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Non-diabetic chronic kidney disease with severe albuminuria — MSRA MCQ

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ModerateNephrologyNon-diabetic chronic kidney disease with severe albuminuriaMSRA

A 52-year-old man with hypertension is reviewed in general practice. He does not have diabetes. He takes ramipril 10 mg once daily, which is the highest dose he tolerates. His clinic BP is 126/74 mmHg, potassium is 4.7 mmol/L, and he is clinically euvolaemic. His eGFR values have been 63, 61 and 60 mL/min/1.73 m² over 10 months. Two early-morning urine ACR measurements, taken 3 months apart, are 74 mg/mmol and 78 mg/mmol. Urine dipstick is negative for blood and urine culture is negative. He has no lower urinary tract symptoms, visible haematuria or systemic symptoms. His laboratory-reported 5-year Kidney Failure Risk Equation risk is 2.0%. 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: E — Refer for nephrology assessment and continue ramipril at the highest tolerated dose

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

This man has persistent A3 albuminuria: two early-morning ACR results are at least 70 mg/mmol. NICE recommends nephrology referral for adults without diabetes who have an ACR of 70 mg/mmol or more, alongside treatment with an ACE inhibitor or ARB titrated to the highest licensed tolerated dose. His low 5-year Kidney Failure Risk Equation result does not override this separate albuminuria-based referral criterion. Ramipril should therefore be continued. A is inappropriate because stable eGFR and controlled BP do not remove the indication for referral created by persistent ACR at least 70 mg/mmol in non-diabetic CKD. C is unnecessary: albuminuria has already been confirmed on two appropriately collected early-morning samples. D is not indicated because there is no persistent invisible haematuria or other feature suggesting a urological cause requiring urgent investigation. E is inappropriate because NICE finerenone guidance applies to selected adults with stage 3–4 CKD associated with type 2 diabetes; it does not replace nephrology referral in this non-diabetic patient.

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