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Chronic kidney disease with diabetic albuminuria following ACE inhibitor dose titration — MSRA MCQ

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ModerateNephrologyChronic kidney disease with diabetic albuminuria following ACE inhibitor dose titrationMSRA

A 63-year-old man with type 2 diabetes, hypertension and CKD G3a A3 has persistent albuminuria (urine ACR 46 mg/mmol). Ramipril has been increased from 5 mg to 10 mg once daily, which he tolerates clinically. Before the dose increase, creatinine was 118 micromol/L (eGFR 55 mL/min/1.73 m²) and potassium was 4.7 mmol/L. Twelve days later, creatinine is 151 micromol/L (eGFR 42 mL/min/1.73 m²) and potassium is 5.0 mmol/L. His BP is 132/76 mmHg. He is euvolaemic and has had no vomiting, diarrhoea, intercurrent illness, NSAID use, recent contrast exposure or new medicines. What is the most appropriate management now?

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

Reveal the answer and explanation

Correct answer: A — Continue ramipril 10 mg once daily and repeat creatinine, eGFR and potassium in 1 to 2 weeks

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

The creatinine rise is 28% from baseline (118 to 151 micromol/L), and the eGFR fall is approximately 24% (55 to 42 mL/min/1.73 m²). Both remain below NICE thresholds requiring dose reduction or discontinuation after initiation or up-titration of a renin–angiotensin system antagonist: a creatinine rise of 30% or more, or an eGFR fall of 25% or more. NICE advises repeating renal function and potassium after 1 to 2 weeks without modifying treatment when changes remain below these thresholds. B and C are attractive because the biochemical change is close to the action threshold, but are premature in this clinically well, euvolaemic patient with no reversible precipitant. Dose reduction or cessation would be appropriate if repeat results crossed the threshold, or if a reversible cause had been excluded after a larger deterioration. D is inappropriate because combined ACE inhibitor and ARB therapy should not be used in CKD. E misses the required early repeat testing after a recent dose increase; routine CKD surveillance is not sufficiently prompt.

Reference: Chronic kidney disease: assessment and management (NG203), Recommendations (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203), Recommendations (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations Chronic kidney disease: assessment and management (NG203), Recommendations (2021; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations