Hypertension with CKD — RACGP Fellowship MCQ

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HardChronic disease managementHypertension with CKDRACGP Fellowship

A 73-year-old woman has persistent systolic hypertension. Home BP average is 154/82 mmHg, eGFR is 38 mL/min/1.73 m², potassium is 4.4 mmol/L and urine ACR is 18 mg/mmol. She takes amlodipine 5 mg and has ankle oedema. What is the most appropriate management?

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Correct answer: E — Add or titrate an ACE inhibitor or ARB with renal function and potassium monitoring

The correct answer is E. This patient requires ACE-I or ARB monotherapy with close monitoring. Evidence supports RAAS inhibition as first-line therapy in hypertensive CKD with proteinuria because it reduces albuminuria and slows disease progression. Her normal potassium (4.4 mmol/L) and normal renal function decline risk support safe initiation of monotherapy; dual RAAS therapy carries unacceptable hyperkalemia risk (≈3-fold) and is not recommended as initial therapy (rules out B). Option B fails because CCBs lack renoprotection and increase oedema. Option A is factually wrong—hypertension at eGFR 38 requires active management to prevent further decline (not avoidance). Option D: diuretics are not renoprotective agents and do not slow CKD progression. Monitoring renal function and K+ at 1–2 weeks post-initiation is essential to detect acute eGFR dip or hyperkalaemia and adjust dosing accordingly.

Reference: RACGP: Chronic kidney disease in the elderly. https://www.racgp.org.au/getattachment/a7f4211b-749b-461c-97f3-83ffdfb71929/CKD-in-the-elderly.aspx; supported by Australian general practice study (NPS MedicineWise MedicineInsight, 2013–2017, PMC6405190) on RAAS inhibitor safety and efficacy in CKD.