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Accelerated chronic kidney disease progression — MSRA MCQ

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HardNephrologyAccelerated chronic kidney disease progressionMSRA

A 58-year-old man is reviewed following serial CKD monitoring. He has hypertension treated with ramipril 10 mg once daily and amlodipine 10 mg once daily. He does not have diabetes. His blood pressure is 128/74 mmHg. He is clinically euvolaemic and reports no intercurrent illness, urinary symptoms, NSAID use, recent contrast exposure or change in medication. His eGFR was 78 mL/min/1.73 m² 10 months ago, 67 mL/min/1.73 m² 5 months ago and 57 mL/min/1.73 m² today. Early-morning urine ACR values were 9 mg/mmol and 8 mg/mmol, 4 months apart. Urine dipstick is negative for blood. His laboratory-reported 4-variable Kidney Failure Risk Equation estimates a 5-year risk of kidney replacement therapy of 1.3%. 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: A — Arrange renal ultrasound and refer for nephrology specialist assessment

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

This patient has CKD because albuminuria has persisted for more than 3 months, despite previously preserved eGFR. He also meets NICE criteria for accelerated CKD progression: eGFR has fallen from 78 to 57 mL/min/1.73 m² (a sustained fall of more than 25%) with a change in GFR category from G2 to G3a within 12 months. NICE recommends both renal ultrasound for accelerated progression and specialist referral when this progression criterion is met. The low 5-year KFRE does not override other referral criteria; it is one route to referral, not an exclusion criterion. A is inappropriate because the demonstrated trajectory warrants investigation and specialist assessment rather than delayed surveillance. B is incomplete: ultrasound is indicated, but accelerated progression also warrants nephrology referral. C incorrectly treats KFRE as the sole determinant of referral. E is inappropriate because there is a progressive, serial decline over 10 months with no acute precipitant, clinical instability or abrupt creatinine rise to suggest AKI. Continue cardiovascular risk management and blood-pressure control while referral and imaging are arranged.

Reference: Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203) — Recommendations (2021) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations