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Type 2 diabetes with albuminuric CKD — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Type 2 diabetes with albuminuric CKDUSMLE Step 3

A 67-year-old with type 2 diabetes and albuminuric CKD takes metformin and empagliflozin. During stable outpatient follow-up, eGFR is confirmed at 28 mL/min/1.73 m², potassium is 4.4 mEq/L, and there is no acute illness. Which medication adjustment is appropriate?

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Correct answer: B — Discontinue metformin while continuing kidney-protective empagliflozin

The best answer is “Discontinue metformin while continuing kidney-protective empagliflozin”. Metformin is contraindicated once eGFR is below 30 mL/min/1.73 m² and should be stopped. In contrast, an SGLT2 inhibitor with kidney benefit is recommended in eligible diabetic CKD down to eGFR 20 and may be continued at still lower eGFR if tolerated until kidney-replacement therapy begins.

Reference: ADA Standards of Care in Diabetes—2026: Chronic Kidney Disease and Risk Management: https://doi.org/10.2337/dc26-S011