medical record 
A Standard descriptive 

statistics 

4 Yuxian Xie et al.  2022 Assessment of 
urinary 
podocalyxin as 
an alternative 
marker for 
urinary albumin 
creatinine ratio in 
the early stage of 
diabetic kidney 
disease in older 
patients.12 

D correlational studies The correlation 
coefficient 
between PCX 
(Podocaxin) and 
ACR (albumin 
creatinine ratio) is 
0.852. Based on 
the ROC curve 
analysis, PCX's 
area under the 
ROC (receiving 
operator 
characteristic) 
curve is 0.946; the 
cutoff is 3.09. 
Finally, the 
sensitivity and 
specificity are 0.84 
and 0.91, 
respectively. 132 
cases of DKD 
(diabetic kidney 
disease) 
diagnosed with 
ACR; among 
them, PCX 
predicted 104 
cases of DKD. The 
percentage 
correction value 
was 78.8% 

S purposive sampling;  
V  type 2 DM with no 

history of diabetic kidney 
diseases 

I medical record 
A Kruskal–Wallis, one-way 

anova and spearman test 

5 Natalia Nowak et 
al. 

2018 Markers of early 
progressive renal 
decline in type 2 
diabetes suggest 
different 
implications for 
etiological 
studies and 
prognostic test 
development.13 

D comparative study ACR remained 
independently 
associated with an 
increased risk of 
the development 
of early renal 
decline. 

S purposive sampling;  
V 1368 patients with T2D 

attending the Joslin Clinic 
between 2003 and 2009 

I medical record 
A Wilcoxon rank and 

regression linear 

6 Takaya Sasaki et 
al. 

2021 Pathologic 
Diabetic 

D longitudinal study  The frequency of 
the duration of S purposive sampling;  

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NO Author Year Title Methods (design, samples, 
variables, instrument, 

analysis) 

Results 

Nephropathy in 
Autopsied 
Diabetic Cases 
with Normo 
albuminuria From 
a Japanese 
Community-
Based Study.14 

V used autopsy specimens 
obtained from deceased 
people in the town of 
Hisayama from July 2002 
to November 2017 

diabetes mellitus 
is>5 years, 
increasing UACR 
(Urinary albumin- 
creatinine ratio) 
levels. Diabetic 
cases with class 
IIa or higher 
glomerular DN 
(diabetic 
nephropathy) 
lesions 
increased 
significantly with 
increasing UACR 
levels 

I data autopsy 
A linear regression analysis 

7 Ze Wang et al. 2023 The positive 
association 
between urinary 
albumin-
creatinine ratio 
and 
lower extremity 
peripheral arterial 
disease in 
Chinese diabetes 
patients: A cross-
section study 
with propensity 
score matching 
analysis.6 

D cross-sectional study Elevated urinary 
ACR level was 
associated with 
decreased ABI 
(ankle-brachial 
index) in patients 
with diabetes. 
Therefore, 
elevated urinary 
ACR was 
associated with 
PAD (peripheral 
arterial disease) in 
Chinese patients 
with diabetes. 

S purposive sampling;  
V Patients were diagnosed 

with diabetes according 
to the World Health 
Organization criteria 
defined over 18 years.  

I laboratory data 
A Fisher's exact tests or 

Chi-square tests, T-tests 
and One-Way Anova 
analysis, Mann Whitney 
U tests and Kruskal-
Wallis tests, multivariate 
logistic regression 
analysis 

8 Wai Kin Chan et al. 2021 Association 
between serum 
bilirubin levels 
and progression 
of albuminuria in 
Taiwanese with 
type 2 diabetes 
mellitus.15 

D longitudinal study  A significant 
association was 
observed between 
the UACRs at 
baseline and the 
serum BIL groups 
(p < 0.001) 

S purposive sampling;  
V Patients diagnosed with 

type 2 diabetes, 
according to the 9th 
version of the 
International 
Classification of 
Diseases, Clinical 
Modification 

I database medical 
records from Chang 
Gung Memorial Hospital 
(CGMH) 

A ANOVA 
9 Lin Hou et al. 2020 Associations of 

serum uric acid 
level with diabetic 

D retrospective analysis 
study 

UACR identified 
as a risk factor for 

S purposive sampling;  

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NO Author Year Title Methods (design, samples, 
variables, instrument, 

analysis) 

Results 

retinopathy and 
albuminuria in 
patients with type 
2 diabetes 
mellitus.7 

V patients with type 2 DM 
(aged 21 to 85 years) 
who underwent treatment 
from March 2017 to 
September 2017 at the 
Department of 
Endocrinology, 
Shandong Provincial 
Hospital Affiliated with 
Shandong University. 

