UACR adjustment attenuates associations of selected routine blood markers with documented diabetic retinopathy more than eGFR adjustment: a cross-sectional study in type 2 diabetes
- 1The Second Clinical College of Guangzhou University of Chinese Medicine
- 2Department of Ophthalmology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine
Abstract
Background: Studies of routine blood markers and diabetic retinopathy often adjust for estimated glomerular filtration rate (eGFR), although albuminuria captures a different aspect of kidney damage. We compared these associations under eGFR and urinary albumin-to-creatinine ratio (UACR) adjustment.
Methods: We analyzed 8,159 adults hospitalized with type 2 diabetes from January 2020 to March 2026. Primary exposures were serum albumin, total bilirubin, fibrinogen and the FIB-4 index. Four models were fitted in a fixed complete-case sample, with additional adjustment for eGFR, log UACR, or both. The outcome was documented diabetic retinopathy (DR), based on ophthalmological assessment and discharge diagnosis; DR = 0 included unassessed patients without a DR diagnosis. Prevalence ratios were estimated by marginal standardization.
Results: Among 3,978 complete-case patients, 958 (24.1%) had documented DR. Adjustment for log UACR attenuated the serum albumin association more than adjustment for eGFR (73.3% versus 34.3%; difference 38.9 percentage points, 95% CI 30.7 to 49.0) and moved the fibrinogen estimate close to one. Binary albuminuria produced substantially less attenuation than continuous log UACR. Multiple imputation supported the renal-adjustment comparison, although the albumin interval included the null after mutual renal adjustment. Serum albumin remained associated with documented DR after restriction to eGFR ≥90 mL/min/1.73 m ² (prevalence ratio 0.762, 95% CI 0.649 to 0.873), whereas no clear evidence of an eGFR association was observed within this stratum (0.981, P = 0.823). Conclusions: In this single-center inpatient cohort, eGFR and UACR adjustment yielded different estimates for the studied blood-marker associations with documented DR. Attenuation denotes proportional reduction in the absolute log prevalence-ratio estimate, not a causal proportion explained. Dichotomizing UACR discarded information and reduced attenuation in these models.
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BibTeX
@article{zhang2026uacr,
title = {{UACR adjustment attenuates associations of selected routine blood markers with documented diabetic retinopathy more than eGFR adjustment: a cross-sectional study in type 2 diabetes}},
author = {Jing Zhang and Mingliang Xu and Baoyi Xiong and Baohua Luo and Long Pang},
journal = {Frontiers in Endocrinology},
year = {2026},
month = oct,
doi = {10.3389/fendo.2026.1983060},
url = {https://www.frontiersin.org/articles/10.3389/fendo.2026.1983060/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - UACR adjustment attenuates associations of selected routine blood markers with documented diabetic retinopathy more than eGFR adjustment: a cross-sectional study in type 2 diabetes
AU - Jing Zhang
AU - Mingliang Xu
AU - Baoyi Xiong
AU - Baohua Luo
AU - Long Pang
PY - 2026
DA - 2026/10/27
JO - Frontiers in Endocrinology
DO - 10.3389/fendo.2026.1983060
UR - https://www.frontiersin.org/articles/10.3389/fendo.2026.1983060/full
AB - Background: Studies of routine blood markers and diabetic retinopathy often adjust for estimated glomerular filtration rate (eGFR), although albuminuria captures a different aspect of kidney damage. We compared these associations under eGFR and urinary albumin-to-creatinine ratio (UACR) adjustment. Methods: We analyzed 8,159 adults hospitalized with type 2 diabetes from January 2020 to March 2026. Primary exposures were serum albumin, total bilirubin, fibrinogen and the FIB-4 index. Four models were fitted in a fixed complete-case sample, with additional adjustment for eGFR, log UACR, or both. The outcome was documented diabetic retinopathy (DR), based on ophthalmological assessment and discharge diagnosis; DR = 0 included unassessed patients without a DR diagnosis. Prevalence ratios were estimated by marginal standardization. Results: Among 3,978 complete-case patients, 958 (24.1%) had documented DR. Adjustment for log UACR attenuated the serum albumin association more than adjustment for eGFR (73.3% versus 34.3%; difference 38.9 percentage points, 95% CI 30.7 to 49.0) and moved the fibrinogen estimate close to one. Binary albuminuria produced substantially less attenuation than continuous log UACR. Multiple imputation supported the renal-adjustment comparison, although the albumin interval included the null after mutual renal adjustment. Serum albumin remained associated with documented DR after restriction to eGFR ≥90 mL/min/1.73 m ² (prevalence ratio 0.762, 95% CI 0.649 to 0.873), whereas no clear evidence of an eGFR association was observed within this stratum (0.981, P = 0.823). Conclusions: In this single-center inpatient cohort, eGFR and UACR adjustment yielded different estimates for the studied blood-marker associations with documented DR. Attenuation denotes proportional reduction in the absolute log prevalence-ratio estimate, not a causal proportion explained. Dichotomizing UACR discarded information and reduced attenuation in these models.
SN - 1664-2392
ER -