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CKD G3b with resistant hypertension — MSRA MCQ

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HardNephrologyCKD G3b with resistant hypertensionMSRA

A 66-year-old man with CKD G3b due to hypertensive kidney disease attends for hypertension review. He has no diabetes, heart failure, oedema or symptoms of cardiovascular disease. He takes losartan 100 mg once daily, amlodipine 10 mg once daily and indapamide MR 1.5 mg once daily, all at tolerated doses. He avoids NSAIDs and potassium-containing salt substitutes. His adherence is confirmed from repeat prescription records and discussion. He has no postural symptoms; seated and standing blood pressures are 154/92 mmHg and 150/90 mmHg respectively. A 7-day home blood pressure average is 141/86 mmHg. His eGFR has been stable at 34–36 mL/min/1.73 m² for 8 months, potassium is 4.4 mmol/L, sodium is 139 mmol/L and bicarbonate is 24 mmol/L. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: E — Add low-dose spironolactone and check sodium, potassium and renal function within 1 month

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

This is confirmed resistant hypertension: blood pressure remains above target on tolerated doses of an ARB, calcium-channel blocker and thiazide-like diuretic, with adherence reviewed, postural hypotension excluded and persistent elevation confirmed by home monitoring. NICE recommends low-dose spironolactone as step 4 treatment when potassium is 4.5 mmol/L or less. His potassium is 4.4 mmol/L, so spironolactone is the preferred fourth agent. His CKD G3b does not itself preclude spironolactone, but it increases the risk of hyperkalaemia, particularly alongside losartan. This makes planned biochemical monitoring essential: sodium, potassium and renal function should be checked within 1 month of initiation and subsequently as clinically indicated. A and C are plausible alternatives because NICE suggests an alpha-blocker or beta-blocker when potassium exceeds 4.5 mmol/L; that threshold has not been met here. D may be appropriate where there is fluid overload or another indication for loop diuresis, but he is euvolaemic and indapamide remains part of the recommended three-drug baseline regimen. E is reasonable if treatment remains uncontrolled despite four optimised agents or if there are complicating factors, but it is not required before an indicated step-4 drug is started.

Reference: NICE NG136: Hypertension in adults: diagnosis and management — Step 4 treatment (2019; current NICE guidance checked 16 August 2026) — https://www.nice.org.uk/guidance/ng136/chapter/recommendations NICE NG136: Hypertension in adults: diagnosis and management — Resistant hypertension confirmation and monitoring (2019; current NICE guidance checked 16 August 2026) — https://www.nice.org.uk/guidance/ng136/chapter/recommendations Spironolactone 12.5 mg Film-coated Tablets — Summary of Product Characteristics (Updated 2025) — https://www.medicines.org.uk/emc/product/12015/smpc