albumin creatinine ratio (ACR) and guidance when to use a renin-angiotensin system antagonist (ACEI or ARB) in CKD

Last reviewed 08/2021

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)

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

 

Reference:

• NICE (July 2014). Chronic kidney disease early identification and management of chronic kidney disease in adults in primary and secondary care