CLINICAL RESEARCH www.jasn.

org

Estimating Urine Albumin-to-Creatinine Ratio from

Protein-to-Creatinine Ratio: Development of Equations
using Same-Day Measurements
Robert G. Weaver,1 Matthew T. James,1,2 Pietro Ravani,1,2 Colin G.W. Weaver ,2
Edmund J. Lamb,3 Marcello Tonelli,1 Braden J. Manns,1,2 Robert R. Quinn,1 Min Jun,4 and
Brenda R. Hemmelgarn1,2
Departments of 1Medicine and 2Community Health Sciences, Cumming School of Medicine, University of Calgary,
Calgary, Alberta, Canada; 3Pathology Department, Clinical Biochemistry, East Kent Hospitals University National
Health Service Trust, Canterbury, Kent, United Kingdom; and 4The George Institute for Global Health, University of
New South Wales Sydney, Sydney, Australia

ABSTRACT
Background Urine albumin-to-creatinine ratio (ACR) and protein-to-creatinine ratio (PCR) are used to
measure urine protein. Recent guidelines endorse ACR use, and equations have been developed incor-
porating ACR to predict risk of kidney failure. For situations in which PCR only is available, having a method
to estimate ACR from PCR as accurately as possible would be useful.
Methods We used data from a population-based cohort of 47,714 adults in Alberta, Canada, who had
simultaneous assessments of urine ACR and PCR. After log-transforming ACR and PCR, we used cubic
splines and quantile regression to estimate the median ACR from a PCR, allowing for modification by
specified covariates. On the basis of the cubic splines, we created models using linear splines to develop
equations to estimate ACR from PCR. In a subcohort with eGFR,60 ml/min per 1.73 m2, we then used the
kidney failure risk equation to compare kidney failure risk using measured ACR as well as estimated ACR
that had been derived from PCR.
Results We found a nonlinear association between log(ACR) and log(PCR), with the implied albumin-to-
protein ratio increasing from ,30% in normal to mild proteinuria to about 70% in severe proteinuria, and
with wider prediction intervals at lower levels. Sex was the most important modifier of the relationship
between ACR and PCR, with men generally having a higher albumin-to-protein ratio. Estimates of kidney
failure risk were similar using measured ACR and ACR estimated from PCR.

CLINICAL RESEARCH
Conclusions We developed equations to estimate the median ACR from a PCR, optionally including spec-
ified covariates. These equations may prove useful in certain retrospective clinical or research applications
where only PCR is available.

JASN 31: 591–601, 2020. doi: https://doi.org/10.1681/ASN.2019060605

Over the past decade the prognostic significance of

albuminuria has been demonstrated in predicting
risk of CKD progression and other outcomes such
as cardiovascular events.1–3 Consequently, albumin-
uria has been incorporated into the CKD staging sys-
tem as well as risk scores to predict the development
of kidney failure.4,5 The albumin-to-creatinine ratio
(ACR) is recommended by guidelines6,7 as the pre-
ferred test for quantifying albuminuria/proteinuria
for several reasons. Assays for measurement of
Received June 18, 2019. Accepted November 22, 2019.
Published online ahead of print. Publication date available at
www.jasn.org.
Correspondence: Dr. Brenda Hemmelgarn, Department of
Community Health Sciences, Cumming School of Medicine,
University of Calgary, TRW Building, Room 3D10, 3280 Hospital
Drive NW, Calgary, AB T2N 4Z6, Canada. Email: brenda.
hemmelgarn@ahs.ca
Copyright © 2020 by the American Society of Nephrology

JASN 31: 591–601, 2020 ISSN : 1046-6673/3103-591 591

 CLINICAL RESEARCH www.jasn.org
albuminuria are typically susceptible to less analytical im-
precision than total protein, particularly at lower levels of
proteinuria. Further, albumin is the predominant urinary
protein in the majority of kidney diseases, and it is possible
to accurately measure urine albumin at levels in the physi-
ologic range.8 Finally, ACR is more sensitive than protein-
to-creatinine ratio (PCR) in detecting the onset of diabetic
nephropathy.6,7 Despite these benefits of ACR, in many in-
stances, particularly when using secondary data for re-
search, PCR but not ACR is available. To capitalize on the
prognostic power of albuminuria from existing data sets, it
would be useful to estimate ACR from PCR as accurately as
possible.
Prior studies have investigated the relationship between
ACR and PCR measurements and noted their nonlinear
association. 9– 12 Specifically, the ACR/PCR ratio varies
with the level of proteinuria, with the proportion of total
protein that is albumin varying from 20% to 30% at normal
levels of proteinuria and rising to approximately 70% at
higher levels.9,13 There is also weaker correlation between
ACR and PCR at lower proteinur ia levels than at
higher. 8,9,14 Patient characteristics such as age, sex, GFR,
diabetes, and race may also affect the relationship between
ACR and PCR, 9,10,12 whereas the laboratory methods used,
particularly for measuring urine protein, may also be im-
portant. 8,15 However, a method to estimate ACR from PCR
that addresses the nonlinearity or includes the effect of
covariates other than sex has not been developed, poten-
tially limiting current approaches for estimating the former
from the latter. In addition, findings regarding the effect of
sex on the relationship between ACR and PCR have been
contradictory. 10,16
We therefore sought to develop equations to estimate ACR
from PCR, taking into account potential modification by pa-
tient characteristics, using a population-based cohort with
pairs of ACR/PCR measurements conducted on the same
day in the same patient. We examined the influence of several
clinically relevant covariates, using a flexible approach to allow
for a nonlinear association.
METHODS
Data Sources, Study Population, and Covariates
We used population-level laboratory and administrative
data from Alberta, Canada.17 The study population included
all adults in Alberta (population of 4.3 million as of 2017)
aged $18 years who had outpatient urine ACR and PCR
measurements on the same day (presumably from the
same urine sample) between May 2002 and December
2016. As we were interested in potential modification by
eGFR category, we included only ACR/PCR pairs where
there was a serum creatinine measurement on the same
day. For patients who had multiple ACR/PCR pairs, we ran-
domly chose one. We established the commencement date of
592 JASN
Significance Statement
The urine albumin-to-creatinine ratio (ACR) is the preferred metric
for quantifying albuminuria, and it also has been incorporated into
equations to predict risk of kidney failure. However, often only the
protein-to-creatinine ratio (PCR) is available. Previous studies have
described the association between ACR and PCR, although none
have provided a method to estimate ACR from PCR that accounts
for the nonlinear association or the effect of covariates other than
sex. The authors used same-sample urine ACR/PCR measurement
pairs from a population-based cohort of 47,714 adults to derive
equations to estimate ACR from PCR, taking into account non-
linearity and modification by several clinical characteristics. These
equations may be useful in specific retrospective applications
where an estimate of ACR is desired but only PCR is available.
RRT by linking to our provincial renal program database,
and excluded patients with a prior kidney transplant or re-
ceiving maintenance dialysis. We linked to demographic
data to establish sex and age, and defined diabetes and hy-
pertension from hospitalization and physician claims data,
using validated algorithms.18,19 We calculated eGFR using
the CKD Epidemiology Collaboration equation.20 We also
identified the analyzers and methods used for measuring
ACR and PCR in the largest cities in Alberta (Calgary and
Edmonton) during most of the study timeframe, although
we were unable to obtain this information for laboratories in
other parts of the province.
Statistical Analyses
Model Development: Primary Approach
Because the distribution of ACR and PCR are known to be
highly skewed, we analyzed the relationship between lo-
g(ACR) and log(PCR). Anticipating residual skewness, we
conducted median rather than mean regression because it
does not assume conditional normality21 and provides an
estimate of a measure of central tendency that is more mean-
ingful in a skewed distribution. Median regression (a special
case of quantile regression) uses nonparametric methods to
fit models with coefficients that can be interpreted similarly
to those from least squares regression. An additional advan-
tage of median regression is that the median value is unaf-
fected by the log transformation, i.e., the log of the median is
the same as the median of the log, which is not true of the
mean. We addressed the nonlinearity of the relationship be-
tween log(ACR) and log(PCR) by transforming log(PCR)
with a restricted cubic spline, a recommended approach
for modeling a nonlinear association 22 using five knots
placed at standard locations. 23 We assessed for potential
modification by age, sex, hypertension, diabetes, eGFR cat-
egory, and laboratory location (a proxy for analyzer and
method used), adding each covariate to the model by includ-
ing the categorical variable and interaction terms between
the covariate and each of the four spline variables, to allow
for effects that varied with PCR. We estimated standard er-
rors using bootstrapping, recommended if the conditional
distribution of the dependent variable is heteroscedastic
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Table 1. Patient characteristics in the full cohort, the subcohort used for application of the KFRE, and the subcohort used for
the repeated measures analysis
% of Patientsa
Characteristic Full Cohort Subcohort for Application of the Subcohort for Repeated Measures Analysis
(N547,714) KFRE (n59998) (n517,259) (74,341 Pairs)b
Age in yr, median (IQR) 59.3 (47.2–70.4) 71.3 (61.9–79.1) 58.9 (49.0–70.1)
Age category, yr
18–49 29.8 8.3 26.9
50–69 44.5 37.6 47.9
$70 25.7 54.1 25.2
Women 46.6 46.4 43.9
KDIGO CKD PCR category, mg/gc
A1: ,150 (normal/mild) 65.8 45.3 59.4
A2: 150–500 (moderate) 19.0 25.4 20.9
A3: .500 (severe) 15.2 29.3 19.7
KDIGO CKD ACR category, mg/gc
A1: ,30 (normal/mild) 61.9 42.4 54.7
A2: 30–300 (moderate) 23.8 31.0 26.4
A3: .300 (severe) 14.3 26.6 18.9
KDIGO CKD eGFR category, ml/
min per 1.73 m2
G1: eGFR$90 35.0 — 32.1
G2: eGFR560–89 33.3 — 33.4
G3A: eGFR545–59 12.3 38.9 13.2
G3B: eGFR530–44 11.1 34.5 13.5
G4: eGFR515–29 7.1 22.9 7.1
G5: eGFR,15 1.1 3.7 0.7
Hypertension 62.4 87.7 66.8
Diabetes 47.1 56.7 54.9
Year of ACR/PCR test pair
2002–2006 11.9 16.0 16.2
2007–2011 29.3 40.4 39.8
2012–2016 58.8 43.6 44.0
Laboratory locationd
Edmonton 66.5 62.7 67.5
Calgary 17.8 24.9 16.4
Other 15.8 12.4 16.1
a
Unless otherwise indicated.
b
Percents in this column are calculated on the basis of the number of patients, using characteristics on the date of the earliest pair.
c
To convert ACR or PCR from milligrams per gram to milligrams per millimole, multiply by 0.113.
d
In Edmonton, most urine albumin measurements were made using a Siemens Advia 1800 analyzer, with an immunoturbidimetric method. Urine protein was
measured using a colorimetric method (pyrogallol red) on a Protein Pointe Scientific analyzer (from September 2013 to December 2016), a Wako analyzer (July 2011
to September 2013), and a Genzyme analyzer (before July 2011). In Calgary, most measurements were made with a Roche Integra analyzer, with albumin measured
with an immunoturbidimetric method and protein with a turbidimetric method (benzethonium chloride). Testing at other sites was done using various analyzers and
methods, which we were unable to determine in all cases.

