skip to main content

Diabetic kidney disease with CKD G3a A3 — MSRA MCQ

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

HardNephrologyDiabetic kidney disease with CKD G3a A3MSRA

A 62-year-old man with type 2 diabetes, hypertension and diabetic kidney disease is reviewed in general practice. His eGFR values have been 55, 53 and 54 mL/min/1.73 m² over 10 months. Two early-morning urine ACR measurements, 3 months apart, are 78 mg/mmol and 84 mg/mmol. Urine dipstick is negative for blood and urine culture is negative. He takes ramipril 10 mg once daily and dapagliflozin 10 mg once daily. Both are tolerated. Potassium is 4.6 mmol/L. He is clinically euvolaemic and has no cardiovascular symptoms. Repeated clinic BP measurements are 138/84 mmHg. His laboratory-reported 5-year Kidney Failure Risk Equation risk is 3.4%. 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: C — Add amlodipine, continue ramipril and dapagliflozin, arrange at least 6-monthly renal monitoring, and do not routinely refer to nephrology

This man has CKD G3a A3 due to diabetes, with persistent severe albuminuria but stable kidney function, no haematuria and a 5-year kidney failure risk below 5%. NICE recommends nephrology referral for ACR of 70 mg/mmol or more unless it is known to be caused by diabetes and already appropriately treated. He is appropriately treated with a maximally tolerated ACE inhibitor and an SGLT2 inhibitor, so ACR alone does not require routine referral. However, an ACR of 70 mg/mmol or more changes the clinic BP target to below 130/80 mmHg. His repeated clinic BP of 138/84 mmHg is therefore above target. Adding amlodipine is appropriate while continuing ramipril and dapagliflozin. For G3a A3 CKD, NICE advises at least 2 eGFR checks annually, with ACR monitoring individualised. B incorrectly ignores the diabetes-and-appropriate-treatment exception to the ACR referral criterion. C uses the lower-risk BP target and insufficient monitoring frequency. D exceeds licensed ACE-inhibitor dosing and offers no additional benefit. E removes established albuminuria-lowering treatment without a contraindication.

Reference: NICE NG203: Chronic kidney disease: assessment and management — recommendations (2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — blood pressure control and pharmacotherapy (2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — frequency of monitoring (2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations