Version July 2025
A1C: hemoglobin A1C; ACEi: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; DKA: diabetic ketoacidosis; DKD: diabetic kidney disease; uACR: urine albumin-to-creatinine ratio.
* May begin screening with diabetes duration of 3 years in patients age ≥10 years or pubertal with A1C above target or multiple occurrences of DKA in the preceding year.
¶ First morning random urine sample is preferred.
Δ Screening may be performed every 3 to 6 months if A1C is above target or in the presence of other microvascular complications (eg, retinopathy, neuropathy) or multiple occurrences of DKA in the preceding year.
◊ Repeat uACR is performed to rule out transient causes of albuminuria. If repeat random uACR is ≥30 mg albumin/g creatinine (≥3.4 mg/mmol), moderately or severely increased albuminuria is confirmed, and a third sample is not needed. If repeat random uACR is normal, a third sample should be obtained. If uACR is ≥300 mg albumin/g creatinine on any sample, confirmation should be performed promptly. If confirmed, pediatric nephrology should be consulted. Otherwise, all assessments should occur 2 to 3 months apart.
§ Obtain repeat sample as first morning sample to reduce likelihood of orthostatic proteinuria and influence of exercise.
¥ Lisinopril and enalapril are the most commonly used agents in the United States. We provide counseling on risks (teratogenicity) and pregnancy prevention before initiation and regularly thereafter. Refer to UpToDate content on management of DKD for more information.
‡ Benign causes of elevated albumin-to-creatinine ratio include orthostatic proteinuria, menses, fever, illness, kidney disease, and exercise. Pathologic causes include nephrotic syndrome, lupus nephritis, and poststreptococcal glomerulonephritis. For a comprehensive discussion of pathologic causes of elevated albumin-to-creatinine ratio, refer to UpToDate content on evaluation of proteinuria in children.