[i.e., variation in log(ACR) changes with log(PCR)]. 24
Through this process we created models for median lo-
g(ACR) with no covariates, specified covariates, and all
covariates. In addition, to better describe the prediction in-
terval for estimated log(ACR), we fit quantile regression
models for the 25th and 75th percentiles. Because the coef-
ficients from models with cubic splines with interactions are
difficult to interpret, we assessed the effect of each covariate
graphically by plotting the predicted median ACR versus the
measured PCR, including 95% confidence intervals (95%
CIs), for each covariate value using models that contained
the spline, the covariate, and interactions. We also tested the
statistical significance of each covariate in a full model by
using a Wald test for the groups of variables that correspon-
ded to each covariate.
Alternative Approaches
Because models incorporating restricted cubic splines do not
easily allow the estimation of predicted values from the coef-
ficients alone, we created models with log(PCR) transformed
with a linear spline, with knots on the basis of inflections of the
cubic spline. We created four models: one with only the linear
spline of log(PCR); one with sex and linear spline interactions
added; one with age, sex, diabetes, hypertension, GFR cate-
gory, and linear spline interactions added; and one with all
covariates, including laboratory location.

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Assessment of Model Performance
To visually assess the overall performance of the full cubic
spline model for median ACR across a wide range of PCR
values, we created a scatterplot of measured ACR versus pre-
dicted ACR. We compared this with scatterplots applying
other equations13,16 that have been developed to estimate
ACR from PCR.
Comparison with Albuminuria and Proteinuria Category
Thresholds
We used cubic splines to estimate the median, 25th and 75th
percentiles of ACR at the Kidney Disease Improving Global
Outcomes (KDIGO) PCR category thresholds of 150 and
500 mg/g,6 first in an unadjusted model and then in models
containing one covariate. We also estimated the PCR value
that would be equivalent to a predicted ACR at the KDIGO
ACR category thresholds. We then compared the sensitivity,
specificity, positive predictive value (PPV), negative predictive
value (NPV), and overall correct classification for the mea-
sured ACR category versus measured PCR category, and for
the measured ACR category versus predicted ACR category,
with respect to KDIGO category thresholds, using measured
ACR category as the reference. We also calculated C-statistics
for the models, using these thresholds.
Predictive Performance using the Kidney Failure Risk Equation
We selected patients with eGFR,60 ml/min per 1.73 m2 and
at least 2 years of follow-up for commencement of RRT, and
compared observed cases of RRT within 2 years with the num-
ber expected from applying the four-variable kidney failure
risk equation (KFRE), which uses log(ACR), eGFR, age, and
sex.5,16 We performed this comparison using measured ACR,
then ACR estimated from PCR. We also calculated sensitivity,
specificity, PPV, NPV, and correct classification for observed
RRT versus .10% calculated risk.
Assessment of Within-Person Correlation of ACR/PCR Ratio
Finally, we investigated within-person correlation of the
ACR/PCR ratio in a data set comprising individuals with
more than one ACR/PCR pair by estimating the intraclass
correlation coefficient in a mixed linear regression model to
estimate mean log(ACR), using cubic spline terms of log(PCR),
covariates, and interactions as before, with between-person
variability modeled with a random intercept.
This study was approved by the University of Calgary’s
Conjoint Health Research Ethics Board. Analysis was conduc-
ted using Stata MP version 14.2.
RESULTS
We identified 120,564 pairs of outpatient same-day/same-per-
son ACR and PCR measurements; these represented 4.4% of
outpatient ACR measurements and 21.1% of outpatient PCR
measurements, proportions that were fairly consistent
594 JASN
10000
3000
Measured ACR (mg/g)
1000
300
100
30
10
3
15 50 150 500 1500 5000 15000
Measured PCR (mg/g)
Females Males
Figure 1. This scatterplot (on log/log scale) of measured ACR
versus measured PCR shows the non-linearity of the log(ACR)
versus log(PCR) relationship, and the weaker correlation between
ACR and PCR at lower proteinuria levels. Cohort size is 47,714
pairs; the graph includes a 20% random sample of 9466 pairs.
The green, red, and black lines show the thresholds for A1 versus
A2, A2 versus A3, and A3 versus nephrotic range, respectively.
The blue dots represent men and the red dots represent women.
The blue and red lines show the values predicted by one of the
linear spline models for median ACR (model L2), for men (blue)
and women (red). To convert ACR or PCR from milligrams per
gram to milligrams per millimole, multiply by 0.113.
throughout the study period. In 106,948 cases (88.7%) there
was also a serum creatinine measurement on the same day.
After excluding 1606 who had previously initiated RRT, there
were 105,342 eligible pairs of ACR and PCR measurements
from 47,714 individuals; the final cohort consisted of a ran-
dom pair chosen from each person. Measurements were well
distributed across albuminuria/proteinuria categories, from
patients with a wide range of demographic and clinical char-
acteristics (Table 1).
Figure 1 shows a scatterplot of ACR versus PCR on a log
scale for a 20% random sample (for clarity) of ACR/PCR
pairs. A curvilinear relationship at lower levels of ACR and
PCR shows the nonlinearity of the log(ACR) versus
log(PCR) relationship, whereas the greater dispersion dem-
onstrates the poorer correlation between ACR and PCR at
lower levels of proteinuria. Although the log transformation
reduced the skewness of the conditional distribution of lo-
g(ACR), we noted that some remained and varied according
to PCR (negatively skewed at higher ranges; near normal or
slightly positively skewed at lower ranges). Figure 2 shows a
scatterplot of the ACR/PCR ratio versus PCR for the same
random sample.
Regression Modeling
In quantile regression models of log(PCR) transformed with a
restricted cubic spline, we found that the implied median al-
bumin-to-protein percent rose from ,30% in A1 proteinuria
(ACR,30 mg/g) to .60% in A3 proteinuria (ACR.300 mg/g)
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lower range, and the implied median albumin-to-protein

