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Diabetic CKD with albuminuria — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Diabetic CKD with albuminuriaUSMLE Step 3

A patient with type 2 diabetes, eGFR 38 mL/min/1.73 m2 and albumin-to-creatinine ratio 640 mg/g takes maximally tolerated lisinopril. Potassium is 4.7 mEq/L and there is no recurrent genital infection. Which therapy most reduces kidney and cardiovascular risk?

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Reveal the answer and explanation

Correct answer: C — Continue ACE inhibition and add an SGLT2 inhibitor for kidney protection

The best answer is “Continue ACE inhibition and add an SGLT2 inhibitor for kidney protection”. Diabetic CKD with marked albuminuria and eGFR 38 warrants an SGLT2 inhibitor in addition to maximally tolerated ACE inhibition to reduce kidney and cardiovascular risk. Hydrochlorothiazide, ibuprofen, or withdrawing ACE inhibition do not provide this benefit. A GLP-1 receptor agonist may help metabolic and cardiovascular risk but does not replace SGLT2 therapy here.

Reference: KDIGO, Diabetes Management in Chronic Kidney Disease: https://kdigo.org/guidelines/diabetes-ckd/