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Information ⬇

Synonym/Acronym

ACR

Rationale

To assist in the identification and management of early diabetes in order to avoid or delay onset of diabetic-associated kidney disease.

Patient Preparation

There are no food, fluid, activity, or medication restrictions unless by medical direction. Either a random or a 24-hr urine collection may be ordered. As appropriate, provide the required urine collection container and specimen collection instructions.

Normal Findings

Method: Immunoturbidometry for albumin, spectrophotometry for Cr.

Albumin, Urine (Random)Conventional UnitsSI Units (Conventional Units × 0.113)
MaleLess than 17 mg/g creatinineLess than 1.9 mg/mmol creatinine
FemaleLess than 25 mg/g creatinineLess than 2.8 mg/mmol creatinine
Albumin/Creatinine Ratio (ACR)Conventional UnitsSI Units (Conventional Units × 0.113)
NormalLess than 30 mg/g creatinineLess than 3.4 mg/mmol creatinine
Clinically significant albuminuria30–299 mg/g creatinine3.4–33.8 mg/mmol creatinine
Overt albuminuriaGreater than 300 mg/g creatinineGreater than or equal to 33.9 mg/mmol creatinine
Laboratory reports include the measured levels of random urine albumin and creatinine, and reporting units may vary between laboratories; reference ranges are often listed as “not established.”

Critical Findings and Potential Interventions ⬆ ⬇

N/A

Overview ⬆ ⬇

(Study type: Urine from a random or timed specimen collected in a clean plastic collection container; related body system: Endocrine and urinary systems.)

Chronic kidney disease (CKD) is a significant health concern worldwide. International research has been undertaken to evaluate the risk factors common to cardiovascular disease, diabetes, and hypertension; these three diseases are all associated with CKD. Albuminuria, which can result from increased glomerular permeability to proteins, is considered an independent risk factor predictive of kidney or cardiovascular disease. The National Kidney Foundation and American Society for Clinical Pathology recommend using timed or random urine albumin (formerly microalbumin) and eGFR together to screen for CKD.

The term albuminuria, formerly known as microalbuminuria, describes concentrations of albumin in urine that are greater than normal but are undetectable by the dipstick used in routine urinalysis or by traditional spectrophotometry methods. Albuminuria precedes the nephropathy associated with diabetes and is often elevated years before the creatinine clearance test shows abnormal values. Studies have shown that the median duration from onset of albuminuria to development of nephropathy is 5 to 7 yr. For additional information regarding screening guidelines and management of diabetes, refer to the studies titled “Glucose”

The random urine ACR is frequently used as a quick and reliable screen for diabetes and hypertension. A first morning void specimen is best if a random urine albumin will be tested. The American Diabetes Association (ADA) recommends periodic measurement of urine albumin as requested by the health-care provider (HCP) with serum creatinine (Cr) and estimated glomerular filtration rate (eGFR). Timed collections are often impractical and do not provide improved accuracy of results, so random samples are almost universally requested. Due to biological variability in excretion of urinary albumin and other factors that may independently cause increased urine albumin levels (e.g., congestive heart failure, exercise within 24 hr of testing, fever, hydration level, hyperglycemia [marked], hypertension [marked], infection, and menstruation), two of three specimens tested within a 3- to 6-mo period should be abnormal before making a determination for significant albuminuria. Guidelines for frequency of testing are based on the type of diabetes being treated and level of the patient’s ability to meet treatment goals.

The Minuteful Kidney test is an FDA-approved device for home use that uses artificial intelligence to determine levels of urine albumin, creatinine, and ACR. It is available by prescription only for monitoring patients who have or are at risk of developing kidney disease. The test system includes a smartphone application and test kit (ACR reagent impregnated test strip and “color board” against which semiquantitative results for the patient's urine sample can be visualized. The app provides complete test instructions, including how to upload a picture of the color board that is sent directly and securely to the requesting HCP.) For additional information, refer to Appendix E:Current Trends in Healthcare.