100
percent versus PCR for the lower range. In addition, for
ACR/PCR (percent albumin)

80 the model with sex, Supplemental Figure 4 shows the pre-

60
40
20
0 in Supplemental Figure 22. Table 3 provides equations to es-
15 50 150 500 1500
Measured PCR (mg/g)
Females Males
Figure 2. This scatterplot of the ratio of measured ACR/mea-
sured PCR versus measured PCR for a 20% random sample of
ACR/PCR pairs shows the variation in the albumin-to-protein with
proteinuria level. Measured PCR is shown on a log scale, whereas
measured ACR/measured PCR is shown as a percent. The green,
red, and black vertical lines show the thresholds for A1 versus A2,
A2 versus A3, and A3 versus nephrotic range of PCR, re-
spectively. The blue dots represent men and the red dots rep-
resent women, whereas the curved blue and red lines show the
values predicted by one of the cubic spline models for median
ACR (model C2), for men (blue) and women (red).
(Supplemental Figure 1), and that the association between ACR
and PCR became more linear, with relatively less dispersion, in
A3 proteinuria (Supplemental Figure 2). We also found that
sex, hypertension, diabetes, age category, eGFR category, and
laboratory location all significantly modified the log(ACR) ver-
sus log(PCR) relationship (all P,0.001). Supplemental Figures
3–21 illustrate the effect of these covariates on the ACR-PCR
relationship. For each covariate we include three figures:
the predicted median ACR versus PCR for the entire range
(log scale), the predicted median ACR versus PCR for the
dicted median and 25th and 75th percentiles of ACR for men
and women separately.
Table 2 shows summary statistics for the cubic and linear
spline models with specified combinations of covariates. The
correlation coefficients show the close correspondence be-
tween the cubic and linear spline models, which is confirmed
5000 15000 timate the median ACR and the interquartile range (IQR)
from a PCR, on the basis of the linear spline model with no
covariates, whereas Supplemental Table 1 provides equations
on the basis of a model containing the linear spline and sex.
Regression coefficients for the four linear spline models in-
cluded in Table 2 are provided in Supplemental Table 2.
Overall Performance of the Models
Figure 3 shows a scatterplot of measured ACR versus predicted
median ACR from the full cubic spline model, whereas
Supplemental Figure 23 shows a similar plot using the linear
spline model with only sex. In both plots, the points are dis-
tributed fairly symmetrically about the line of identity
throughout the entire range, with greater scatter at lower
ACR values. Scatterplots on the basis of two equations devel-
oped by others to estimate PCR from ACR show less linearity
and symmetry with respect to the line of identity
(Supplemental Figures 24 and 25).
Estimates of ACR at KDIGO PCR Category Thresholds
Figure 4 shows the estimated median and 95% CIs of predicted
ACR at the KDIGO PCR category thresholds for the overall
cohort and for groups defined by specified covariates, on the
basis of cubic spline quantile regression models for the 50th
percentile. Supplemental Figure 26 shows the estimated me-
dian and IQR on the basis of models for the 25th, 50th,

Table 2. Summary statistics for selected median regression models on the basis of cubic and linear splines, and specified
covariates
Models with Log(PCR) Models with Log(PCR)
Transformed with a Five-Knot Transformed with a Four-Knot Correlation Coefficient
Variables included Restricted Cubic Spline Linear Spline between Estimates from
No. of Pseudo No. of Pseudo Model Pairs
Model Model
Coefficients R2 Coefficients R2
Spline of log(PCR) only C1 5 0.624 L1 6 0.623 .0.99
Spline of log(PCR), sex, and interactions C2 10 0.629 L2 12 0.628 .0.99
Spline of log(PCR), sex, age, diabetes, C3 40 0.637 L3 48 0.635 .0.99
hypertension and eGFR category, and
interactions
Spline of log(PCR) sex, age, diabetes, C4 50 0.642 L4 60 0.641 .0.99
hypertension, eGFR category,
laboratory location, and interactions
The knots for the restricted cubic spline were at percentiles 5, 27.5, 50, 72.5, and 95 of log(PCR) (3.4668, 4.0625, 4.5664, 5.3992, and 7.7333, corresponding to PCR
values of 32.0, 58.1, 96.2, 221, and 2283 mg/g). Knots for the linear spline were at values of log(PCR) of 3.689, 4.094, 5.521, and 6.908, corresponding to PCR values
of 40, 60, 250, and 1000 mg/g. The number of coefficients includes the constant. The interactions are between the covariate and the spline terms. Pseudo R2 is the
proportion of the sum of absolute deviations from the median that is explained by the model.

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Table 3. Equations to estimate median and 25th and 75th percentiles of ACR from a PCR measurement, on the basis of
quantile regression models for log(ACR) containing only the linear spline terms for log(PCR)
Range of PCR, Equation to Estimate Median Equation to Estimate 25th Percentile Equation to Estimate 75th Percentile
mg/g Log(ACR) Log(ACR) Log(ACR)
PCR,40 0.951810.12643log(PCR) 0.552810.12973log(PCR) 1.452010.10743log(PCR)
PCR 40 to ,60 21.256810.72513log(PCR) 20.141610.31793log(PCR) 23.719311.50923log(PCR)
PCR 60 to ,250 26.783712.07513log(PCR) 26.246711.80923log(PCR) 24.957111.81163log(PCR)
PCR 250 to 22.964911.38343log(PCR) 27.183311.97883log(PCR) 21.447711.17603log(PCR)
,1000
PCR$1000 20.023910.95773log(PCR) 20.086710.92643log(PCR) 20.190210.99393log(PCR)
Log refers to the natural logarithm, so ACR5exp[log(ACR)]52.71828log(ACR). Median predicted ACR5exp[median of predicted log(ACR)]. ACR and PCR are in
milligrams per gram.

and 75th percentiles, whereas the estimates themselves are
shown in Supplemental Table 3. Overall, the median ACR
corresponding to a PCR of 150 mg/g was 35.5 mg/g (95%
CI, 34.9 to 36.1), with an IQR of 16.0–65.8 mg/g, whereas the
median ACR corresponding to a PCR of 500 mg/g was 301 mg/g
(95% CI, 298 to 304), with an IQR of 213–357 mg/g. Being a
man, younger, and having higher eGFR were associated with a
higher median ACR for a PCR of 150 and 500 mg/g, whereas
diabetes and hypertension were associated with a higher me-
dian ACR only for a PCR of 150 mg/g. Laboratory testing in
Calgary was associated with a higher median ACR for a PCR of
500 mg/g, but with a lower median ACR for a PCR of 150 mg/g,
compared with laboratory testing in Edmonton. Supplemental
Table 3 also provides the estimated PCR corresponding to the
KDIGO ACR category thresholds of 30 and 300 mg/g. For exam-
ple, the PCR associated with a predicted median ACR of 30 mg/g
was 139 mg/g (123 mg/g for men and 155 mg/g for women).
ACR Classification Accuracy from PCR
The sensitivity, specificity, PPV, NPV, and overall agreement
for measured ACR category versus measured PCR category,
and measured ACR category versus ACR category estimated
spline model, and 705 patients (7.1%; 95% CI, 6.6 to 7.6) using
the model with the linear spline and sex (Table 5). For 10% 2-
year risk of RRT, sensitivity was slightly higher but specificity
slightly lower for predictions on the basis of PCR; the overall
correct classification was similar using measured ACR (87.7%;
95% CI, 87.0 to 88.3) versus ACR predicted from the full cubic
spline model (87.2%; 95% CI, 86.6 to 87.9) and ACR predicted
from the model with the linear spline and sex (87.0%; 95% CI,
86.3 to 87.7). C-statistics were almost identical.
Assessment of Within-Person Correlation of ACR/PCR
Ratio
Finally, in a cohort including 74,341 ACR/PCR pairs for
17,259 individuals, we fit a mixed linear regression model
for log(ACR) and found the intraclass correlation coefficient
to be 0.64, indicating that 64% of the variance that was not
10000
3000
1000
Measured ACR (mg/g)

from PCR using the full cubic spline model are provided in
Table 4 for the A1/A2 and A2/A3 thresholds. The sensitivity 300
for identifying A2 versus A1 albuminuria improved when us-
ing the ACR category imputed from the full model compared 100
with using the measured PCR category (from 79.1% to
30
83.2%), but at the loss of some specificity. The overall agree-
ment using the ACR category imputed from the model was 10
slightly higher than it was using the PCR category at the A1/A2
threshold (88.8% versus 87.9%) and marginally higher at the 3
A2/A3 threshold (97.8% versus 97.6%).

