The importance of uACR for more accurate chronic kidney disease (CKD) diagnosis and staging and to assess the risk of progression

Chronic kidney disease (CKD) affects over 1 in 7 U.S. adults (or approximately 37 million people), with its prevalence rising due to increasing rates of hypertension, diabetes, and obesity.¹ CKD often progresses without symptoms until later, more advanced stages. Early identification and management of CKD is critical in delaying disease progression, as well as reducing CKD-related complications. 

Current clinical guidelines, including the Kidney Disease: Improving Global Outcomes (KDIGO) initiative, the National Kidney Foundation (NKF), the American Heart Association (AHA), and the American College of Cardiology (ACC), recommend combining both urine albumin-to-creatine ratio (uACR) and estimated glomerular filtration rate (eGFR) testing for a complete picture of kidney health.

In this article:

Clinical challenge | Why it matters | Ordering recommendations | Interpreting test results | Supporting resources

Clinical challenge: Lack of symptoms and awareness inhibits early detection of CKD

The early stages of CKD are often silent, progressing without symptoms and with damage often going unnoticed until the kidneys are severely impaired. Up to 90% of people with CKD are unaware they have it until later stages, making routine evaluation critical for early detection and intervention.¹

The urine albumin-creatinine ratio (uACR) is the preferred, accurate method to detect early kidney damage, particularly in at-risk patients such as those with diabetes, hypertension, or a family history of kidney disease.²

Why it matters: uACR testing can identify CKD earlier

Albuminuria is one of the first indications of CKD, indicating kidney microvasculature damage and often appearing before estimated glomerular filtration rate (eGFR) declines.³

Traditionally, the relied upon marker for determining kidney health has been the estimated glomerular filtration rate using the serum creatinine level and urine dipstick for proteinuria.⁴ However, relying solely on an eGFR test can miss early-stage kidney disease because it primarily measures filtering capacity, which may remain normal even when structural damage is present.

While eGFR provides a measure of kidney dysfunction and defines the stage of CKD, the uACR indicates the presence of kidney damage. Combining eGFR and uACR is essential for a complete evaluation. Together, they help appropriately diagnose and stage CKD and assess the risk of progression. Additionally, uACR is useful to detect early-stage CKD, as a normal eGFR can still be accompanied by albuminuria.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) estimates that screening with eGFR alone would fail to identify ~60% of CKD patients with elevated albuminuria.⁵

Yet uACR screening is still vastly underutilized, even in high-risk adults.⁶

The 2024 update to Clinical Practice Guidelines confirms the value of uACR testing for CKD diagnosis and monitoring

For a more complete assessment of kidney function and damage, guidelines recommend both eGFR blood testing and urine albumin-to-creatinine ratio (uACR) testing.⁷ This combination enables early detection and more accurate staging, which is essential to managing the progression of CKD.

More effective, earlier diagnosis of CKD with guideline-based uACR testing

In March 2024, the NKF and the KDIGO initiative released new guidelines on the testing algorithm for CKD:³

• Test using combo of serum creatinine eGFR and urine albumin-creatinine ratio (uACR) annually for patients with diabetes, hypertension, known CKD, family history of CKD, or other risk factors
• Adding the combined eGFR using serum creatinine andcystatin C (eGFRcr-sys) for patients with CKD stage 3A or greater, an elevated uACR, on a high- or low-meat diet, or with extreme low/high body mass

The American Diabetes Association^® (ADA) recommends an annual screening with both urinary albumin-to-creatinine ratio (uACR) and estimated glomerular filtration rate in patients with type 1 diabetes with duration of ≥5 years and in all patients with type 2 diabetes regardless of treatment. For patients with diabetes and kidney disease—defined by a uACR ≥30 mg/g and/or an eGFR  of <60 mL/min/1.73 m2, monitoring twice annually is recommended to guide therapy.⁸

The American Heart Association (AHA) and the American College of Cardiology (ACC) recommend annual uACR and eGFR testing for individuals with diabetes, hypertension, or high cardiovascular-kidney-metabolic (CKM) risk to detect early kidney damage (albuminuria) and decreased function (eGFR <60), which are key markers for assessing cardiovascular disease and managing high-risk patients.⁹

Ordering recommendations: The Quest Kidney Profile, including eGFR and uACR tests, enables earlier detection with just 1 test code

The Kidney Profile includes both uACR and eGFR, enabling earlier detection with just 1 test code and providing guideline-based testing required to help diagnose CKD, manage disease progression, and establish follow-up testing.

Recommended tests: Kidney Profile

Kidney Profile including Creatinine, Serum and Albumin, Random Urine with Creatinine

• Test code: 39165
• CPT^® code(s): 82043, 82565, 82570

Components include Creatinine [375] and Albumin, Random Urine with Creatinine [6517].

Note: Each of the component tests may also be ordered individually.

Test pathways: Guideline-based CKD testing algorithm

Providers can reference the following pathway to follow current guidelines for CKD screening and monitoring:

1. Start with the Kidney Profile (test code 39165)
2. Add eGFR (creatinine-cystatin C) for some patients (test code 13581)
3. Interpret results using the updated KDIGO heat map

Who should be screened with the Kidney Profile?

The guideline-based Kidney Profile is suitable for individuals who are moderately obese or ≥65 years old, as well as adults age 18 and older who are at risk for or who have CKD, including individuals with

• Diabetes
• Cardiovascular disease
• Hypertension
• Previous kidney damage
• Systemic disease with potential kidney involvement (eg, systemic lupus erythematosus)
• Family history of CKD

Related tests

Estimated Glomerular Filtration Rate (eGFR) with Creatinine and Cystatin C

• Test code: 13581
• CPT code(s): 82565, 82610*

Laboratory Testing for Chronic Kidney Disease Diagnosis and Management (multiple tests)

Refer to this test guide for an overview of tests used to detect CKD in adults, as well as monitor progression, comorbidities, complications, and response to therapy.

Testing for Comorbidities and Complications of Chronic Kidney Disease (multiple tests)

Review this algorithm for a description of testing for comorbidities and complications of CKD.

* CPT code is subject to a Medicare Limited Coverage Policy and may require a signed ABN when ordering.

Note: The CPT codes provided are based on American Medical Association guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.

Note: Each of the component tests may also be ordered individually.

Interpreting test results with CKD heat map

The Quest Kidney Profile generates a comprehensive results report to map follow-up testing frequency according to National Kidney Foundation recommendations, and includes the following:

• A summary of results and next steps, including referral to nephrologist
• Medical guideline-recommended, follow-on testing
• Overlay of patient results on National Kidney Foundation Risk Map

CKD risk heat map

Supporting resources