What is the appropriate line of care for a patient with an elevated albumin-to-creatinine ratio?

Management of a Patient with Elevated Albumin-to-Creatinine Ratio (83 mg/g)

For a 61-year-old male patient with an albumin-to-creatinine ratio of 83 mg/g, initiation of an ACE inhibitor or angiotensin receptor blocker (ARB) is recommended as first-line therapy to reduce the risk of chronic kidney disease progression. 1, 2

Assessment and Classification

• The patient's albumin-to-creatinine ratio of 83 mg/g falls within the range of moderately increased albuminuria (30-299 mg/g), which is a marker of kidney damage and increased cardiovascular risk 2, 3
• This level of albuminuria is associated with increased risk for progression to overt nephropathy, end-stage renal disease, and cardiovascular events 3, 4
• Due to high biological variability in urinary albumin excretion, confirmation with 2-3 specimens collected within a 3-6 month period is recommended before establishing a definitive diagnosis 1, 2

Treatment Approach

First-Line Therapy

• Initiate an ACE inhibitor or ARB for this patient with moderately elevated urinary albumin-to-creatinine ratio (30-299 mg/g) 1, 2
• Monitor serum creatinine and potassium levels after starting ACE inhibitors or ARBs to detect potential increases in creatinine or changes in potassium 1, 2
• Do not discontinue renin-angiotensin system blockade for minor increases in serum creatinine (≤30%) in the absence of volume depletion 1

Optimization of Other Risk Factors

• Optimize blood pressure control to reduce risk or slow progression of diabetic kidney disease 1
• If the patient has diabetes, optimize glucose control to reduce risk or slow progression of kidney disease 1
• Recommend dietary protein intake of approximately 0.8 g/kg body weight per day (the recommended daily allowance) 1, 2, 3

Monitoring and Follow-up

• Continue monitoring UACR to assess response to therapy and disease progression 1, 2
• Assess estimated glomerular filtration rate (eGFR) at baseline and annually thereafter 1, 2
• Monitor for potential complications of chronic kidney disease if eGFR is <60 mL/min/1.73 m² 1

Referral Considerations

• Consider referral to a nephrologist if there is uncertainty about the etiology of kidney disease, difficult management issues, or rapidly progressing kidney disease 1
• Prompt referral to a nephrologist is warranted if eGFR <30 mL/min/1.73 m² 1, 2

Clinical Pearls and Pitfalls

• Even mildly increased albuminuria is associated with increased cardiovascular risk, especially in patients with coronary artery disease 5
• Gender differences exist in creatinine excretion (men have approximately 55% higher excretion rates than women), which may affect interpretation of albumin-to-creatinine ratios 6
• Temporary elevations in UACR can occur due to exercise within 24 hours, infection, fever, congestive heart failure, marked hyperglycemia, menstruation, and marked hypertension 1, 2
• Early intervention with ACE inhibitors or ARBs can slow progression to overt proteinuria and reduce cardiovascular risk 4