Management of Elevated Albumin-to-Creatinine Ratio

Confirmation of Elevated ACR

First morning void urine samples should be used for ACR measurement to minimize variability 3
Elevated ACR should be confirmed with 2 additional tests during the subsequent 3-6 months due to high day-to-day variability 4
Avoid testing during urinary tract infection, as this can cause false positive results 4

Serum creatinine with eGFR calculation using the 2021 CKD-EPI equation without race variable should be performed, as recommended by the American Diabetes Association 1, 5
Comprehensive metabolic panel to assess overall kidney function should be conducted, as suggested by the European Society of Cardiology 6
If eGFR is <60 mL/min/1.73 m² and/or albuminuria is >30 mg/g, repeat ACR testing every 6 months, according to the Kidney Disease: Improving Global Outcomes guideline 1
12-lead ECG for all patients with elevated ACR, especially if hypertensive, is recommended by the European Heart Journal 6

Consider cystatin C measurement in adults with eGFRcreat 45-59 mL/min/1.73 m² who don't have other markers of kidney damage to confirm CKD diagnosis, as suggested by the American College of Physicians 7
For diabetic patients, HbA1c testing to assess glycemic control should be performed, as recommended by the American Diabetes Association 8
Echocardiography if ECG abnormalities or signs/symptoms of cardiac disease are present, is recommended by the European Society of Cardiology 6
Fundoscopy for patients with diabetes or severe hypertension (BP >180/110 mmHg) should be conducted, as suggested by the European Society of Cardiology 6

For patients with moderately increased albuminuria (ACR 30-299 mg/g), monitor ACR and eGFR at least annually, according to the Kidney Disease: Improving Global Outcomes guideline 1, 2
For patients with severely increased albuminuria (ACR >300 mg/g) or eGFR <45 mL/min/1.73 m², monitor twice yearly, as recommended by the American Diabetes Association 8
More frequent monitoring is warranted when there are changes in clinical status or when starting new medications like SGLT2 inhibitors, ACE inhibitors, or ARBs, as suggested by the American Diabetes Association 8

Consider nephrology referral when eGFR <45 mL/min/1.73 m² or if there is consistent finding of significant albuminuria (ACR >300 mg/g), as recommended by the American Diabetes Association 8
Immediate nephrology referral is recommended once eGFR drops below 30 mL/min/1.73 m², according to the American Diabetes Association 8