Albumin-to-Creatinine Ratio Guidelines

Classification and Risk Category

An albumin-to-creatinine ratio (ACR) of 31 mg/g indicates moderately increased albuminuria, signaling early kidney damage that requires confirmation with repeat testing and immediate intervention to prevent progression to more severe kidney disease, according to the American Diabetes Association 1, 2
The American Diabetes Association classifies ACR into three categories: Normal ACR (<30 mg/g creatinine), Moderately increased albuminuria (30-299 mg/g creatinine), and Severely increased albuminuria (≥300 mg/g creatinine) 1, 2

The American Diabetes Association recommends confirming an elevated ACR with 2 additional urine samples collected over the next 3-6 months before making a definitive diagnosis of albuminuria, due to day-to-day variability in urinary albumin excretion and potential transient elevations 1
Two of three specimens collected within 3-6 months should be abnormal to confirm the diagnosis, as stated by the American Diabetes Association 1

The American Diabetes Association recommends starting an ACE inhibitor or ARB immediately if you have diabetes and hypertension, as these medications are specifically recommended for ACR 30-299 mg/g, with a strong evidence supporting this (Grade B recommendation) 2
The American Diabetes Association recommends targeting blood pressure <130/80 mmHg, and monitoring serum creatinine and potassium levels periodically when using these medications 2
The American Diabetes Association recommends intensifying glucose control to reduce risk of progression (Grade A recommendation) 2
The American Diabetes Association recommends restricting dietary protein to 0.8 g/kg body weight per day (the recommended daily allowance) 1, 2

The American Diabetes Association states that an elevated ACR increases risk for progression to more severe kidney disease, cardiovascular events and mortality, and end-stage renal disease requiring dialysis, at any level of kidney function (eGFR) 1, 2

The American Diabetes Association recommends considering nephrology referral if eGFR is <60 mL/min/1.73 m² (Stage 3a CKD or worse), rapid progression occurs, uncertainty exists about the cause of kidney damage, or eGFR <30 mL/min/1.73 m² (mandatory referral) 1, 2