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Chronic kidney disease — MCCQE Part 1 MCQ

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HardFatigueChronic kidney diseaseMCCQE Part 1

A 63-year-old with type 2 diabetes has an eGFR of 48 mL/min/1.73 m² and persistent urine ACR of 32 mg/mmol despite maximally tolerated ramipril and empagliflozin. Potassium is 4.5 mmol/L and blood pressure is controlled. Which additional therapy most directly reduces kidney and cardiovascular risk?

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Correct answer: A — Add finerenone with potassium and kidney-function monitoring

Persistent albuminuric CKD remains a high cardiorenal risk despite optimized ACE-inhibitor and SGLT2-inhibitor therapy. Diabetes Canada's 2025 update supports adding finerenone, a nonsteroidal mineralocorticoid receptor antagonist, when albuminuria persists and serum potassium is within the eligible range. Potassium and eGFR must be checked after initiation and during titration because hyperkalemia can occur. ACE inhibitor or ARB therapy and the SGLT2 inhibitor should usually continue if tolerated. Dual renin-angiotensin blockade with aliskiren increases adverse events without added benefit. A calcium-channel blocker or loop diuretic may have other indications but does not provide the same evidence-based residual kidney-risk reduction in this euvolemic patient.

Reference: Diabetes Canada, Chronic Kidney Disease in Diabetes: 2025 Update, https://guidelines.diabetes.ca/cpg/chapter-29-2025-update