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Type 2 diabetes-associated chronic kidney disease with albuminuria — MSRA MCQ

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HardNephrologyType 2 diabetes-associated chronic kidney disease with albuminuriaMSRA

A 63-year-old woman with type 2 diabetes has CKD G3a A3 (eGFR 58 mL/min/1.73 m²; urine ACR 46 mg/mmol). She takes maximally tolerated ramipril and dapagliflozin. Four weeks ago, finerenone 10 mg once daily was started for diabetic CKD with albuminuria. She feels well, has had no intercurrent illness, diarrhoea, vomiting, NSAID use or change in antihypertensive treatment. Her blood pressure is 124/70 mmHg. Repeat blood tests show potassium 4.7 mmol/L and eGFR 40 mL/min/1.73 m². What is the most appropriate action regarding finerenone today?

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

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Correct answer: E — Maintain finerenone 10 mg once daily and continue potassium and renal-function monitoring

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

Finerenone is licensed for CKD stage 3 or 4 with albuminuria associated with type 2 diabetes. In diabetic CKD, the starting dose is 10 mg once daily when eGFR is 25 to under 60 mL/min/1.73 m², with potassium and eGFR checked after 4 weeks. Although her potassium of 4.7 mmol/L would ordinarily permit up-titration to 20 mg, her eGFR has fallen from 58 to 40 mL/min/1.73 m², a reduction of more than 30%. The SmPC specifies that, in this situation, 10 mg should be maintained rather than increased. B is attractive because potassium is at or below 4.8 mmol/L, but ignores the renal-function exception to up-titration. C incorrectly applies an initiation threshold to a patient already receiving treatment; continuation is permitted at substantially lower eGFR values, subject to potassium-guided adjustment. D overstates the consequence of a greater than 30% eGFR fall: it prevents escalation but does not mandate permanent discontinuation in diabetic CKD. E is not a licensed dose-adjustment strategy. The unexpectedly large decline should also prompt clinical review for an alternative cause of renal deterioration, but it does not alter the specified finerenone dose decision.

Reference: Kerendia 20 mg film-coated tablets - Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/13438/smpc Kerendia 20 mg film-coated tablets - Summary of Product Characteristics, section 4.2 (2026) — https://www.medicines.org.uk/emc/product/13438/smpc Kerendia 20 mg film-coated tablets - Summary of Product Characteristics, section 4.2 (2026) — https://www.medicines.org.uk/emc/product/13438/smpc