skip to main content

Type 2 diabetic kidney disease with persistent albuminuria — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModerateNephrologyType 2 diabetic kidney disease with persistent albuminuriaMSRA

A 64-year-old man with type 2 diabetes is reviewed in general practice. He has CKD G3b associated with diabetic kidney disease. His eGFR has been stable at 41–43 mL/min/1.73 m² for 8 months. Two early-morning urine ACR measurements, 3 months apart, are 58 mg/mmol and 62 mg/mmol. His BP is 126/74 mmHg. He takes ramipril 10 mg once daily and dapagliflozin 10 mg once daily, both at the highest tolerated licensed doses. His potassium is 4.9 mmol/L. He has no previous hyperkalaemia, no heart failure, and is not taking potassium supplements, trimethoprim, spironolactone or other mineralocorticoid receptor antagonists. Which is the most appropriate next change in renoprotective pharmacotherapy?

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

Reveal the answer and explanation

Correct answer: A — Start finerenone 10 mg once daily and arrange additional serum potassium and eGFR monitoring within 4 weeks

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

This man meets NICE criteria for finerenone: he has type 2 diabetes with stage 3 CKD, persistent albuminuria and eGFR above 25 mL/min/1.73 m² despite optimised ACE-inhibitor and SGLT2-inhibitor treatment. Finerenone is therefore an appropriate add-on treatment. His eGFR of 41 mL/min/1.73 m² requires a starting dose of 10 mg once daily, rather than 20 mg. A potassium of 4.9 mmol/L does not preclude initiation: the SmPC states that initiation may be considered when potassium is greater than 4.8 to 5.0 mmol/L, provided additional potassium monitoring is undertaken within the first 4 weeks. Potassium and eGFR should be rechecked 4 weeks after initiation. A is incorrect because 20 mg is not the recommended starting dose at this eGFR. B incorrectly stops ramipril; finerenone is an add-on to optimised ACE inhibitor or ARB therapy. D is plausible because spironolactone is also a mineralocorticoid receptor antagonist, but it is not the indicated renoprotective add-on here and would be more relevant for resistant hypertension or heart failure. E incorrectly treats 4.8 mmol/L as an absolute initiation threshold.

Reference: Finerenone for treating chronic kidney disease in type 2 diabetes (TA877): Recommendations (23 March 2023) — https://www.nice.org.uk/guidance/ta877/chapter/1-Recommendations Kerendia 10 mg film-coated tablets: Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/13437/smpc