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Chronic kidney disease G3b without diabetes — MSRA MCQ

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HardNephrologyChronic kidney disease G3b without diabetesMSRA

A 64-year-old man with hypertensive chronic kidney disease is reviewed in general practice. He does not have diabetes, heart failure or cardiovascular disease. He takes candesartan 32 mg once daily, which is the highest tolerated licensed dose, and amlodipine 5 mg once daily. He is clinically euvolaemic, his BP is 128/74 mmHg, and potassium is 4.6 mmol/L. His eGFR values have been 43, 42 and 42 mL/min/1.73 m² over 10 months. Two early-morning urine ACR measurements, 3 months apart, are 9 mg/mmol and 11 mg/mmol. Urine dipstick is negative for blood and urine culture is negative. His laboratory-reported 5-year Kidney Failure Risk Equation risk is 2.8%. He has no history of recurrent genital infection or diabetic ketoacidosis. 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: D — Offer an SGLT2 inhibitor as add-on treatment while continuing candesartan

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

He has confirmed CKD G3b A2: eGFR has remained below 45 mL/min/1.73 m² for more than 3 months, with persistent moderately increased albuminuria. His ARB is already optimised and tolerated. NICE recommends dapagliflozin or empagliflozin as an add-on option for adults with CKD and eGFR 20 to less than 45 mL/min/1.73 m², irrespective of diabetes status or ACR, provided standard care including the highest tolerated ACE inhibitor or ARB is used unless contraindicated. Therefore, an SGLT2 inhibitor should now be offered; where both agents are suitable, the least expensive option should be used. A is not indicated: eGFR below 45 alone is not a NICE referral criterion. He has stable renal function, no haematuria, ACR below 70 mg/mmol and a KFRE risk below 5%. B is incorrect because finerenone is recommended for CKD associated with type 2 diabetes, which he does not have. D misapplies the ACR threshold: ACR of at least 22.6 mg/mmol is required only when eGFR is 45 to 90 mL/min/1.73 m² in people without diabetes. E is incorrect because SGLT2 inhibitors are add-on treatment and do not replace tolerated renin–angiotensin system blockade.

Reference: NICE TA1075: Dapagliflozin for treating chronic kidney disease — Recommendations (Published 2 July 2025) — https://www.nice.org.uk/guidance/TA1075/chapter/1-Recommendations NICE TA942: Empagliflozin for treating chronic kidney disease — Recommendations (Published 20 December 2023) — https://www.nice.org.uk/guidance/TA942/chapter/1-Recommendations NICE NG203: Chronic kidney disease: assessment and management — Referral criteria and pharmacotherapy for persistent proteinuria (Updated November 2023) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations