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RASi Threshold uACR 3 T1DM Albuminuria — ESENeph MCQ

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ModerateDiabetic Kidney DiseaseRASi Threshold uACR 3 T1DM AlbuminuriaESENeph

A 25-year-old woman with type 1 diabetes and CKD G2 (eGFR 82 mL/min/1.73m2, uACR 5 mg/mmol) asks when she should start an ACE inhibitor for kidney protection. Her BP is 118/74 mmHg. What is the recommended threshold for starting RASi in type 1 diabetes?

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Correct answer: C — Only when uACR exceeds 3 mg/mmol (mildly increased)

In type 1 diabetes, KDIGO 2024 and NICE CKD guidelines recommend starting ACEi/ARB when uACR exceeds 3 mg/mmol (the threshold for mildly increased albuminuria, previously called microalbuminuria). This is a lower threshold than the general CKD population (where RASi is typically started at uACR >30 mg/mmol without diabetes). The rationale is that even mildly increased albuminuria in T1DM predicts progression to overt nephropathy, and early RASi intervention delays this progression. With uACR 5 mg/mmol, this patient meets criteria. Annual uACR screening should begin 5 years after T1DM diagnosis (or from diagnosis in T2DM).

Reference: KDIGO 2024 – CKD Guideline; NICE 2021 – NG203 CKD; ADA 2024 – Standards of Medical Care