Application of the Kidney Failure Risk Equation
We identified 9998 patients with eGFR,60 ml/min per
1.73 m2 and 2 years of follow-up to estimate the risk of kidney
failure using the KFRE (for baseline characteristics see Ta-
ble 1). Among these, 484 (4.8%; 95% CI, 4.4 to 5.3) were
observed to commence RRT within 2 years; using predictions
on the basis of the KFRE, the corresponding estimates were
665 patients (6.7%; 95% CI, 6.2 to 7.2) using measured ACR,
694 patients (6.9%; 95% CI, 6.5 to 7.5) using the full cubic
3 10 30 100 300 1000 3000 10000
Predicted ACR (mg/g)
Figure 3. This scatterplot of measured ACR versus predicted
median ACR from the full cubic spline model (C4), for a 20%
random sample shows a relatively symmetrical distribution
around the line of identity (the diagonal line) indicating unbiased
prediction. The blue dots represent men and the red dots rep-
resent women. To convert ACR or PCR from milligrams per gram
to milligrams per millimole, multiply by 0.113.

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Median and 95% Cl for predicted ACR (mg/g)

400
300

200
150

100

60

40
30

20

10
Overall

Female
Male

18-49
50-69
70+

No diabetes
Diabetes

No hypertension
Hypertension

eGFR >=30
eGFR 15-29
eGFR <15

Edmonton
Calgary
Other
PCR = 150 mg/g PCR = 500 mg/g

Figure 4. The estimated median and 95% CIs of ACR at the KDIGO A1/A2 and A2/A3 PCR thresholds of 150 and 500 mg/g, vary by
covariate. To convert ACR or PCR from milligrams per gram to milligrams per millimole, multiply by 0.113. Age is in years and eGFR is
in ml/min per 1.73 m2, The estimates are on the basis of quantile regression models for the 50th percentile of log (ACR), with log(PCR)
transformed with a restricted cubic spline, and with each model containing only the specified covariate, the spline terms, and the
interactions between the specified covariate and the spline terms.

explained by the fixed effects was explained by between- PCR. Sex was the most important modifier of the relationship
person variability, and that there was moderately strong between ACR and PCR, with men generally having a higher
within-person correlation of the ACR/PCR ratio. albumin-to-protein ratio than women. The sex difference in
the median albumin-to-protein ratio varied substantially by
level of proteinuria, with the greatest difference occurring
DISCUSSION from 100 to 200 mg/g, where the median proportion for
women was 0.6 times that for men (e.g., for PCR of 150 mg/g,
We used a large, population-based cohort of same-day urine the median proportion was 30% for men and 18% for women;
ACR/PCR pairs to examine the relationship between the ACR median predicted ACR was 45 mg/g for men and 28 mg/g
and PCR for a wide range of proteinuria levels and clinically for women). At higher ranges, the difference was attenuated
relevant covariates. Consistent with prior research, we found (e.g., female/male ratio of 0.87 at PCR of 500 mg/g), and for
substantial variation in the median albumin-to-protein ratio PCR,45 mg/g the proportion was slightly higher for women
with the level of proteinuria, with the median ratio approaching than men. Our findings were generally consistent with
70% in severe (A3) proteinuria, but dropping to below 30% in those of Fisher et al.,10 who used urine samples from 3481
normal/mild (A1) proteinuria. Using splines to represent PCR patients and fit a multivariable regression equation for the
measurements, we developed equations to allow the estimation log(ACR)/log(PCR) ratio. They found a female/male ratio
of ACR from PCR, accounting for the nonlinear association be- of 0.75, with no allowance for variation with level of protein-
tween ACR and PCR measurements. These equations allow the uria, and excluding the highest 2.5% of ACR measurements.
accurate estimation of the median expected ACR from a PCR Our findings are also consistent with studies that found
measurement, for a wide range of PCR values. To describe the higher rates of albuminuria among men than women, but
range of probable ACR values corresponding to a PCR measure- higher rates of nonalbumin proteinuria among women than
ment, we also developed equations to estimate the 25th and 75th men.15,25,26 Our results contradict, however, the method used
percentiles of the expected ACR. Although we used advanced by Tangri et al.16 to convert PCR to ACR, which implies a
methods, the final equations are relatively simple to use. constant albumin/protein ratio of 38% for men and 57%
All covariates significantly modified the ACR–PCR associ- for women (i.e., female/male ratio of 1.5).
ation; however, the effect of these covariates on predicted me- Laboratory location was also an important modifier. In
dian PCR was small compared with the IQR for predicted Calgary and Edmonton, urine albumin was measured by an

JASN 31: 591–601, 2020 Equations to Estimate ACR from PCR 597
 CLINICAL RESEARCH www.jasn.org

immunoturbidimetric method. However, urine protein was

.0.99 (.0.99 to .0.99)

Table 4. Sensitivity, specificity, PPVs, NPVs, and overall agreement for measured PCR category, and ACR category imputed from PCR using model C4, at KDIGO measured by a turbidimetric method (benzethonium chlo-

Values except ROC statistic are reported in percent. A1/A2 threshold: ACR530 mg/g, PCR5150 mg/g. A2/A3 threshold: ACR5300 mg/g, PCR5500 mg/g. Positive cases are above the threshold. ROC, receiver
0.86 (0.86 to 0.87)
0.95 (0.95 to 0.96)

0.96 (0.96 to 0.97)

ROC C-Statistic
ride) in Calgary but by a colorimetric method (pyrogallol

(95% CI)
red) in Edmonton. Given that urine protein measurement is
known to vary by method, it is likely that the differences
between the sites were largely related to differences in protein
measurement. McTaggart et al.15 found that the pyrogallol red
method gave significantly lower protein measurements than
87.9 (87.6 to 88.2)
88.8 (88.5 to 89.1)

97.6 (97.4 to 97.7)

97.8 (97.6 to 97.9)
the benzethonium chloride method (i.e., higher apparent al-
Agreement
% Overall

bumin-to-protein ratios). We also noted a higher albumin-to-

(95% CI)

protein ratio for pyrogallol red, but only for PCR under ap-
proximately 300 mg/g; above this range, measurement with
pyrogallol red was associated with a lower albumin-to-
protein ratio.
79.1 (78.5 to 79.7) 93.3 (93.1 to 93.6) 88.0 (87.4 to 88.4) 87.9 (87.5 to 88.3)
83.2 (82.6 to 83.7) 92.3 (92.0 to 92.6) 86.9 (86.4 to 87.4) 89.9 (89.6 to 90.3)

94.7 (94.1 to 95.2) 98.0 (97.9 to 98.2) 89.0 (88.3 to 89.7) 99.1 (99.0 to 99.2)
95.4 (94.8 to 95.8) 98.2 (98.0 to 98.3) 89.7 (89.0 to 90.4) 99.2 (99.1 to 99.3)

Age, eGFR category, diabetes, and hypertension were also

important modifiers. Younger age and higher eGFR were as-
(95% CI)
NPV

sociated with a higher median albumin-to-protein ratio

across all proteinuria ranges. At PCR under approximately
400 mg/g, patients with diabetes and those with hypertension
had a higher median albumin-to-protein ratio than those
who did not (e.g., at PCR of 150 mg/g, 26% for diabetes
versus 20% for no diabetes, and 25% versus 21% for hyper-
(95% CI)
PPV

tension versus no hypertension), but at higher PCR levels

there was little difference. Others have noted the association
of younger age, 10,25 higher eGFR, 10 and diabetes 10 with
higher albumin-to-protein ratio. Estimates of the effect of
low eGFR were less accurate because of the smaller group
Specificity

sizes (particularly eGFR,15 ml/min per 1.73 m2), so they

(95% CI)

should be interpreted with caution.

