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Type 2 diabetic kidney disease with severe albuminuria — MSRA MCQ

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HardNephrologyType 2 diabetic kidney disease with severe albuminuriaMSRA

A 59-year-old man with type 2 diabetes is reviewed as part of annual CKD care. He has had eGFR values of 68, 66 and 64 mL/min/1.73 m² over 18 months. Early-morning urine ACR measurements were 82 and 88 mg/mmol, 4 months apart. Urine dipstick is negative for blood, and there are no symptoms of urinary obstruction. His blood pressure is 124/76 mmHg. He takes ramipril 10 mg once daily, the highest dose he tolerates, and dapagliflozin 10 mg once daily. He has no intercurrent illness, heart failure, hyperkalaemia or adverse effects from treatment. His laboratory-reported 4-variable Kidney Failure Risk Equation estimates a 5-year risk of kidney replacement therapy of 2.1%. What is the most appropriate management plan now?

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

Reveal the answer and explanation

Correct answer: B — Continue optimised kidney-protective treatment and planned CKD monitoring without routine nephrology referral at present

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

This man has diabetic CKD with persistent severe albuminuria (ACR category A3), but his kidney function is stable, blood pressure is already below the NICE target for ACR 70 mg/mmol or more, and he is receiving appropriately optimised renin-angiotensin system blockade and an SGLT2 inhibitor. His 5-year Kidney Failure Risk Equation result is also below the NICE referral threshold of greater than 5%. Although NICE generally recommends specialist assessment for ACR 70 mg/mmol or more, it makes an explicit exception when the albuminuria is known to be caused by diabetes and the person is already appropriately treated. Therefore, A is incorrect. B incorrectly equates severe albuminuria with accelerated progression: there is no sustained eGFR decline, haematuria or acute presentation. C is incorrect because ultrasound is indicated for CKD with accelerated progression, haematuria, obstructive symptoms, eGFR below 30 mL/min/1.73 m², relevant family history, or anticipated biopsy; none applies here. D is incorrect because an initial ACR of 70 mg/mmol or more does not require confirmation, and persistence has already been demonstrated. Continued primary-care monitoring is appropriate, with referral if progression, haematuria, elevated KFRE risk or another referral criterion develops.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations (25 August 2021; updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Recommendations (25 August 2021; updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Recommendations (25 August 2021; updated 24 November 2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations