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Albuminuric diabetic kidney disease with hyperkalaemia — MSRA MCQ

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Hardall topics relevant for this examAlbuminuric diabetic kidney disease with hyperkalaemiaMSRA

A 68-year-old man with type 2 diabetes attends for chronic kidney disease review. His urine albumin:creatinine ratio is 47 mg/mmol, having been 42 mg/mmol 3 months ago. His eGFR is stable at 28 mL/min/1.73 m². Blood pressure is 128/74 mmHg and HbA1c is 52 mmol/mol. He takes ramipril 10 mg once daily, dapagliflozin 10 mg once daily, linagliptin and atorvastatin. He does not take NSAIDs, potassium supplements or potassium-containing salt substitutes. Two non-haemolysed samples taken one week apart show serum potassium concentrations of 5.2 mmol/L and 5.1 mmol/L. He is clinically euvolaemic. Which is the most appropriate next management step to reduce his renal risk?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Defer finerenone and address hyperkalaemia before reassessment

Explanation lettering: B = shown as A · E = shown as B · A = shown as E

He has stage 4 diabetic kidney disease with persistent albuminuria despite an optimised ACE inhibitor and an SGLT-2 inhibitor. His eGFR of 28 mL/min/1.73 m² and ACR above 3 mg/mmol would otherwise make finerenone an appropriate add-on under NICE guidance. However, the decisive prescribing constraint is his confirmed potassium above 5.0 mmol/L. The finerenone SmPC states that treatment should not be initiated at this level. Potential reversible causes should be reviewed and the potassium reassessed before finerenone is reconsidered. A is inappropriate because changing a tolerated, maximally dosed ACE inhibitor to an ARB does not provide additional antiproteinuric benefit; substitution is relevant when an ACE inhibitor is not tolerated. B is unsafe because spironolactone is another mineralocorticoid receptor antagonist and would increase hyperkalaemia risk; it may be appropriate for a separate indication such as resistant hypertension or HFrEF when renal function and potassium permit. C incorrectly treats finerenone as a replacement for dapagliflozin. NICE positions finerenone as an add-on to optimised standard care, normally including an SGLT-2 inhibitor unless unsuitable. D uses the correct renal starting dose and monitoring interval, but initiation remains inappropriate while potassium exceeds 5.0 mmol/L.

Reference: Finerenone for treating chronic kidney disease in type 2 diabetes — Recommendations (23 March 2023) — https://www.nice.org.uk/guidance/ta877/chapter/1-Recommendations Kerendia 20 mg film-coated tablets — Summary of Product Characteristics (Revised 10 April 2026) — https://www.medicines.org.uk/emc/product/13438/smpc