diabetic 
retinopathy (DR) 

I clinical record data 
A Multivariate logistic 

regression analysis 
10 Kazuo Kobayashi 

et al. 
2019 Retrospective 

analysis of 
effects of 
sodium-glucose 
co-transporter 2 
inhibitors in 
Japanese type 2 
diabetes mellitus 
patients with 
chronic kidney 
disease.16 

D Retrospective study ACR correlated 
significantly with 
age and BP 

S purposive sampling;  
V 935 T2DM patients who 

were registered and 
visited the clinics of 
members of the 
Kanagawa Physicians 
Association between 
November 2016 and 
March 2017 

I clinical record data 
A Multiple linear regression 

analysis 
 Note: D for Desain; S for sampel; V for variables; I for Instrument; A for Analysis. 

Based on the article included (n=10), it was found that ACR levels were associated with 
cardiovascular risk in people with DM. High levels of UACR are also associated with an 
increased risk of CKD. ACR levels are also influenced by the time the patient has diabetes. 
Therefore, an ACR examination is essential for diabetic patients. Chronic kidney disease 
(CKD) is a clinical illness indicated by long-term changes in renal structure or function, as well 
as a persistent deterioration in glomerular filtration. Suppose the underlying condition needs 
to be addressed promptly. In that case, it advances to end-stage renal disease (ESRD), which 
imposes a significant healthcare cost on the patient and family, as well as a financial burden 
on the country.17 

The eGFR and ACR are frequently tested risk factors for renal and cardiovascular outcomes. 
The finding that these risk variables were not linearly associated with these outcomes and 
were not independent of one another in predicting MACE and mortality stresses their 
complicated connection with each other else and to these outcomes. The KDI is a combination 
of these two risk variables. It incorporates data from both risk variables and has a 
straightforward linear association with all three outcomes. Furthermore, its ability to predict 
these three outcomes was comparable to complicated models that contained the eGFR and 
ACR, nonlinear variables, and interaction terms. As a result, the KDI may make it easier to 
identify high-risk patients who will benefit most from preventative medicines. Future 

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epidemiologic research and clinical trials should test and confirm its effectiveness as a risk 
stratification tool.8 

Patients should be educated on how improved blood glucose and albuminuria management 
can help postpone the development of CKD. Empirical data shows that estrogen has a 
renoprotective impact via lowering albuminuria. However, our investigation found that the male 
sex had a protective effect. Our data subgroup analysis revealed that 77% of women were 
over 50, compared to 65% of men (P, 0.001). This means that most female patients were 
postmenopausal with low estrogen levels, negating the possible renoprotective benefit. UACR 
examination can be done using dipsticks, making it easier for laboratories with limited 
equipment. Two stage-3 CKD risk prediction models that used demographic and laboratory 
characteristics as predictors demonstrated intense discrimination and calibration and were 
able to predict the 3-year risk of stage-3 CKD in individuals with type 2 diabetes. The 
comprehensive model is appropriate for healthcare settings with extensive laboratory testing, 
whereas the simplified model is appropriate for primary care settings with less laboratory 
testing, including UACR testing. These stage-3 CKD risk prediction models provide tools for 
healthcare professionals to screen for the risk of developing stage-3 CKD, allowing for earlier 
identification, and they assist healthcare providers in adopting treatments to slow CKD 
development.10 Previous research also found that ACR can improve the prediction of early 
symptoms of DKD (diabetic kidney disease). 18  This aligns with another research, which states 
that UACR levels can predict a decrease in kidney function early on in diabetics. 13 Another 
observable marker besides UACR is blood pressure, where blood pressure and UACR 
correlate with early decline in kidney function. 

In many countries, DN accounts for around half of all instances of end-stage renal disease. 
The normal clinical course of DN is microalbuminuria followed by overt albuminuria and 
eventually a loss in kidney function, with pathologic DN lesions progressing with increasing 
albuminuria. As a result, albuminuria is a clinical feature of DN. On the other hand, some 
diabetic individuals have reported a fast deterioration in kidney function without overt 
albuminuria. ACR levels also increase with the duration of diabetes.14 Increased urine ACR 
levels were independently linked with lower ABI in diabetic patients, and the risk of low ABI 
(PAD) was obvious in all subgroups investigated and after thorough adjustments. As a result, 
our findings indicated that higher urine ACR was related to PAD in diabetic individuals.6  

There was a significant association between the UACRs at baseline and the serum bilirubin 
groups. However, there was a substantial association between bilirubin levels and baseline 
UACR. Higher bilirubin levels are related to a decreased likelihood of albuminuria 
advancement in type 2 diabetes patients, implying that serum bilirubin levels may be a 
surrogate indication of diabetic nephropathy progression.15  

