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CKD with severe albuminuria and ACE inhibitor-associated hyperkalaemia — MSRA MCQ

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HardNephrologyCKD with severe albuminuria and ACE inhibitor-associated hyperkalaemiaMSRA

A 67-year-old woman with hypertension and CKD G3a A3 is reviewed 10 days after ramipril 1.25 mg once daily was added. Her urine ACR is 96 mg/mmol and clinic BP before treatment was 148/84 mmHg. She takes amlodipine 10 mg once daily, indapamide 2.5 mg once daily and spironolactone 25 mg once daily, which was started previously for resistant hypertension. She has no heart failure. Before ramipril, creatinine was 92 micromol/L, eGFR 53 mL/min/1.73 m² and potassium 4.7 mmol/L. Today, creatinine is 118 micromol/L, eGFR 44 mL/min/1.73 m² and potassium 5.7 mmol/L. She feels well, is clinically euvolaemic, has had no vomiting or diarrhoea, and has not taken NSAIDs or potassium supplements. What is the most appropriate management today?

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

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Correct answer: B — Stop spironolactone, continue ramipril unchanged and repeat urea, electrolytes and creatinine within 1 week

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

Ramipril is indicated because she has CKD with hypertension and A3 albuminuria. Her creatinine increase is 28% from baseline and eGFR fall is below 25%; NICE advises not to modify a renin–angiotensin system antagonist solely for changes below these thresholds, but to repeat testing after initiation. The discriminating finding is potassium 5.7 mmol/L in the setting of concurrent spironolactone. For hypertension, potassium of 5.0–5.9 mmol/L should prompt assessment for reversible contributors and stopping or reducing potassium-sparing drugs where possible before reducing the ACE inhibitor. She is clinically stable, has no acute kidney injury trigger and potassium is below the NICE threshold of 6.0 mmol/L at which stopping the renin–angiotensin system antagonist is advised after other potassium-promoting drugs have been addressed. A and B withdraw or reduce the disease-modifying ACE inhibitor prematurely. C would be appropriate for more severe hyperkalaemia, clinically significant acute illness or ECG abnormalities, none of which are present. D overlooks a modifiable potassium-promoting medicine and risks further hyperkalaemia. Spironolactone should be stopped, ramipril maintained, and potassium and renal function rechecked promptly.

Reference: NICE NG203: Chronic kidney disease: assessment and management, recommendations 1.6.5 and 1.6.15–1.6.23 (2021; checked August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NHS Specialist Pharmacy Service: ACE inhibitors and angiotensin II receptor blockers monitoring (2021; checked August 2026) — https://sps.nhs.uk/monitorings/ace-inhibitors-and-angiotensin-ii-receptor-blockers-monitoring/