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Non-diabetic chronic kidney disease — MSRA MCQ

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HardNephrologyNon-diabetic chronic kidney diseaseMSRA

A 61-year-old man with non-diabetic CKD is reviewed in general practice. His eGFR has been stable at 38 mL/min/1.73 m² on three measurements over 8 months. Early-morning urine ACR is 7 mg/mmol on two occasions. He has hypertension and takes ramipril 10 mg once daily, the highest dose he tolerates, and amlodipine 10 mg once daily. His clinic BP is 128/76 mmHg. He is clinically euvolaemic and has no acute illness, heart failure, recurrent genital infections or history of diabetic ketoacidosis. HbA1c is 39 mmol/mol. What is the most appropriate additional kidney-protective treatment now?

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

Reveal the answer and explanation

Correct answer: A — Start empagliflozin 10 mg once daily in addition to current treatment

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

Empagliflozin 10 mg once daily should be added. NICE recommends empagliflozin for adults with CKD as an add-on to optimised standard care, including the highest tolerated ACE inhibitor or ARB dose unless contraindicated. Eligibility includes an eGFR of 20 to below 45 mL/min/1.73 m² regardless of diabetes status or albuminuria. This patient has stable CKD G3b, is already receiving maximally tolerated ramipril, and has an eGFR of 38 mL/min/1.73 m²; his relatively low ACR does not exclude treatment. A confuses the separate criterion for people with eGFR 45–90 mL/min/1.73 m², in whom either type 2 diabetes or ACR at least 22.6 mg/mmol is required. C is inappropriate because finerenone is recommended for CKD associated with type 2 diabetes, not non-diabetic CKD. D is wrong because SGLT2 inhibition supplements rather than replaces renin–angiotensin system blockade when the latter is tolerated. E is unnecessary: stable G3b CKD with low-grade albuminuria does not itself meet NICE specialist-referral criteria, and referral is not a prerequisite to starting empagliflozin.

Reference: Empagliflozin for treating chronic kidney disease (TA942): Recommendations (20 December 2023) — https://www.nice.org.uk/guidance/ta942/chapter/1-Recommendations Chronic kidney disease: assessment and management (NG203): Referral criteria and pharmacotherapy (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203): Pharmacotherapy (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations