What is the management plan for a patient with an increased Albumin (ACR) to Creatinine ratio and a normal estimated Glomerular Filtration Rate (eGFR)?

Management of Increased Albumin-to-Creatinine Ratio with Normal eGFR

Patients with increased albumin-to-creatinine ratio (ACR) and normal estimated glomerular filtration rate (eGFR) should be treated with an ACE inhibitor or angiotensin receptor blocker (ARB) to reduce the risk of chronic kidney disease progression and cardiovascular events. 1

Understanding the Clinical Significance

• An elevated ACR (≥30 mg/g creatinine) with normal eGFR represents early kidney damage and is associated with increased risk for progression to more advanced kidney disease and cardiovascular events, even before GFR decline occurs 2, 3
• This condition is classified as Stage 1 or 2 chronic kidney disease (depending on exact eGFR value) with albuminuria category A2 (30-299 mg/g) or A3 (≥300 mg/g) 1
• Albuminuria is a continuous risk factor - higher values, even within what was previously called "microalbuminuria" range (30-299 mg/g), correlate with worse outcomes 1, 4

Initial Assessment

• Confirm persistent albuminuria with 2-3 specimens collected over a 3-6 month period due to biological variability of >20% between measurements 1
• Rule out factors that can transiently elevate ACR: exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, menstruation, and marked hypertension 1
• Assess for other risk factors that may accelerate kidney disease progression: hypertension, diabetes, smoking, obesity, dyslipidemia 1

Treatment Algorithm

First-line Therapy:

• For ACR 30-299 mg/g: Initiate ACE inhibitor or ARB therapy (Grade B recommendation) 1
• For ACR ≥300 mg/g: Strongly recommended to initiate ACE inhibitor or ARB therapy (Grade A recommendation) 1
• Titrate to maximum tolerated dose for optimal albuminuria reduction 1

Blood Pressure Management:

• Target blood pressure <140/90 mmHg for those with ACR <30 mg/g 1
• Consider more intensive target of <130/80 mmHg for those with ACR ≥30 mg/g 1
• Optimize blood pressure control to reduce risk of CKD progression 1

Glucose Control (if diabetic):

• Optimize glycemic control to reduce risk of CKD progression 1
• Consider SGLT2 inhibitors in patients with type 2 diabetes and ACR ≥30 mg/g for additional kidney protection, even with normal eGFR 1

Monitoring:

• Monitor serum creatinine and potassium levels after initiating ACE inhibitors or ARBs 1
• Expect a small rise in serum creatinine (up to 30%) which is generally acceptable; larger increases warrant further investigation 1
• Follow ACR and eGFR at least annually to assess treatment response and disease progression 1
• For those with albuminuria (ACR ≥30 mg/g), more frequent monitoring (2-4 times per year) may be appropriate 1

Special Considerations

• ACE inhibitors or ARBs are not recommended for primary prevention in patients with normal blood pressure and normal ACR (<30 mg/g) 1
• Avoid ACE inhibitors and ARBs during pregnancy 1
• Elevated ACR increases risk for acute kidney injury during hospitalizations or procedures; this risk should be considered when planning care 5
• Patients with diabetes should be screened annually for albuminuria regardless of eGFR 1

Referral to Nephrology

• Consider referral to nephrology for:
  • Uncertainty about etiology of kidney disease (especially if typical features of diabetic kidney disease are absent) 1
  • Rapidly increasing albuminuria despite treatment 1
  • Difficult management issues (e.g., resistant hypertension) 1
  • If eGFR declines to <30 mL/min/1.73 m² 1

Early intervention with ACE inhibitors or ARBs in patients with elevated ACR, even with normal eGFR, can significantly reduce the risk of progression to more advanced kidney disease and associated cardiovascular complications 1.

I hope this helps!