Albumin creatinine ratio (ACR) and guidance when to use a renin-angiotensin system antagonist (ACEI or ARB) in CKD
NICE suggest that:
- offer a renin-angiotensin system antagonist to people with chronic kidney disease (CKD) and:
- diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
- hypertension and an ACR of 30 mg/mmol or more (ACR category A3)
- an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease)
- diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
Notes:
Classification of CKD
- CKD is classified according to estimated GFR (eGFR) and albumin:creatinine ratio (ACR), using 'G' to denote the GFR category (G1-G5, which have the same GFR thresholds as the CKD stages 1-5 recommended previously) and 'A' for the ACR category (A1-A3), for example:
- a person with an eGFR of 25 ml/min/1.73 m2 and an ACR of 15 mg/mmol has CKD G4A2.
- a person with an eGFR of 50 ml/min/1.73 m2 and an ACR of 35 mg/mmol has CKD G3aA3
- an eGFR of less than 15 ml/min/1.73 m2 (GFR category G5) is referred to as kidney failure
Note that:
- increased ACR is associated with increased risk of adverse outcomes
- decreased GFR is associated with increased risk of adverse outcomes
- increased ACR and decreased GFR in combination multiply the risk of adverse outcomes
GFR ( ml/min/1.73 m^2) and ACR categories and risk of adverse outcomes |
| A1 < 3 mg/mol (normal to mildly increased) | A2 3 -30 mg/mol (moderately increased) | A3 > 30mg/mol (severely increased) |
G1 | >= 90 ml/min/1.73 m^2 (Normal and High) | low risk * | moderately increased risk | high risk |
G2 | 60-89 ml/min/1.73 m^2 (Mild reduction related to normal range for young adult) | low risk * | moderately increased risk | high risk |
G3a | 45-59 ml/min/1.73 m^2 (mild-moderate reduction) | moderately increased risk | high risk | very high risk |
G3b | 30-44 ml/min/1.73 m^2 (moderate-severe reduction) | high risk | very high risk | very high risk |
G4 | 15-29 ml/min/1.73 m^2 (severe reduction) | very high risk | very high risk | very high risk |
G5 | < 15 ml/min/1.73 m^2 (kidney failure) | very high risk | very high risk | very high risk |
ACR (albumin creatinine ratio) category | ACR (mg/mmol) |
A1 | <3 |
A2 | 3-30 |
A3 | >30 |
Reference:
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