What does an albumin-to-creatinine ratio (ACR) of 126 mg/g indicate?

Albumin-to-Creatinine Ratio of 126 mg/g: Moderately Increased Albuminuria

An albumin-to-creatinine ratio (ACR) of 126 mg/g indicates moderately increased albuminuria (stage A2), signaling early kidney damage that requires confirmation with repeat testing and immediate intervention with ACE inhibitors or ARBs to prevent progression to end-stage renal disease. 1

Classification and Risk Stratification

Your ACR of 126 mg/g falls into the A2 category (moderately increased albuminuria), defined as ACR between 30-299 mg/g 1. This category was previously called "microalbuminuria," though this term is no longer recommended 1.

Key points about your result:

• This represents early kidney damage that is detectable before significant decline in kidney function occurs 1
• At any level of kidney function (GFR), an elevated ACR increases your risk for cardiovascular disease, kidney disease progression, and mortality 1
• The risk increases continuously as ACR rises, even within the moderately increased range 1

Confirmation Required Before Diagnosis

You need 2 out of 3 additional first-morning urine samples showing ACR ≥30 mg/g over the next 3-6 months to confirm persistent albuminuria 1, 2. This is critical because ACR has high day-to-day variability exceeding 20% 2.

Before confirming chronic kidney disease, exclude these transient causes that can falsely elevate ACR: 2

• Active urinary tract infection or fever
• Vigorous exercise within 24 hours
• Congestive heart failure exacerbation
• Marked hyperglycemia (very high blood sugar)
• Menstruation
• Uncontrolled hypertension

Immediate Management Steps

1. Assess Baseline Kidney Function

Measure serum creatinine and calculate estimated GFR (eGFR) using the CKD-EPI equation to determine your baseline kidney function 2. This, combined with your ACR, determines your monitoring frequency and treatment intensity.

2. Blood Pressure Management with Specific Medications

Start an ACE inhibitor or ARB immediately, regardless of your current blood pressure 1, 2. These medications provide specific kidney-protective effects beyond blood pressure lowering by reducing protein leakage 2.

Target blood pressure: <130/80 mmHg 1, 2

Important contraindication: If you are a woman of childbearing age, ACE inhibitors and ARBs are contraindicated unless you are using reliable contraception due to severe birth defect risks 2

Alternative medications if ACE inhibitors/ARBs are contraindicated include beta-blockers, non-dihydropyridine calcium channel blockers, or diuretics 2

3. Optimize Blood Sugar Control (If Diabetic)

Glycemic control is the primary prevention strategy for preventing diabetic kidney disease progression 2. Work with your physician to optimize your diabetes management.

4. Dietary Modifications

Restrict dietary protein to 0.8 g/kg body weight per day (the recommended daily allowance) 2

Lipid management targets: 2

• LDL cholesterol <100 mg/dL if diabetic, <120 mg/dL otherwise
• Limit saturated fat to <7% of total calories

Monitoring Schedule

Your monitoring frequency depends on your eGFR: 1, 2

• If eGFR ≥60 mL/min/1.73 m²: Monitor ACR and eGFR annually
• If eGFR 45-59 mL/min/1.73 m²: Monitor every 6 months
• If eGFR 30-44 mL/min/1.73 m²: Monitor every 3-4 months
• If eGFR <30 mL/min/1.73 m²: Immediate nephrology referral required

The goal is to reduce your ACR by at least 30-50%, ideally achieving ACR <30 mg/g 1. While this is difficult in many cases, sustained reduction in albuminuria is a validated marker of slowed kidney disease progression 1.

When to Refer to Nephrology

Consider nephrology referral if: 2

• Rapid progression of kidney disease
• Uncertainty about the underlying cause
• Advanced kidney disease (eGFR <30 mL/min/1.73 m²)
• Inadequate response to initial treatment
• ACR progresses to ≥300 mg/g persistently
• Refractory hypertension requiring ≥4 antihypertensive medications

Clinical Context

In type 1 diabetes, moderately increased albuminuria typically develops after 10+ years and usually accompanies diabetic retinopathy 2. In type 2 diabetes, it can be present at diagnosis since disease onset is difficult to date precisely 2.

Common pitfall: Do not dismiss this result as "borderline" or "not that bad." Even moderately increased albuminuria significantly increases your risk for cardiovascular events and kidney disease progression 1. Early intervention at this stage can prevent progression to more severe kidney damage.