What does an albumin-to-creatinine ratio (ACR) of 94 indicate?

Albumin-to-Creatinine Ratio (ACR) of 94 mg/g Indicates Moderately Increased Albuminuria

An albumin-to-creatinine ratio (ACR) of 94 mg/g indicates moderately increased albuminuria (formerly called microalbuminuria), which is a sign of kidney damage and an independent risk factor for cardiovascular disease and progression of chronic kidney disease (CKD). 1

Classification and Significance

• ACR values are categorized as follows:

  • Normal to mildly increased: <30 mg/g
  • Moderately increased albuminuria: 30-299 mg/g
  • Severely increased albuminuria: ≥300 mg/g 1, 2

• At 94 mg/g, this falls clearly within the moderately increased albuminuria range, indicating:

  • Early kidney damage
  • Increased risk for CKD progression
  • Elevated cardiovascular risk independent of other factors 1, 2

Clinical Implications

Risk Assessment

• According to the KDIGO heatmap, the presence of moderately increased albuminuria increases the risk for CKD progression and cardiovascular events 1
• The risk level depends on the concurrent estimated glomerular filtration rate (eGFR):
  • With normal eGFR (≥90 ml/min/1.73m²): Moderate risk
  • With reduced eGFR: Higher risk that increases as eGFR declines 1

Confirmation Required

• A single ACR value of 94 mg/g is not sufficient for diagnosis
• Confirmation requires 2 out of 3 abnormal specimens collected within a 3-6 month period 2
• Rule out transient causes of elevated albumin excretion:
  • Exercise within 24 hours
  • Urinary tract infection
  • Marked hyperglycemia
  • Marked hypertension
  • Congestive heart failure
  • Febrile illness 1, 2

Management Recommendations

Blood Pressure Control

• Target blood pressure <130/80 mmHg 2
• First-line therapy: ACE inhibitor or ARB
  • Goal: Reduce urinary albumin by ≥30% 2
  • Monitor serum creatinine and potassium within 2-4 weeks of starting or adjusting therapy 2

Glycemic Control

• Target HbA1c <7% for patients with diabetes 2
• Consider SGLT2 inhibitor with proven kidney benefit if eGFR ≥20 ml/min/1.73m² 2

Lifestyle Modifications

• Low-sodium diet (<2g/day)
• Moderate protein intake (~0.8 g/kg/day)
• Regular physical activity
• Smoking cessation
• Weight management if overweight/obese 2
• Avoid nephrotoxic medications (NSAIDs, certain antibiotics) 2

Monitoring and Follow-up

Frequency of Monitoring

• More frequent monitoring (every 3-6 months) is recommended after detection of moderately increased albuminuria 1, 2
• Monitor for:
  • Changes in ACR
  • Decline in eGFR
  • Development of CKD complications 1, 2

Referral to Nephrologist

• Consider nephrology referral if:
  • Continuously increasing urinary albumin levels
  • Rapidly declining eGFR
  • eGFR <30 ml/min/1.73m²
  • Uncertainty about the etiology of kidney disease 2

Common Pitfalls to Avoid

1. Relying on a single measurement: Albuminuria can vary by 40-50% day-to-day; confirmation with repeat testing is essential 1, 2

2. Using dipstick tests alone: Standard dipstick tests have poor sensitivity (43.6%) for detecting moderately increased albuminuria 3

3. Ignoring time of collection: First morning void samples are preferred to minimize confounding factors 2

4. Overlooking non-renal causes: Transient elevations can occur due to exercise, fever, urinary tract infections, and other conditions 1, 2

5. Focusing only on kidney outcomes: Moderately increased albuminuria is also an independent cardiovascular risk factor that warrants aggressive risk factor management 1, 2