What is the recommended treatment for a patient with an elevated albumin (Albumin)/creatinine ratio and normal estimated Glomerular Filtration Rate (eGFR)?

Management of Elevated Albumin/Creatinine Ratio with Normal eGFR

With an albumin/creatinine ratio of 53 mg/g (moderately elevated albuminuria) and normal eGFR of 111 mL/min/1.73 m², you should first confirm the elevated albuminuria with repeat testing, then initiate an ACE inhibitor or ARB if the patient has diabetes and hypertension, while optimizing glycemic control and blood pressure management to prevent progression to chronic kidney disease.

Confirm the Diagnosis

• Repeat the urine albumin-to-creatinine ratio on two additional samples to confirm the elevation, as albuminuria >30 mg/g creatinine should be confirmed on two of three samples before initiating treatment 1.
• The albumin/creatinine ratio of 53 mg/g falls into the "moderately elevated" category (30-299 mg/g), which is an early indicator of diabetic kidney disease and a marker for cardiovascular disease risk 1.
• Be aware that UACR demonstrates high within-individual variability (coefficient of variation 48.8%), so a single elevated value may not reflect true albuminuria 2.

Determine Treatment Based on Clinical Context

If Patient Has Diabetes and Hypertension:

• Start either an ACE inhibitor or angiotensin receptor blocker (ARB) for patients with diabetes, hypertension, and modestly elevated urinary albumin-to-creatinine ratio (30-299 mg/g creatinine) 1.
• This recommendation is based on evidence that ACE inhibitors/ARBs reduce the risk of progressive kidney disease and cardiovascular events in this population 1, 3.
• Titrate to the maximum tolerated dose indicated for blood pressure treatment 1.
• For individuals of childbearing age, provide reproductive counseling and avoid ACE inhibitors/ARBs if not using reliable contraception due to teratogenic effects 1.

If Patient Has Diabetes Without Hypertension:

• ACE inhibitors or ARBs are NOT recommended for primary prevention in patients with diabetes who have normal blood pressure and moderately elevated albuminuria 1.
• Focus on optimizing glucose control to reduce the risk or slow progression of diabetic kidney disease 1.
• Implement lifestyle modifications including healthy nutrition, physical activity, sleep optimization, and weight management if appropriate 1.

If Patient Does Not Have Diabetes:

• Investigate other causes of albuminuria, including primary glomerular diseases, hypertension-related kidney disease, or other systemic conditions 1.
• Consider nephrology referral if there is uncertainty about etiology, active urinary sediment (red blood cells or cellular casts), rapidly increasing albuminuria, or absence of expected clinical features 1.

Optimize Risk Factors

• Achieve optimal glycemic control with target A1C individualized based on patient factors, as this reduces the risk of developing or progressing diabetic kidney disease 1.
• Target blood pressure <130/80 mmHg in adolescents ≥13 years or <90th percentile for age, sex, and height in younger patients 1.
• Maintain dietary protein intake at approximately 0.8 g/kg body weight per day (the recommended daily allowance) for patients with nondialysis-dependent chronic kidney disease 1.

Monitoring Strategy

• Monitor UACR and eGFR annually to detect disease progression and assess response to treatment 1.
• Check serum creatinine and potassium levels at least annually when using ACE inhibitors, ARBs, or diuretics 1.
• Do not discontinue ACE inhibitor/ARB therapy for minor increases in serum creatinine (<30%) in the absence of volume depletion 1.
• Continue monitoring even with normal eGFR, as both albuminuria and eGFR are independent predictors of progression to end-stage kidney disease 4.

Important Caveats

• The combination of moderately elevated albuminuria (30-299 mg/g) with preserved eGFR (>90 mL/min/1.73 m²) represents Stage G1 or G2 chronic kidney disease if other kidney damage is present 1.
• Albuminuria is a continuous measurement, and even values within the "moderately elevated" range carry different levels of cardiovascular and renal risk 1.
• The high biological variability of UACR means that relying on a single measurement may lead to misclassification; the probability that a UACR increase from 30 to 53 mg/g represents a true 30% increase is only approximately 50% without repeat testing 2.
• Referral to nephrology is recommended if there is uncertainty of etiology, worsening UACR, or decrease in eGFR over time 1.