What symptoms to check for in a patient with a sharp rise in Albumin-to-Creatinine Ratio (ACR) and stable estimated Glomerular Filtration Rate (eGFR)?

From the Guidelines

A sharp rise in albumin-to-creatinine ratio (ACR) with stable estimated glomerular filtration rate (eGFR) necessitates immediate monitoring for symptoms indicative of worsening kidney damage, including edema, foamy urine, increased blood pressure, fatigue, and changes in urination patterns, as emphasized by the 2022 standards of medical care in diabetes 1. When evaluating a patient with a sharp rise in ACR and stable eGFR, it is crucial to consider the dual assessment of kidney function and damage, as recommended by the Kidney Disease: Improving Global Outcomes (KDIGO) controversies conference in 2021 1. Key symptoms to monitor include:

• Swelling in the feet, ankles, hands, or face (edema)
• Foamy or bubbly urine
• Increased blood pressure
• Fatigue
• Decreased appetite
• Increased urination, particularly at night
• Unexplained weight gain due to fluid retention These symptoms may indicate progressing kidney damage, despite stable eGFR values. Regular blood pressure checks are vital, as hypertension can both cause and result from kidney damage, and urine color changes or blood in urine should prompt immediate medical attention 1. The elevated ACR indicates increased protein leakage through the kidneys' filtering system, which can progress to more severe kidney damage even when eGFR remains stable. Patients with diabetes or hypertension should be particularly vigilant, as these conditions commonly affect kidney function, and it is essential to report any new or worsening symptoms to the healthcare provider promptly for appropriate management, considering the continuous measurement of UACR and its association with renal and cardiovascular outcomes 1.

From the Research

Symptoms to Check for in a Patient with a Sharp Rise in Albumin-to-Creatinine Ratio (ACR) and Stable estimated Glomerular Filtration Rate (eGFR)

• A sharp rise in ACR with stable eGFR may indicate kidney damage or disease progression, and the following symptoms should be checked:
  • Cardiovascular disease events, such as heart attacks or strokes 2
  • Allograft failure in kidney transplant recipients 3
  • All-cause death 3
  • Kidney disease progression, including advanced CKD 2
• The patient's medical history and risk factors should also be considered, including:
  • Hypertension 4
  • Diabetes 4, 5
  • Age greater than 50 years 4
  • Obesity 6
• Laboratory tests, such as urine albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR), should be monitored regularly to assess kidney function and disease progression 4, 2, 5, 3, 6

Risk Factors and Associations

• Elevated ACR is independently associated with allograft failure, cardiovascular disease events, and all-cause death in stable kidney transplant recipients 3
• Asian Americans are more likely to have elevated ACR levels (> 300 mg/g) but less likely to have reduced eGFR levels (< 60 ml/min/1.73 m2) compared to White participants 6
• The combination of an increase in ACR and a decrease in eGFR is strongly associated with the risk of advanced CKD 2