Compared to individuals with a low SUA (serum uric acid) level, those with a raised SUA level 
showed a higher frequency of DR and albuminuria. As a result, even within the normal range 
of SUA, people with somewhat high SUA levels may be predisposed to diabetic retinopathy 
(DR) and diabetic nephropathy (DN). As a result, SUA levels in individuals with type 2 diabetes 
should be closely monitored. Several diseases of the kidneys cause elevated SUA levels. A 
decrease in the estimated glomerular filtration rate or improper handling of filtered uric acid 
are two possible causes of increased SUA over the proximal tubules. The substance uric acid 

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is an essential component in the development of kidney diseases. The leading cause is DN, 
several research have also concentrated on the connection between SUA level and DN.7 

ACR was reduced in individuals with microalbuminuria and macroalbuminuria but rose 
dramatically in those with normo albuminuria. Other studies found various levels of 
improvement in ACR. ACR was reduced in individuals with microalbuminuria and 
macroalbuminuria but rose dramatically in those with normo albuminuria. Other studies found 
varying degrees of ACR improvement. ACR was highly associated with age and blood 
pressure. The effect of SGLT2i on ACR was independent of age, and the use of SGLT2i 
appears to be an effective method for treating diabetes in advanced age. However, caution 
should be used in individuals with normal albuminuria or increasingly poor renal function. In 
addition to their direct influence on blood glucose levels, sodium-glucose co-transporter 2 
inhibitors (SGLT2i) have numerous indirect benefits, such as lowering blood pressure (BP) 
and improving dyslipidemia and liver function.16 

Reduction of UACR levels can slow kidney damage and cardiovascular disease—a reduction 
of UACR from baseline at 12 weeks for verinurad plus febuxostat.11 Diabetes kidney disease 
is one of the leading causes of morbidity and death in people with diabetes. Diabetic kidney 
disease affects 20%-40% of persons with diabetes, both types 1 and 2. If not treated 
effectively, this condition will progress to end-stage renal disease (ESRD).19  

DISCUSSION  

The article that has been reviewed found that ACR examination is critical to monitor kidney 
damage in patients with type 2 diabetes. ACR can also be used as a marker of DN. ACR levels 
correlate with uric acid levels and bilirubin levels in patients. DM sufferers should be educated 
about maintaining blood sugar levels to maintain kidney conditions. Prolonged suffering from 
DM is also associated with ACR levels.10 The formation of Advanced Glycation End Products 
(AGEs) from glucose with amino acid residues in body tissues is caused by high and 
prolonged blood glucose levels. The kidneys eliminate AGEs in small quantities, but in people 
with diabetes mellitus, the number of AGEs is very high in the plasma, which makes kidney 
work more difficult.5 Chronic diabetes relates to organ damage, malfunction, and failure, 
particularly of the eyes, nerves, feet, blood vessels, kidneys, and heart. Diabetes has been 
linked to microvascular problems, including retinopathy, neuropathy, and nephropathy. 
Diabetes microvascular problems include kidney damage known as diabetic nephropathy 
(DN), which is the most prevalent consequence of type 2 diabetes mellitus and the leading 
cause of end-stage renal disease globally, with substantial morbidity and death. It occurs in 
around 40% of diabetic individuals after 10 years of type 2 diabetes mellitus diagnosis.20 
Diabetic kidney disease (DKD) is uncontrollably managed due to the involvement of complex 
pathophysiological pathways that impact practically all renal tissues, including glomeruli, 
tubules, interstitial, and blood vessels. Following hyperfiltration, microalbuminuria develops, 
followed by proteinuria and a low estimated glomerular filtration rate (eGFR). Early glycemic 
variability reduction (before macro albuminuria) can prevent renal function degradation.21 
Hyperglycemia in patients with diabetes mellitus causes microalbuminuria, which can increase 
intraglomerular pressure. A glomerular capillary that can increase permeability. If the albumin 
filtration is increased in the glomerulus, exceeding the reabsorption capacity of the tubules, 
then there will be an increase in the excretion of albumin in the urine. Creatinine is released 

