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Diabetic Nephropathy — UKMLA MCQ

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ModerateNephrologyDiabetic NephropathyUKMLAMRCGP AKTPARAMRCEM SBAMRCP Part 1PSA

A 60-year-old man with type 2 diabetes has persistent albuminuric chronic kidney disease. His repeat urine albumin-to-creatinine ratio is 120 mg/mmol, eGFR is stable at 55 ml/min/1.73 m², blood pressure is 152/88 mmHg and serum potassium is 4.5 mmol/L. He is not taking an ACE inhibitor or angiotensin receptor blocker. Which statement about kidney-protective drug treatment is correct?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — An ACE inhibitor or ARB should be started and titrated to the highest licensed dose tolerated

NICE recommends an ACE inhibitor or ARB for adults with diabetes and CKD when ACR is at least 3 mg/mmol, titrated to the highest licensed dose tolerated. This patient has persistent A3 albuminuria, hypertension, stable kidney function and no baseline hyperkalaemia, so option B is correct. An eGFR below 60 is not itself a contraindication; creatinine/eGFR and potassium should instead be monitored before treatment and 1–2 weeks after initiation and each dose increase. Dual ACE inhibitor–ARB treatment is not recommended in CKD. Treatment should not be delayed until an arbitrary ACR of 300 mg/mmol. Where indicated, an SGLT2 inhibitor provides additional cardiorenal protection alongside optimised standard care rather than replacing indicated ACE inhibitor or ARB therapy.

Reference: NICE. Chronic kidney disease: assessment and management (NG203), recommendations 1.6.6 and 1.6.13–1.6.15. 2021; reviewed 2025. https://www.nice.org.uk/guidance/ng203/chapter/Recommendations