The Hidden Burden of Undiagnosed Diabetic Kidney Disease in Primary Care: Lessons from a Rural Indian Health System

BackgroundDiabetic kidney disease (DKD) is a major contributor to chronic kidney disease and related morbidity among individuals with type 2 diabetes mellitus.Early detection can delay disease progression; however, DKD often remains undiagnosed in primary-care settings, particularly in rural health systems.Evidence on the magnitude of undiagnosed DKD within routine diabetes care in India remains limited. MethodsA community-based cross-sectional analytical study was conducted from May to June 2024 among adults with type 2 diabetes mellitus attending primary-care services in a rural area of Kerala, India.Sociodemographic, clinical, and laboratory data were collected using structured interviews and medical record review.Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation.Undiagnosed DKD was defined as chronic kidney disease (eGFR <60 mL/min/1.73m) in individuals without a prior documented diagnosis.Descriptive analyses, group comparisons, and logistic regression were performed. FindingsAmong 110 participants, 22.7% (95% CI: 15.0-30.5%)were identified with previously undiagnosed DKD, with all cases first detected at stage 3 or beyond.Individuals with undiagnosed DKD showed a significantly higher prevalence of elevated serum creatinine, anaemia, hyperkalaemia, and poor glycaemic control.Documentation of urine albumin testing and prior eGFR calculation was significantly lower among affected participants.In multivariable analysis, older age, hypertension, longer duration of diabetes, and higher serum creatinine levels were independently associated with undiagnosed DKD.The multivariable logistic regression model demonstrated good discriminatory performance, with an area under the receiver operating characteristic curve (AUC) of 0.89 (95% CI: 0.82-0.95). InterpretationA substantial hidden burden of undiagnosed diabetic kidney disease exists within routine primary-care diabetes services, with detection occurring predominantly at advanced stages. J o u r n a l P r e -p r o o fThese findings indicate missed opportunities for early diagnosis despite regular healthsystem contact and highlight the need to strengthen systematic renal assessment within existing primary-care programmes.