Comparison of Associations of Urine Protein-Creatinine Ratio Versus Albumin-Creatinine Ratio With Complications of CKD: A Cross-sectional Analysis

Fisher, Herrick; Hsu, Chi-yuan; Vittinghoff, Eric; Lin, Feng; Bansal, Nisha

doi:10.1053/j.ajkd.2013.07.013

Cited by 50 publications

(47 citation statements)

References 33 publications

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“…Some other reports suggested that protein-to-creatinine ratio was comparable with ACR (17,25). Regarding proteinuria measurement, recommendations from different guidelines are also different.…”

Section: Discussionmentioning

confidence: 95%

Measures of Urinary Protein and Albumin in the Prediction of Progression of IgA Nephropathy

Zhao¹,

Zhu²,

Liu³

et al. 2016

CJASN

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Background and objectives Proteinuria is an independent predictor for IgA nephropathy (IgAN) progression. Urine albumin-to-creatinine ratio (ACR), protein-to-creatinine ratio, and 24-hour urine protein excretion (UPE) are widely used for proteinuria evaluation in clinical practice. Here, we evaluated the association of these measurements with clinical and histologic findings of IgAN and explored which was the best predictor of IgAN prognosis.Design, setting, participants, & measurements Patients with IgAN were followed up for $12 months, were diagnosed between 2003 and 2012, and had urine samples available (438 patients). Spot urine ACR, protein-tocreatinine ratio, and 24-hour UPE at the time of renal biopsy were measured on a Hitachi Automatic Biochemical Analyzer 7180 (Hitachi, Yokohama, Japan).Results In our patients, ACR, protein-to-creatinine ratio, and 24-hour UPE were highly correlated (correlation coefficients: 0.71-0.87). They showed good relationships with acknowledged markers reflecting IgAN severity, including eGFR, hypertension, and the biopsy parameter (Oxford severity of tubular atrophy/interstitial fibrosis parameter). However, only ACR presented with positive association with the Oxford segmental glomerulosclerosis/adhesion parameter and extracapillary proliferation lesions. The follow-up time was 37.0 (22.0-58.0) months, with the last follow-up on April 18, 2014. In total, 124 patients reached the composite end point (30% eGFR decline, ESRD, or death). In univariate survival analysis, ACR consistently had better performance than protein-to-creatinine ratio and 24-hour UPE as represented by higher area under the curve using time-dependent survival analysis. When adjusted for well known risk factors for IgAN progression, ACR was most significantly associated with the composite end point (hazard ratio, 1.56 per 1-SD change of standard normalized square root-transformed ACR; 95% confidence interval, 1.29 to 1.89; P,0.001). Compared with protein-to-creatinine ratio and 24-hour UPE, addition of ACR to traditional risk factors resulted in more improvement in the predictive ability of IgAN progression (c statistic: ACR=0.70; protein-tocreatinine ratio =0.68; 24-hour UPE =0.69; Akaike information criterion: ACR=1217.85; protein-to-creatinine ratio =1229.28; 24-hour UPE =1234.96; P,0.001).Conclusions In IgAN, ACR, protein-to-creatinine ratio, and 24-hour UPE had comparable association with severe clinical and histologic findings. Compared with protein-to-creatinine ratio and 24-hour UPE, ACR showed slightly better performance in predicting IgAN progression.

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Section: Discussionmentioning

confidence: 95%

Measures of Urinary Protein and Albumin in the Prediction of Progression of IgA Nephropathy

Zhao¹,

Zhu²,

Liu³

et al. 2016

CJASN

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“…study, medication and protein intake data were not available . Furthermore, neither considered the relationship between serum bicarbonate and albuminuria, which seems to be higher in those with low bicarbonate and could influence the associations described . While the study by Moranne et al .…”

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confidence: 97%

Prevalence of and risk factors for reduced serum bicarbonate in chronic kidney disease

et al. 2014

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Several factors not typically considered to associate with reduced serum bicarbonate in chronic kidney disease were identified including albuminuria ≥ 10 mg/g, anaemia, smoking, higher serum albumin, higher waist circumference, and use of angiotensin converting enzyme inhibitors or angiotensin receptor blockers. Future studies should explore the longitudinal effect of these factors on serum bicarbonate concentration.

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“…Our group previously reported that the PCR is highly correlated with the ACR and that an ACR of 30 mg/g creatinine is equivalent to a PCR of approximately 0.08-0.09 g/g creatinine, based on the analyzed datasets (Yamamoto et al 2011(Yamamoto et al , 2014. Fisher et al (2013) reported that the ACR and PCR are relatively similar and that an ACR of 30 mg/g creatinine is equivalent to a PCR of approximately 0.08-0.11 g/g creatinine based on regression and Lowess smooth analyses in a recent large CKD cohort study. These results imply that the PCR cut-off is not precisely equal to 0.15 g/g creatinine and that a lower PCR is more suitable than previously considered.…”

Section: Discussionmentioning

confidence: 99%

“…However, this assumption is based on incomplete evidence, and no validation studies are available. The latest studies of the relationship between ACR and PCR have indicated that an ACR of 30 mg/g creatinine is equal to a PCR of slightly lower than 0.15 g/g creatinine (Yamamoto et al 2011(Yamamoto et al , 2014Fisher et al 2013). These results challenge the validity of the PCR-based classification method recommended by the Japanese CKD guideline.…”

Section: Introductionmentioning

confidence: 99%

Modified Cut-Off Value of the Urine Protein-To-Creatinine Ratio Is Helpful for Identifying Patients at High Risk for Chronic Kidney Disease: Validation of the Revised Japanese Guideline

Yamamoto

Yoshida

et al. 2015

Tohoku J. Exp. Med.

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Chronic kidney disease (CKD) is a global public health issue, and strategies for its early detection and intervention are imperative. The latest Japanese CKD guideline recommends that patients without diabetes should be classified using the urine protein-to-creatinine ratio (PCR) instead of the urine albumin-tocreatinine ratio (ACR); however, no validation studies are available. This study aimed to validate the PCR-based CKD risk classification compared with the ACR-based classification and to explore more accurate classification methods. We analyzed two previously reported datasets that included diabetic and/ or cardiovascular patients who were classified into early CKD stages. In total, 860 patients (131 diabetic patients and 729 cardiovascular patients, including 193 diabetic patients) were enrolled. We assessed the CKD risk classification of each patient according to the estimated glomerular filtration rate and the ACR-based or PCR-based classification. The use of the cut-off value recommended in the current guideline (PCR 0.15 g/g creatinine) resulted in risk misclassification rates of 26.0% and 16.6% for the two datasets. The misclassification was primarily caused by underestimation. Moderate to substantial agreement between each classification was achieved: Cohen's kappa, 0.56 (95% confidence interval, 0.45-0.69) and 0.72 (0.67-0.76) in each dataset, respectively. To improve the accuracy, we tested various candidate PCR cut-off values, showing that a PCR cut-off value of 0.08-0.10 g/g creatinine resulted in improvement in the misclassification rates and kappa values. Modification of the PCR cut-off value would improve its efficacy to identify high-risk populations who will benefit from early intervention.

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Comparison of Associations of Urine Protein-Creatinine Ratio Versus Albumin-Creatinine Ratio With Complications of CKD: A Cross-sectional Analysis

Cited by 50 publications

References 33 publications

Measures of Urinary Protein and Albumin in the Prediction of Progression of IgA Nephropathy

Measures of Urinary Protein and Albumin in the Prediction of Progression of IgA Nephropathy

Prevalence of and risk factors for reduced serum bicarbonate in chronic kidney disease

Modified Cut-Off Value of the Urine Protein-To-Creatinine Ratio Is Helpful for Identifying Patients at High Risk for Chronic Kidney Disease: Validation of the Revised Japanese Guideline

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