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from the kidneys relatively constantly in the plasma daily through filtration and secretion. Since 
almost all the skeleton muscles produce creatinine, individuals with larger muscles may have 
higher creatinine levels. Blood creatinine tests with urine creatinine usually assess the speed 
of glomerular filtration. A doubling of creatinine levels indicates a decrease in kidney function 
by 50 %.5 Prolonged hyperglycemia in patients can produce alterations in the basal membrane 
of the glomerulus, including the proliferation of mesangium cells. High blood sugar interacts 
with proteins, altering the structure and function of cells, including the basal membrane of the 
glomerulus, resulting in a broken protein barrier and protein leakage into the urine. 
(microalbuminuria). One typical complication is a kidney anomaly that begins with 
microalbuminuria and progresses to clinical proteinuria, as well as a decline in glomerular 
filtration rate function, which leads to kidney failure and requires more extensive management 
and therapy. The diagnosis of diabetic nephropathy begins with an appearance of albuminuria 
in patients with type 2 diabetes. When the amount of protein and albumin in the urine is still 
meagre, it can be detected using the standard urinalysis method; however, if it is greater than 
30 mg/24 hours or greater than 20 mg/min, it is also known as microalbuminuria. The degree 
of albuminuria or proteinuria can also be measured by the ratio of creatinine in urine taken 
simultaneously, known as the albumin or creatinine ratio (ACR).22 

The emergence of chronic kidney disease (CKD) and its eventual development into this fatal 
condition continues to be a significant contributor to lower life expectancy and early death. 
Severe chronic kidney disease (CKD) requires close monitoring for indicators of disease 
progression and promptly referred to experts for dialysis or potential renal transplant. 
Proteinuria and glomerular filtration rate are kidney damage markers used by the Kidney 
Disease Improving Global Outcomes (KDIGO) foundation recommendations to characterize 
chronic kidney disease (CKD). Chronic renal disease is defined as having both parameters—
abnormalities of kidney structure or function for longer than three months—along with 
glomerular filtration rate [GFR] less than 60 mL/min and albumin greater than 30 mg per gram 
of creatinine. A GFR of less than 15 mL/min is considered end-stage renal disease.23 

Patients with diabetes may experience an imbalance in their sex hormones. Research has 
indicated that men with diabetes have lower levels of testosterone and higher amounts of 
estradiol in comparison to those without the disease. Nonetheless, women with diabetes had 
lower levels of estrogen and higher amounts of testosterone than women without the disease, 
indicating that a sex hormone imbalance may be linked to diabetes. When compared to 
women without diabetes, females with diabetes may have lower levels of estradiol, which 
might increase urine albumin excretion, lower creatinine clearance, and worsen tubular 
fibrosis in the kidneys. These effects could raise the chance of having renal problems.24 

In diabetic individuals, oxidative stress has been implicated as a pathogenic factor in the 
development of nephropathy. Bilirubin is a potent antioxidant that mainly shields cells from fat 
perspiration. From biliverdin, it is produced by Reducer of biliverdin. It is transformed into 
biliverdin during its antioxidant action, which happens immediately. Biliverdin reductase 
reduces it once more to bilirubin. The specific nature of the connection between blood bilirubin 
level and the emergence of Diabetic people may or may not have nephropathy. 

Nevertheless, it is anticipated that elevated bilirubin levels in the serum within a normal range 
can prevent oxidative tension and inflammation, hence averting the onset of nephropathy 

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caused by diabetes. Previously, low serum bilirubin levels have been linked to research. 
Predicts the onset of chronic renal disease among individuals with diabetes mellitus type 2.25 

However, many of these consequences can be mitigated by minimizing diabetic 
complications. This is possible with diabetes medicines. Even though a variety of drugs have 
been shown to reduce blood glucose (glycaemia), current care has failed to achieve and 
maintain ideal glycemic control in diabetic patients. Non-adherence to diabetes treatments is 
one of the leading causes of poor glycemic control. Noncompliance with diabetes treatment 
has several implications. Some of these were higher out-of-pocket expenses, increased 
overall healthcare costs, morbidity increases, and deaths.26 Patients with demanding glycemic 
management and minimal HbA1c variability showed steady renal function with no 
deterioration. Patients' renal function would not decline if they had optimal glucose control. 
Early glycemic variability reduction (before macro albuminuria) can halt renal function 
degradation. HbA1c_CV should be monitored and minimized regularly for diabetes 
treatment.21 This study had some limitations; the data retrieved was limited from article search 
results in the database with unpaid criteria due to funding limitations. 

CONCLUSION 

UACR examination is necessary for people with type 2 diabetes to monitor the condition of 
the kidneys. The examination was carried out using the patient's urine sample. Low ACR levels 
will slow kidney damage, so routine treatment is needed in type 2 DM patients.  

The national Social Security Agency on Health (BPJS) that is the Chronic Disease 
Management Program called as Prolanis, which has scheduled free examinations every 6 
months for DM and HT patients, is one of the efforts of health services to be able to monitor 
the kidney condition of DM and HT patients so that the first step in treatment can be carried 
out as a follow-up to the results of the examination. 

Conflict of interest 

There is no conflict of interest in this research.  

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