Optimizing urine albumin-to-creatinine ratio testing and referral pathways for chronic kidney disease: a nominal group technique consensus study among Italian experts

Abstract

Background: Chronic kidney disease (CKD) represents a major global health burden, often diagnosed at advanced stages when treatment is less effective. Albuminuria, assessed by the urine albumin-to-creatinine ratio (uACR), is a key biomarker for CKD detection and risk stratification. Despite guideline recommendations, adherence to uACR testing remains low, limiting early diagnosis and timely referral. The ALLIANCE project aimed to develop a multidisciplinary consensus on optimizing uACR testing and referral pathways for improved CKD management in at-risk populations. Methods: A modified nominal group technique was used to achieve expert consensus. Seven nephrologists and eight specialists in other disciplines (cardiologists, endocrinologists, diabetologists, and a clinical biochemist) participated in structured discussions and ranked statements across three domains: (1) at-risk population definition, (2) barriers to uACR testing, and (3) CKD management and referral. Relevance rankings were analyzed using hierarchical clustering. Results: Twenty-seven consensus statements were developed, eight of which were deemed highly relevant. Key recommendations included expanding CKD risk awareness to encompass obesity and family history, enhancing clinician education, and improving coordination between nephrologists and other specialists. Early nephrology referral was emphasized for patients with marked albuminuria, rapid renal decline, or specific risk factors. Integration of digital health tools, including shared electronic health records, was advised to support coordinated care. Conclusions: The ALLIANCE project identified critical gaps in CKD detection and management. Addressing these through clinician education, standardized uACR testing protocols, and multidisciplinary collaboration may improve outcomes and reduce cardiorenal risk. Implementation of these consensus recommendations could facilitate earlier diagnosis and better management of high-risk patients.