category thresholds (reference standard: KDIGO category of measured ACR)

Our results are in general agreement with the equivalence

implied by the KDIGO ACR/PCR category thresholds of
30/150 and 300/500 mg/g. However, the modification of the
albumin-to-protein ratio by covariates suggests that the
Sensitivity
(95% CI)

thresholds could be refined by inclusion of covariates to opti-

mize classification (Figures 3 and 4, Supplemental Table 3).
For example, the PCR corresponding to a median ACR of
30 mg/g was 139 mg/g overall, but was 155 mg/g among
women and 123 mg/g among men. The full model resulted
ACR category imputed from model with
ACR category imputed from PCR using

in only slight improvement in classification into KDIGO cat-

cubic spline and all covariates (C4)
Comparison with Category of

KDIGO category of measured PCR

KDIGO category of measured PCR

egories (from 87.9% to 88.8% at the A1/A2 threshold; from

model with cubic spline and all

97.6% to 97.8% at the A2/A3 threshold). However, the de-

Measured ACR

nominator in these calculations was the entire cohort, which

understates the benefit of the model, as classification could
only be improved for cases near the thresholds; among these,
the improvement would have been larger. Any increases in
covariates (C4)

accuracy resulting from inclusion of covariates should be bal-

anced against the implementation challenges resulting from
increased complexity. In most cases, using either the model
with only the linear spline of PCR, or the linear spline and sex,
operator characteristic.

will provide an adequate estimate of ACR. For example, if

retrospective estimation of ACR or retrospective classification
Threshold
Category
KDIGO

into albuminuria categories is required for a large number of

patients with only PCR, then the effort in estimating median
A1/A2

A2/A3

ACR from PCR and covariates on the basis of additional co-

efficients in Supplemental Table 2 could be justified by

598 JASN JASN 31: 591–601, 2020

 www.jasn.org CLINICAL RESEARCH

Table 5. Comparisons of predicted versus observed cases of RRT commencement within 2 years among those with
eGFR,60 ml/min per 1.73 m2, on the basis of the KFRE, and estimates of classification accuracy at 10% risk, using measured
ACR versus ACR estimated from the PCR
Prediction using Prediction using Median ACR Prediction using Median ACR
Observed RRT within
RRT Cases Measured ACR Estimated from PCR with Estimated from PCR with
2 yr (95% CI)
(95% CI)a Model C4 (95% CI)a Model L2 (95% CI) a

Cohort for comparing

predicted vs. observed
cases requiring RRT
Overall cohort (n59998) 6.7 (6.2 to 7.2) 6.9 (6.5 to 7.5) 7.1 (6.6 to 7.6) 4.8 (4.4 to 5.3)
ACR ,30 mg/g (n54237) 0.7 (0.5 to 1.0) 0.9 (0.6 to 1.2) 0.9 (0.6 to 1.2) 0.3 (0.2 to 0.5)
ACR 30–300 mg/g (n53104) 3.8 (3.1 to 4.5) 4.2 (3.5 to 5.0) 4.4 (3.7 to 5.2) 2.1 (1.6 to 2.7)
ACR .300 mg/g (n52657) 19.5 (18.0 to 21.1) 19.8 (18.3 to 21.3) 20.0 (18.5 to 21.6) 15.3 (13.9 to 16.7)
Estimates of classification
accuracy for 10% 2 yr risk of
RRT versus observed RRT in
2 yr
Sensitivity 87.8 (84.6 to 90.4) 89.3 (86.2 to 91.7) 89.3 (86.2 to 91.7)
Specificity 87.7 (87.0 to 88.3) 87.1 (86.5 to 87.8) 86.9 (86.2 to 87.6)
PPV 26.6 (24.5 to 28.9) 26.1 (24.0 to 28.3) 25.7 (23.7 to 27.9)
NPV 99.3 (99.1 to 99.5) 99.4 (99.2 to 99.5) 99.4 (99.2 to 99.5)
Overall correct classification 87.7 (87.0 to 88.3) 87.2 (86.6 to 87.9) 87.0 (86.3 to 87.7)
ROC C-statistic 0.94 (0.94 to 9.96) 0.95 (0.94 to 0.96) 0.95 (0.94 to 0.96)
Data are shown as percent, unless otherwise indicated. Values reported in percent except for the ROC C-statistic. Model C4 is the full cubic spline median re-
gression model; L2 is the linear spline median regression model containing only the linear spline, sex, and interactions between the spline and sex. All classification
into ACR categories is on the basis of measured ACR. ROC, receiver operator characteristic.
a
Calculated using log(ACR), eGFR, age, and sex according to the equation given in Tangri et al.16

improved estimation; in other applications this may not be
the case.
Although the models provide precise estimates of the ex-
pected median ACR (narrow 95% CIs), there was substantial
unexplained variability in the ACR–PCR relationship, espe-
cially at lower levels of proteinuria, resulting in wide predic-
tion intervals (Supplemental Figure 2). The greater variability
at lower ranges of PCR was likely partly related to greater in-
dividual variability in disease states at lower ranges, as the
albumin-to-protein ratio is associated with the location of
kidney damage.6,27 This is supported by the moderately strong
within-person correlation of the ACR/PCR ratio, seen in the
mixed model. It was also likely related to greater variability in
the reactivity of different total protein assays at these levels.8
The use of the KFRE to compare 2-year expected and ob-
served RRT found little difference between using measured
ACR and ACR estimated from PCR. In our cohort, both mea-
sured ACR and ACR predicted from PCR overestimated the
risk of kidney failure by a small but similar amount. However,
most cases of RRT (both expected and observed) were in peo-
ple with A3 albuminuria, and the ACR-to-PCR conversion is
more accurate in this range; very few had A1 albuminuria,
where the conversion is less accurate. Its use with the KFRE
in people with A1 albuminuria has therefore not been ade-
quately tested.
Because of the wide prediction intervals for ACR, particu-
larly at lower levels, the equations should only be used in
specific situations. Table 6 summarizes potential clinical and

Table 6. Potential applications for PCR to ACR conversion equations, with recommendations and limitations
Potential Application Recommendation and Limitations
Clinical: Current use (e.g., is it acceptable to test with a PCR and use the Not recommended. ACR is the preferred test to assess albuminuria.6
equations to estimate ACR for CKD staging or kidney failure risk
prediction?)
Clinical: Retrospective/historical use (e.g., when there is a prior PCR Obtain an ACR when possible. If not feasible, one can use the equations to
result but no ACR is available) calculate the median, 25th and 75th percentiles of ACR, to estimate the
likely range. Estimation is more accurate in A3 proteinuria (.500 mg/g).
Research: Prospective use (e.g., collect data on PCR and convert to Not recommended. ACR is the preferred test to assess albuminuria.6
ACR)
Research: Retrospective use (e.g., to estimate ACR from historical PCR One can use the PCR and available covariates to estimate the median
data when no ACR available) expected ACR. One can also estimate the 25th and 75th percentiles of
ACR to estimate the likely range. Estimation is more accurate in A3
proteinuria (.500 mg/g).

