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Diabetic Kidney Disease — ABIM Board MCQ

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HardNephrologyDiabetic Kidney DiseaseABIM Board

A 59-year-old man with a 12-year history of type 2 diabetes has an estimated GFR of 48 mL/min/1.73 m2 and a urine albumin-to-creatinine ratio of 450 mg/g on two measurements. His blood pressure is 126/74 mm Hg while taking the maximally tolerated dose of lisinopril, and his hemoglobin A1c is 6.8% while taking metformin. Serum potassium is 4.6 mEq/L. He has no history of ketoacidosis, recurrent genital infection, or symptomatic hypotension. Which of the following is the best next pharmacologic intervention to reduce the risk of chronic kidney disease progression and cardiorenal events, independent of the need for additional glycemic lowering?

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Correct answer: E — Add empagliflozin

The correct answer is E. An SGLT2 inhibitor should be added for albuminuric diabetic CKD despite adequate blood pressure and glycemic control. This patient closely matches the EMPA-KIDNEY population: eGFR 45–89 mL/min/1.73 m2 with UACR at least 200 mg/g while receiving appropriate renin-angiotensin system inhibition. Empagliflozin reduces kidney disease progression and cardiovascular death through benefits that are not dependent on additional A1c lowering. Semaglutide can provide cardiovascular, weight, and kidney benefits but is not a substitute for initiating foundational SGLT2 inhibition in an eligible patient. Pioglitazone and sitagliptin lower glucose without comparable CKD-progression benefits. Combining an ACE inhibitor with an ARB increases the risks of hyperkalemia and acute kidney injury without improving renal outcomes.

Reference: US Food and Drug Administration. JARDIANCE (empagliflozin) Prescribing Information, sections 1 and 14.5, 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/204629s063lbl.pdf