Indications ⬆ ⬇

Interfering Factors ⬆ ⬇

Other Considerations

  • All urine voided for the timed collection period must be included in the collection, or else falsely decreased values may be obtained. Compare output records with volume collected to verify that all voids were included in the collection.

Potential Medical Diagnosis: Clinical Significance of Results ⬆ ⬇

Increased In

Conditions resulting in increased renal excretion or loss of protein.

  • Cardiomyopathy
  • Diabetic nephropathy
  • Exercise
  • Hypertension (uncontrolled)
  • Kidney disease
  • Pre-eclampsia
  • Urinary tract infections

Decreased In

N/A

Nursing Implications ⬆

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

  • Discuss how this test can assist in evaluating for early kidney disease associated with diabetes.
  • Emphasize that good glycemic management delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy.
  • Explain that a urine sample is needed for the test. Information regarding urine specimen collection is presented with other general guidelines in Appendix A: Patient Preparation Specimen Collection.

Potential Nursing Actions

  • Include on the timed collection container’s label urine total volume, test start and stop times/dates, and any medications that may interfere with test results.

After the Study: Implementation & Evaluation Potential Nursing Actions

Avoiding Complications

  • Emphasize, as appropriate, that good management of glucose levels delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy.
  • Explain that unmanaged diabetes can cause multiple health issues, including diabetic kidney disease, amputation of limbs, and ultimately death.

Treatment Considerations

  • Interventions/actions related to glucose management include the following: Monitor and trend results for hemoglobin (Hgb) A1c, BUN, Cr, eGFR, glucose, electrolytes, arterial pH, magnesium, urine albumin and ACR, urine ketones, WBC count, amylase, Hgb/Hct, CRP, liver enzymes, and serum insulin levels. Emphasize the importance of adhering to the HCP-recommended therapeutic regime to manage diabetes. Ensure understanding of performing glucose self-checks and provide education for learning deficits. Discuss the lifestyle alterations necessary to support positive health management secondary to disease process. Ensure airway remains open with adequate ventilation and provide assistance as necessary.

Glucose Excess

  • Facilitate management of excess glucose.
  • Interventions/actions related to glucose excess include the following: Explain that glucose should be checked before meals and at bedtime with administration of prescribed insulin or oral drugs. Facilitate the HCP’s ordered therapy for glucose management (e.g., sliding scale method for determining insulin dose). Closely manage insulin drip in cases of liable glucose excess. Advise the patient to report signs and symptoms of elevated glucose (polyuria, weakness, polydipsia, dry mouth, nausea, vomiting, abdominal pain, hypotension, tachycardia, weight loss, weakness). Monitor for fluid volume deficit associated with osmotic response to elevated glucose.

Glucose Deficit

  • Facilitate management of glucose deficit; follow organizational protocols.
  • Interventions/actions related to glucose deficit include the following: Advise the patient to report signs and symptoms of decreased glucose (tremor, diaphoresis, tiredness, palpitations, headache, restlessness, altered mental status, altered speech and coordination, dizziness, blurred vision, confusion). Facilitate ingestion of about 20 g of oral carbohydrates in alert patients. Facilitate administration of IV glucose in the unconscious patient followed by oral carbohydrate ingestion once alert. Repeat blood glucose check in 15 min and treat for levels less than 70 mg/dL, according to policy. Teach the patient to carry a carbohydrate food as an intervention for hypoglycemic episodes.

Nutritional Considerations

  • Explain that there is no “diabetic diet”; however, a variety of dietary patterns are beneficial for people with diabetes, and many meal-planning approaches with nutritional goals are endorsed by the ADA.
  • Interventions/actions related to nutrition include the following: Facilitate dietary consultation with a certified diabetes educator. Discuss the reasons why those who adhere to dietary recommendations report a better general feeling of health, better weight management, better management of glucose and lipid values, and improved use of insulin. Discuss foods that can be used to treat hypoglycemia: milk, fruit juice, granola bars, cheese and crackers, regular soda, graham crackers, hard candies that contain sugar.

Clinical Judgement

  • Consider ways to assist in adaptation to therapeutic nutritional choices to improve glucose homeostasis.

Follow-Up Evaluation and Desired Outcomes