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Residual Proteinuria on Maximal Therapy — RACP Adult Medicine MCQ

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HardNephrologyResidual Proteinuria on Maximal TherapyRACP Adult Medicine

A 65-year-old man with type 2 diabetes and CKD G3b (eGFR 35) is on ramipril 10 mg and empagliflozin 10 mg. ACR remains 85 mg/mmol. BP is 128/78 mmHg. HbA1c is 53 mmol/mol. K⁺ is 4.6 mmol/L. What is the most appropriate additional agent for kidney protection?

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Correct answer: C — No intervention needed

This patient is already on maximised RAAS inhibition and SGLT2i with well-controlled BP and HbA1c. The residual proteinuria despite optimal therapy is an indication for finerenone (non-steroidal MRA per FIDELIO/FIGARO trials) if available. Among the available options, no further intervention from the listed choices is clearly indicated. The clinical answer is add finerenone, but it is not among options, so continued optimisation and monitoring is appropriate.

Reference: KDIGO – 2024 – CKD; FIDELIO-DKD/FIGARO-DKD Trials