JASN 31: 591–601, 2020 Equations to Estimate ACR from PCR 599
 CLINICAL RESEARCH www.jasn.org
research applications, whether they are recommended, and
associated limitations. We emphasize that the equations should
not be used in clinical care to justify measuring PCR rather than
ACR; ACR is the recommended test for albuminuria.6 The equa-
tions are most suited for retrospective applications (clinical or
research) where PCR results are available but not ACR. We rec-
ommend estimating 25th and 75th percentiles of ACR in addition
to the median, to estimate an approximate range of ACR.
Our study’s strengths include the large number of same-day
ACR/PCR pairs, and linkage with other sources of data to de-
fine relevant covariates. Importantly, our regression models
included methods that addressed the nonlinear relationship
between ACR and PCR, their skewed distributions, heterosce-
dasticity, and covariate effects that varied with PCR.
The study also had limitations. Our results may have been
influenced by the type of patients who were tested with both
ACR and PCR, although by adjusting for several patient char-
acteristics we believe we substantially addressed this. We were
not, however, able to account for the underlying cause of CKD
or race as potential modifiers. Additionally, we were unable to
identify the analyzers and methods used in approximately
20% of tests, and the overall results reflect the particular com-
bination of analyzers and methods in use in Alberta during the
study period. However, the results presented here are appro-
priate for the primary intended purpose of estimating ACR
from PCR in large samples where several analyzers/methods
may have been used. Finally, the equations presented here
should be validated in other cohorts.
Our findings provide an improved method to estimate ACR
from PCR, which can be used in specific retrospective clinical
or research applications, where ACR is unavailable.
ACKNOWLEDGMENTS
Mr. R. Weaver and Dr. Hemmelgarn conceived and designed the
study and drafted the manuscript. Mr. R. Weaver analyzed the data,
and Dr. James, Dr. Ravani, and Mr. C. Weaver provided additional
guidance for the analysis. All authors revised the manuscript critically
for important intellectual content and gave final approval of the
version to be published.
This study is based in part on data provided by Alberta Health and
Alberta Health Services. The interpretation and conclusions con-
tained herein are those of the researchers and do not represent the
views of the Government of Alberta or Alberta Health Services.
Neither the Government of Alberta, Alberta Health, nor Alberta
Health Services express any opinion in relation to this study.
DISCLOSURES
Dr. James and Dr. Hemmelgarn report grants from Amgen Canada, outside the
submitted work. Dr. Jun reports grants from VentureWise (a wholly owned com-
mercial subsidiary of NPS MedicineWise) to conduct a commissioned project
funded by AstraZeneca, outside the submitted work. Dr. Tonelli reports personal
600 JASN
fees from B. Braun and grants from Merck, outside the submitted work. All of the
remaining authors have nothing to disclose.
FUNDING
The study received funding from the Interdisciplinary Chronic Disease
Collaboration (ICDC); the ICDC is funded through an Alberta Innovates
Collaborative Research & Innovation Opportunity Team Grant. Dr. Hemmel-
garn, Dr. James, Dr. Manns, Dr. Quinn, Dr. Ravani, and Dr. Tonelli are sup-
ported by grants from the Canadian Institutes of Health Research. Dr. Tonelli
was supported by the David Freeze Chair in Health Services Research, Dr.
Manns was supported by the Svare Chair in Health Economics, and Dr. Hem-
melgarn was supported by the Roy and Vi Baay Chair in Kidney Disease, all at
the University of Calgary. The funding agencies had no role in the design and
conduct of the study; in the collection, analysis, and interpretation of the data;
or in the preparation, review, or approval of the manuscript.
SUPPLEMENTAL MATERIAL
This article contains the following supplemental material online at
http://jasn.asnjournals.org/lookup/suppl/doi:10.1681/ASN.2019060605/-/
DCSupplemental.
Supplemental Table 1. Equations to estimate the median and 25th
and 75th percentiles of ACR from a PCR measurement, by sex.
Supplemental Table 2. Regression coefficients for four models for me-
dian log (ACR), with log (PCR) represented by a four-knot linear spline.
Supplemental Table 3. Estimated median and IQR for ACR, at the
KDIGO PCR category thresholds of 150 and 500 mg/g, for the overall
cohort and for groups specified by covariates, and estimated PCR
giving predicted median ACR at KDIGO ACR category thresholds.
Supplemental Figure 1. Median and 25th and 75th percentiles of
predicted albumin-to-protein percent, by PCR value.
Supplemental Figure 2. Median and 25th and 75th percentiles of
predicted ACR by PCR value.
Supplemental Figure 3. Effect of sex on predicted median ACR,
log scale.
Supplemental Figure 4. Predicted median and 25th and 75th
percentiles of ACR for men and women, by PCR value.
Supplemental Figure 5. Effect of sex on predicted median ACR,
linear scale, PCR,600 mg/g.
Supplemental Figure 6. Effect of sex on predicted median albu-
min-to-protein percent.
Supplemental Figure 7. Effect of age on predicted median ACR,
log scale.
Supplemental Figure 8. Effect of age on predicted median ACR,
linear scale.
Supplemental Figure 9. Effect of age on predicted median albu-
min-to-protein percent.
Supplemental Figure 10. Effect of eGFR category on predicted
median ACR, log scale.
Supplemental Figure 11. Effect of eGFR category on predicted
median ACR, linear scale.
Supplemental Figure 12. Effect of eGFR category on predicted
median albumin-to-protein percent.
Supplemental Figure 13. Effect of diabetes on median ACR, log scale.
JASN 31: 591–601, 2020

Supplemental Figure 14. Effect of diabetes on median ACR,
linear scale.
Supplemental Figure 15. Effect of diabetes on albumin-to-protein
percent.
Supplemental Figure 16. Effect of hypertension on median ACR,
log scale.
Supplemental Figure 17. Effect of hypertension on median ACR,
linear scale.
Supplemental Figure 18. Effect of hypertension on albumin-to-
protein percent.
Supplemental Figure 19. Effect of laboratory location (proxy for
analyzer and method) on median ACR, log scale.
Supplemental Figure 20. Effect of laboratory location (proxy for
analyzer and method) on median ACR, linear scale.
Supplemental Figure 21. Effect of laboratory location (proxy for
analyzer and method) on albumin-to-protein percent.
Supplemental Figure 22. Comparison of predicted median ACR
on the basis of models with PCR transformed with a restricted cubic
spline (C1), and with PCR transformed with a linear spline (L1).
Supplemental Figure 23. Scatterplot of measured ACR and median
ACR predicted from the linear spline model (L2).
Supplemental Figure 24. Scatterplot of measured ACR versus ACR
estimated from PCR measurements using the equations of Tangri et al.16
Supplemental Figure 25. Scatterplot showing measured ACR versus ACR
estimated from PCR measurements using the equation of Collier et al.13
Supplemental Figure 26. Estimated median, 25th and 75th per-
centiles of ACR at the KDIGO A1/A2 and A2/A3 PCR thresholds of
150 and 500 mg/g, overall and by specified covariate.
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Equations to Estimate ACR from PCR 601
 Erratum

CORRECTION in Table 3, which provides the equations to estimate

Weaver RG, James MT, Ravani P, Weaver CG, Lamb EJ, Tonelli
M, Manns BJ, Quinn RR, Jun M, Hemmelgarn BR: Estimating
Urine Albumin-to-Creatinine Ratio from Protein-to-Creatinine
Ratio: Development of Equations using Same-Day Measurements.
J Am Soc Nephrol 31: 591–601, 2020.
After publication of the above-noted manuscript,
it came to our attention that there was a typographic error
the log of the albumin-creatinine ratio (log[ACR])
from the protein-creatinine ratio (PCR). In the equa-
tion for the 25th percentile of log(ACR) for a PCR
$1000 mg/g, the first coefficient should be 0.0867, rather
than – 0.0867. The correct version of Table 3 is shown
below.
The authors sincerely apologize for any inconvenience this
may have caused.

Table 3. Equations to estimate the median and 25th and 75th percentiles of ACR from a PCR measurement, based on quantile
regression models for log(ACR) containing only the linear spline terms for log(PCR)
Equation to Estimate Equation to Estimate Equation to Estimate
Range of PCR (mg/g)
Median log(ACR) 25th Percentile log(ACR) 75th Percentile log(ACR)
PCR ,40 0.951810.12643log(PCR) 0.552810.12973log(PCR) 1.452010.10743log(PCR)
PCR 40 to ,60 21.256810.72513log(PCR) 20.141610.31793log(PCR) 23.719311.50923log(PCR)
PCR 60 to ,250 26.783712.07513log(PCR) 26.246711.80923log(PCR) 24.957111.81163log(PCR)
PCR 250 to ,1000 22.964911.38343log(PCR) 27.183311.97883log(PCR) 21.447711.17603log(PCR)
PCR $1000 20.023910.95773log(PCR) 0.086710.92643log(PCR) 20.190210.99393log(PCR)
Log refers to the natural logarithm, so ACR5exp(log[ACR])52.71828log(ACR). Median-predicted ACR5exp(median of predicted log[ACR]). ACR and PCR are in
mg/g.

