What to do if urine albumin is elevated?

Management of Elevated Urine Albumin

Your urine albumin of 27.2 μg/mL (equivalent to approximately 18 mg/g creatinine on the albumin/creatinine ratio) falls just below the threshold for moderately increased albuminuria, but warrants close monitoring and preventive measures, particularly if you have diabetes or hypertension. 1

Understanding Your Results

• Your albumin/creatinine ratio of 18 mg/g creatinine is currently in the normal range (A1 category: <30 mg/g), but your spot urine albumin of 27.2 μg/mL is elevated above the reference range of 0-20 μg/mL. 1
• Albuminuria exists on a continuous spectrum of risk—even values within the "normal" range below 30 mg/g are associated with increased cardiovascular and kidney disease risk in a linear fashion. 2, 3
• Before pursuing extensive evaluation, repeat the test in 1-2 weeks, as transient elevations can occur with exercise within 24 hours, infection, fever, congestive heart failure, or marked hyperglycemia. 4
• Two of three specimens collected within a 3-6 month period should be abnormal before confirming persistent albuminuria. 5

Immediate Actions Required

Blood Pressure Assessment and Control

• Check your blood pressure immediately and ensure it is optimally controlled. 1
• If you have diabetes or chronic kidney disease, your blood pressure target should be <130/80 mmHg (some guidelines suggest <140/90 mmHg for non-proteinuric patients without diabetes). 1
• Even with albumin levels in the high-normal range, screening for undiagnosed hypertension is critical, as elevated albuminuria combined with hypertension significantly accelerates kidney function decline. 6

Glucose Control Optimization (If Diabetic)

• Optimize glucose control to reduce risk of progression to overt diabetic kidney disease, targeting HbA1c <7%. 1
• Consider sodium-glucose cotransporter 2 (SGLT2) inhibitors or GLP-1 receptor agonists if you have type 2 diabetes, as these agents reduce chronic kidney disease progression and cardiovascular events. 1

Medication Considerations

• If you have diabetes with hypertension and your albumin/creatinine ratio reaches 30-299 mg/g on repeat testing, initiate an ACE inhibitor or ARB. 1, 5
• If you have diabetes and your albumin/creatinine ratio reaches ≥300 mg/g, an ACE inhibitor or ARB is strongly recommended. 1
• ACE inhibitors and ARBs are NOT recommended for primary prevention if you have normal blood pressure and normal albumin excretion (<30 mg/g). 1, 5
• Never combine an ACE inhibitor with an ARB (dual RAAS blockade), as this increases adverse events without additional benefit. 5, 7

Monitoring Protocol

Short-Term Follow-Up

• Repeat urinary albumin/creatinine ratio in 3-6 months to confirm whether this represents persistent albuminuria or a transient elevation. 1, 5
• If you are started on an ACE inhibitor or ARB, monitor serum creatinine and potassium levels within 2-3 weeks and again at 2-3 months to detect increases in creatinine or hyperkalemia. 1, 2
• Continue monitoring urinary albumin excretion every 6-12 months to assess response to therapy and disease progression. 1, 5, 3

Long-Term Surveillance

• Annual screening with spot urine albumin/creatinine ratio is recommended for all patients with diabetes (≥5 years duration for type 1, at diagnosis for type 2) and those with hypertension. 1
• Monitor estimated glomerular filtration rate (eGFR) annually alongside albuminuria screening. 1

Lifestyle and Risk Factor Modifications

• Implement dietary sodium restriction and aim for moderate potassium intake to augment the antialbuminuric effects of blood pressure control. 1, 3
• If you have chronic kidney disease (eGFR <60 mL/min/1.73 m²), target dietary protein intake of approximately 0.8 g/kg body weight per day. 1
• Maintain LDL cholesterol <100 mg/dL if diabetic or <120 mg/dL otherwise, and achieve weight loss if BMI >30. 3
• Avoid NSAIDs and other nephrotoxic medications that could worsen kidney function. 2

When to Refer to Nephrology

• Refer to nephrology if eGFR falls below 30 mL/min/1.73 m² or if there is uncertainty about the etiology of kidney disease. 1, 4
• Promptly refer for continuously increasing albuminuria levels, continuously decreasing eGFR, or rapidly progressing kidney disease. 1
• Consider nephrology consultation if albumin/creatinine ratio reaches ≥300 mg/g despite optimal medical management. 1

Key Pitfalls to Avoid

• Do not dismiss "high-normal" albumin levels as clinically insignificant—cardiovascular and renal risk increases continuously even below 30 mg/g. 2, 3
• Do not use standard urine dipsticks for protein, as they lack sensitivity for detecting albumin at concentrations of 20-50 mg/L; always use albumin-specific immunoassays with creatinine correction. 1, 3
• Avoid starting ACE inhibitors or ARBs without establishing baseline creatinine and potassium, and ensure close monitoring after initiation. 1, 2
• If ACE inhibitors or ARBs are contraindicated or not tolerated, consider nonsteroidal mineralocorticoid receptor antagonists (if eGFR ≥20-25 mL/min/1.73 m²) for patients with chronic kidney disease and albuminuria. 1