Overall flow for abnormal Urine Albumin to Creatinine Ratio (ACR) results in Healthy.io project

Publication: 10/09/2020  --
Last review: 01/01/1900  
Next review: 10/09/2023  
Referral Guideline/Pathway
ID: 6628 
Approved By: Clinical Commissioning Assurance Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  


This Referral Guideline/Pathway is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Overall flow for abnormal Urine Albumin to Creatinine Ratio (ACR) results in Healthy.io project

Powerpoint version

When to Refer

Routine referral to Renal1

Stage 4 and 5 CKD (with or without diabetes)

Proteinuria (ACR > 70 mg/mmol) unless known to have diabetes and already appropriately treated with ACE Inhibitor or ARB

Proteinuria (ACR > 30 mg/mmol) together with haematuria

Declining eGFR of 25%, and a change in eGFR category or a declining eGFR of 15 ml/min within 12 months

Poorly controlled hypertension despite four antihypertensive drugs at therapeutic doses

Known or suspected rare or genetic causes of CKD

Suspected renal artery stenosis

Suspected renal outflow obstructive disease (refer to urology unless medical emergency)

Investigations to consider in suspected CKD

Important: Not all CKD in patients with diabetes is due to diabetes so please consider other causes e.g. bone pain and raised calcium consider multiple myeloma. If oedamatous and hypoalbuminaemic, consider nephrotic syndrome. If urinary casts, consider glomerular disease.

Investigations to consider

What to look out for

Urine: Urine dipstick and microscopy

Haematuria; proteinuria and casts – altered in glomerular or tubointerstitial disease

Urine: Urine protein quantification: measured in a 24-hour urine sample or by ACR or PCR

The degree of proteinuria correlates with the rate of progression of the underlying kidney disease and is the most reliable prognostic factor in CKD.

Haematology: FBC, ESR, CRP.

Anaemia of chronic disease
Renal Anaemia
Raised ESR/CRP in acute inflammatory flare-ups

Biochemistry: renal function (creatinine, eGFR), electrolytes (sodium and potassium), liver function (Albumin), lipids, bone profile, glucose/Hba1c

Declining eGFR
Raised serum creatinine
Hypoalbuminaemia (e.g. nephrotic syndrome)
Raised glucose/Hba1c in diabetes

Serology: Serum immunoglobulins, serum and urine protein electrophoresis

Monoclonal proteins found in multiple myeloma (most common – IgG)

Serology: Serum complement

Low in SLE and cryoglobulinaemia and some forms of primary glomerulonephritis.

Serology: Autoantibodies

Raised ANA, anti-double stranded DNA, ANCA, antiglomerular basement membrane antibodies e.g. ANCA positive vasculitis, SLE, Anti-GBM disease

Serology: HBsAg; anti-HCV; antistreptolysin O titre (ASOT).

Hepatitis C Linked to cryoglobulinaemia.
Hepatitis B linked to membranous nephropathy and raised ASOT seen in post-streptococcal GN

Radiology: renal ultrasound

Obstruction – refer to urology; renal asymmetry - ?Renal Artery Stenosis - refer to renal for renal artery angiogram. If bilateral shrunken kidneys, likely CKD.


Record: 6628
Clinical condition:

abnormal Urine Albumin to Creatinine Ratio (ACR) results

Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

Evidence base

Not supplied

Approved By

Clinical Commissioning Assurance Group

Document history

LHP version 1.0

Related information

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