1140 ISSN : 1046-6673/3105-1140 JASN 31: 1140, 2020

 Estimating urine albumin-creatinine ratio from protein-creatinine ratio: development of
equations using same-day measurements

Supplementary material

Table of contents

Table S1. Equations to estimate the median, 25th and 75th percentiles of ACR from a PCR measurement,
by sex
Table S2. Regression coefficients for 4 models for median log(ACR), with log(PCR) represented by a 4-
knot linear spline
Table S3. Estimated median and interquartile range for ACR, at the KDIGO PCR category thresholds of
150 and 500 mg/g, for the overall cohort and for groups specified by covariates, and estimated PCR
giving predicted median ACR at KDIGO ACR category thresholds.
Figure S1. Median, 25th and 75th percentiles of predicted albumin:protein percent, by PCR value
Figure S2. Median, 25th and 75th percentiles of predicted ACR by PCR value
Figure S3. Effect of sex on predicted median ACR, log scale
Figure S4. Predicted median, 25th, and 75th percentiles of ACR for males and females, by PCR value
Figure S5. Effect of sex on predicted median ACR, linear scale, PCR < 600 mg/g
Figure S6. Effect of sex on predicted median albumin:protein percent
Figure S7. Effect of age on predicted median ACR, log scale
Figure S8. Effect of age on predicted median ACR, linear scale
Figure S9. Effect of age on predicted median albumin:protein percent
Figure S10. Effect of eGFR category on predicted median ACR, log scale
Figure S11. Effect of eGFR category on predicted median ACR, linear scale
Figure S12. Effect of eGFR category on predicted median albumin:protein percent
Figure S13. Effect of diabetes on median ACR, log scale
Figure S14. Effect of diabetes on median ACR, linear scale
Figure S15. Effect of diabetes on albumin:protein percent
Figure S16. Effect of hypertension on median ACR, log scale
Figure S17. Effect of hypertension on median ACR, linear scale
Figure S18. Effect of hypertension on albumin:protein percent
Figure S19. Effect of lab location (proxy for analyzer and method) on median ACR, log scale
Figure S20. Effect of lab location (proxy for analyzer and method) on median ACR, linear scale
Figure S21. Effect of lab location (proxy for analyzer and method) on albumin:protein percent
Figure S22. Comparison of predicted median ACR based on models with PCR transformed with a
restricted cubic spline (C1), and with PCR transformed with a linear spline (L1).
Figure S23. Scatterplot of measured ACR and median ACR predicted from the linear spline model (L2).
Figure S24: Scatterplot of measured ACR versus ACR estimated from PCR measurements using the
equations of Tangri et al. (2016).
Figure S25. Scatterplot showing measured ACR versus ACR estimated from PCR measurements using the
equation of Collier et al. (2009).
Figure S26. Estimated median, 25th and 75th percentiles of ACR at the KDIGO A1/A2 and A2/A3 PCR
thresholds of 150 and 500 mg/g, overall and by specified covariate.

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Table S1. Equations to estimate the median, 25th and 75th percentiles of ACR from a PCR measurement,
by sex, based on quantile regression models for log(ACR) containing the linear spline terms for log(PCR),
sex, and interactions between sex and the spline terms.
Range of PCR Equation to estimate Equation to estimate 25th Equation to estimate 75th
(mg/g) median of log(ACR) percentile of log(ACR) percentile of log(ACR)
Females:
<40 1.7060 – 0.0572*log(PCR) 1.2796 – 0.0386*log(PCR) 1.6731 + 0.0642*log(PCR)
40 to <60 0.2183 + 0.3460*log(PCR) 0.7094 + 0.1159*log(PCR) -1.4845 + 0.9202*log(PCR)
60 to <250 -6.2539 +1.9269*log(PCR) -5.0158 + 1.5144*log(PCR) -5.3268 + 1.8587*log(PCR)
250 to <1000 -4.4287 + 1.5963*log(PCR) -9.0693 + 2.2486*log(PCR) -1.9764 + 1.2519*log(PCR)
≥1000 0.0445 + 0.9488*log(PCR) -0.0479 + 0.9426*log(PCR) -0.1429 + 0.9864*log(PCR)
Males:
<40 0.7373 + 0.1697*log(PCR) 0.5589 + 0.1083*log(PCR) 1.2593 + 0.1460*log(PCR)
40 to <60 -2.7625 + 1.1184*log(PCR) -0.7944 + 0.4751*log(PCR) -5.9091 + 2.0891*log(PCR)
60 to <250 -6.9212 + 2.1342*log(PCR) -7.6388 + 2.1469*log(PCR) -4.4236 + 1.7263*log(PCR)
250 to <1000 -1.9690 + 1.2372*log(PCR) -4.8345 + 1.6390*log(PCR) -1.1395 + 1.1315*log(PCR)
≥1000 -0.1522 + 0.9742*log(PCR) 0.0862 + 0.9267*log(PCR) -0.2425 + 1.0016*log(PCR)
Log refers to the natural logarithm, so ACR = exp(log(ACR)) = 2.71828log(ACR). Median predicted ACR =
exp(median of predicted log(ACR)). ACR and PCR are in mg/g.

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Table S2. Regression coefficients for 4 models for median log(ACR), with log(PCR) represented by a 4-
knot linear splinea
Model L3: spline of Model L4: Spline of
Model L2:
log(PCR), sex, age, log(PCR), sex, age,
Model L1: spline of
diabetes, diabetes,
Coefficient spline of log(PCR), sex,
hypertension, eGFR hypertension, eGFR
log(PCR) only and spline
category and spline category, lab location
interactions
interactions and spline interactions
Constant 0.9518 1.7060 1.3364 1.3150
S1 0.1264 -0.0572 0.0000 0.0065
S2 0.7251 0.3460 0.4057 0.6304
S3 2.0751 1.9269 2.0689 2.0960
S4 1.3834 1.5963 1.6078 1.4437
S5 0.9577 0.9488 0.8924 0.9078
Male -0.9687 -0.4602 -0.3977
S1*male 0.2269 0.0769 0.0592
S2*male 0.7724 0.8306 0.8919
S3*male 0.2073 0.2046 0.1567
S4*male -0.3591 -0.3364 -0.2948
S5*male 0.0255 0.0253 0.0188
Age2 (50-69)‡ -0.3893 -0.2468
Age3 (70+) -0.8035 -0.8066
S1*age2 0.1315 0.0890
S2*age2 -0.5499 -0.5153
S3*age2 -0.0916 -0.0812
S4*age2 0.1495 0.1504
S5*age2 0.0443 0.0308
S1*age3 0.2864 0.2902
S2*age3 -0.7594 -0.8201
S3*age3 -0.2584 -0.2447
S4*age3 0.2392 0.2450
S5*age3 0.0734 0.0600
Diabetes 0.7794 0.7336
S1*Diabetes -0.1576 -0.1446
S2*Diabetes 0.0269 -0.0305
S3*Diabetes -0.0954 -0.0806
S4*Diabetes -0.0842 -0.0614
S5*Diabetes 0.0318 0.0104
Hypertension 0.4015 0.4172
S1*Hypertension -0.0750 -0.0806
S2*Hypertension 0.2104 0.2475
S3*Hypertension 0.0059 -0.0040
S4*Hypertension -0.1450 -0.1496
S5*Hypertension -0.0069 0.0110
eGFR2 (G4) b
0.9382 2.4382

3
 Model L3: spline of Model L4: Spline of
Model L2:
log(PCR), sex, age, log(PCR), sex, age,
Model L1: spline of
diabetes, diabetes,
Coefficient spline of log(PCR), sex,
hypertension, eGFR hypertension, eGFR
log(PCR) only and spline
category and spline category, lab location
interactions
interactions and spline interactions
eGFR3 (G5) 0.0246 0.1705
S1*eGFR2 -0.2607 -0.6650
S2*eGFR2 0.5950 0.5470
S3*eGFR2 -0.2955 -0.2693
S4*eGFR2 0.0847 0.0718
S5*eGFR2 0.0343 0.0209
S1*eGFR3 0.0000 0.0000
S2*eGFR3 1.2408 1.1727
S3*eGFR3 -0.8760 -0.9144
S4*eGFR3 0.3702 0.3366
S5*eGFR3 0.0549 0.0600
Calgary labb
-0.1802
Other lab -0.0483
S1*Calgary lab 0.0073
S2*Calgary lab -0.1450
S3*Calgary lab 0.1180
S4*Calgary lab 0.1904
S5*Calgary lab -0.0079
S1*Other lab 0.0330
S2*Other lab -0.8841
S3*Other lab -0.1720
S4*Other lab 0.4166
S5*Other lab 0.0318
a
The knots for the linear spline were at log(PCR) = 3.689, 4.094, 5.521 and 6.908, corresponding to PCR
values of 40, 60, 250, 1000 mg/g. S1 to S5 represent the variables for the 5 linear spline segments.
b
The reference age category was 18 to 59, the reference eGFR category was G1 to G3, and the reference
lab location was Edmonton.

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 Table S3. Estimated median and interquartile range for ACR, at the KDIGO PCR category thresholds of
150 and 500 mg/g, for the overall cohort and for groups specified by covariates, and estimated PCR
giving predicted median ACR at KDIGO ACR category thresholds.
PCR = 150 mg/g PCR = 500 mg/g PCR (mg/g) PCR (mg/g)
Estimated Estimated Estimated Estimated giving predicted giving predicted
Covariate median IQR for median IQR for median ACR of median ACR of
ACR ACR ACR ACR 30 mg/g 300 mg/g
None (Overall estimates) 35.5 16.0, 65.8 301 213, 357 139 498
Sex
Female 28.0 13.1, 54.5 277 176, 346 155 528
Male 45.5 21.2, 75.9 315 243, 362 123 481
Age, years
18-49 41.0 15.9, 76.6 336 248, 381 130 460
50-69 35.6 15.7, 66.4 308 220, 359 139 491
≥70 32.2 16.5, 56.4 271 182, 331 145 538
No diabetes 31.4 13.8, 63.4 307 195, 368 147 492
Diabetes 39.2 18.4, 66.6 300 222, 348 132 500
No hypertension 31.0 12.6, 64.5 306 171, 366 148 493
Hypertension 36.9 17.8, 66.0 301 221, 354 136 499
eGFR category
≥30 ml/min/1.73m2 35.9 16.2, 66.6 310 227, 361 138 488
15-29 ml/min/1.73m2 31.6 15.1, 53.7 257 175, 321 146 559
<15 ml/min/1.73m2 19.3 7.9, 41.6 205 121, 282 184 647
Laboratory location
Edmonton 42.3 17.3, 75.2 302 221, 348 127 497
Calgary 34.5 18.0, 58.7 341 258, 390 142 460
Other 22.8 11.9, 45.9 251 153, 316 169 564
The overall estimates are from quantile regression models containing only the cubic spline terms, while
estimates for the effect of each covariate are from quantile regression models containing the cubic
spline terms, the covariate(s), and interactions between the covariate(s) and the spline terms. Estimates
of the median ACR are transformed from quantile regression models for the 50th percentile of log(ACR);
estimates of the IQR of ACR are transformed from quantile regression models for the 25th and 75th
percentiles of log(ACR). Estimates of PCR that give predicted median ACR at the KDIGO ACR category
thresholds are from the 50th percentile models. IQR = interquartile range.

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Figure S1. Median, 25th and 75th percentiles of predicted albumin:protein percent, by value of PCR, from
quantile regression cubic spline models for log(ACR) including only the spline terms for log(PCR)

Figure S2. Median, 25th and 75th percentiles of predicted ACR by PCR value, log scale, from quantile
regression cubic spline models of log(ACR) containing only the spline terms of log(PCR)

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Figure S3. Effect of sex on predicted median ACR, log scale (from a model containing the cubic spline,
sex, and spline interactions).

Figure S4. Predicted median, 25th and 75th percentiles of ACR for males and females, log scale (from
quantile regression models containing the cubic spline, sex and spline interactions).

7
Figure S5. Effect of sex on predicted median ACR, linear scale, PCR < 600 mg/g (from a model containing
the cubic spline, sex, and spline interactions).

Figure S6. Effect of sex on predicted median albumin:protein percent (from a model containing the
cubic spline, sex, and spline interactions).

8
Figure S7. Effect of age on predicted median ACR, log scale (from a model containing the cubic spline,
age, and spline interactions).

Figure S8. Effect of age on predicted median ACR, linear scale (from a model containing the cubic spline,
age, and spline interactions).

9
Figure S9. Effect of age on predicted median albumin:protein percent (from a model containing the
cubic spline, age, and spline interactions).

Figure S10. Effect of eGFR category on predicted median ACR, log scale (from a model containing the
cubic spline, eGFR category, and spline interactions).

10
Figure S11. Effect of eGFR category on predicted median ACR, linear scale (from a model containing the
cubic spline, eGFR category, and spline interactions).

Figure S12. Effect of eGFR category on predicted median albumin to protein percent (from a model
containing the cubic spline, eGFR category, and spline interactions).

11
Figure S13. Effect of diabetes on median ACR, log scale (from a model containing the cubic spline,
diabetes, and spline interactions).

Figure S14. Effect of diabetes on median ACR, linear scale (from a model containing the cubic spline,
diabetes, and spline interactions).

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Figure S15. Effect of diabetes on percent albumin (from a model containing the cubic spline, diabetes,
and spline interactions).

Figure S15. Effect of hypertension on median ACR, log scale (from a model containing the cubic spline,
hypertension, and spline interactions).

13
Figure S17. Effect of hypertension on median ACR, linear scale (from a model containing the cubic
spline, hypertension, and spline interactions).

Figure S18. Effect of hypertension on percent albumin (from a model containing the cubic spline,
hypertension, and spline interactions).

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Figure S19. Effect of lab location (proxy for analyzer and method) on median ACR, log scale (from a
model containing the cubic spline, lab location, and spline interactions).

Figure S20. Effect of lab location (proxy for analyzer & method) on median ACR, linear scale (from a
model containing the cubic spline, lab location, and spline interactions).

15
Figure S21. Effect of lab location (proxy for analyzer and method) on percent albumin (from a model
containing the cubic spline, lab location, and spline interactions).

16
Figure S22. Comparison of predicted median ACR based on models with PCR transformed with a
restricted cubic spline (C1), and with PCR transformed with a linear spline (L1). The knots for the
restricted cubic spline were at percentiles 5, 27.5, 50, 72.5 and 95 of log(PCR) (3.4668, 4.0625, 4.5664,
5.3992 and 7.7333, corresponding to PCR values of 32.0, 58.1, 96.2, 221 and 2283 mg/g). Knots for the
linear spline were at values of log(PCR) of 3.689, 4.094, 5.521 and 6.908, corresponding to PCR values of
40, 60, 250 and 1000 mg/g.

17
Figure S23. Scatterplot of measured ACR and median ACR predicted from the linear spline model (L2) for
a 20% random sample. The blue dots represent males and the red dots females. To convert ACR or PCR
from mg/g to mg/mmol, multiply by 0.113.

18
Figure S24. Scatterplot of measured ACR versus ACR estimated from PCR measurements for a 20%
random sample, using the equations of Tangri et al.1 The equations are: ACR = PCR/1.7566 if female;
ACR = PCR/2.655 if male. Blue dots represent males, red dots females.

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Figure S25. Scatterplot showing measured ACR versus ACR estimated from PCR measurements for a
20% random sample, using the equation of Collier et al.2 Note that the lowest 22% of PCR values could
not be shown as the predicted ACR was negative if the PCR was <52 mg/g. The equation is: ACR = (-4 +
0.68*PCR)/0.113. Blue dots represent males, red dots females.

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Figure S26. Estimated median, 25th and 75th percentiles of ACR at the KDIGO A1/A2 and A2/A3 PCR
thresholds of 150 and 500 mg/g, overall and by specified covariate. To convert ACR or PCR from mg/g to
mg/mmol, multiply by 0.113. The estimates are based on quantile regression models for the 25th, 50th
and 75th percentiles of log(ACR), with log(PCR) transformed with a restricted cubic spline, and with each
model containing only the specified covariate, the spline terms, and the interactions between the
specified covariate and the spline terms.

References:

1. Tangri, N, Grams, ME, Levey, AS, Coresh, J, Appel, LJ, Astor, BC, et al., C. K. D. Prognosis Consortium:
Multinational Assessment of Accuracy of Equations for Predicting Risk of Kidney Failure: A Meta-
analysis. JAMA, 315: 164-174, 2016.
2. Collier, G, Greenan, MC, Brady, JJ, Murray, B, Cunningham, SK: A study of the relationship between
albuminuria, proteinuria and urinary reagent strips. Ann Clin Biochem, 46: 247-249, 2009.

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