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Diabetic kidney disease with albuminuria — MSRA MCQ

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HardNephrologyDiabetic kidney disease with albuminuriaMSRA

A 67-year-old man with type 2 diabetes and diabetic kidney disease is reviewed 4 weeks after finerenone 10 mg once daily was added to ramipril 10 mg once daily and dapagliflozin 10 mg once daily. Both background treatments are at the highest tolerated licensed doses. He is clinically euvolaemic and has no weakness, palpitations, intercurrent illness or use of NSAIDs, potassium supplements or salt substitutes. Before finerenone, his eGFR was 42 mL/min/1.73 m², urine ACR was 96 mg/mmol and potassium was 4.6 mmol/L. Today, eGFR is 37 mL/min/1.73 m², potassium is 4.8 mmol/L and bicarbonate is 24 mmol/L. His BP is 128/74 mmHg. 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: B — Increase finerenone to 20 mg once daily and repeat potassium and eGFR in 4 weeks

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

Finerenone is appropriate here because he has type 2 diabetes, CKD G3b with persistent albuminuria, eGFR above 25 mL/min/1.73 m², and is already receiving optimised ACE-inhibitor and SGLT2-inhibitor treatment. The decisive issue is the scheduled 4-week dose review. For CKD associated with type 2 diabetes, after initiation at 10 mg daily, finerenone should be increased to 20 mg daily when potassium is 4.8 mmol/L or lower, provided renal function has not fallen substantially. His eGFR has fallen from 42 to 37 mL/min/1.73 m², a reduction of about 12%, not the greater-than-30% decline that would require maintaining the 10 mg dose. Potassium must be rechecked 4 weeks after dose adjustment. A is plausible because potassium is at the upper boundary, but it misses the specified up-titration threshold and monitoring interval. B is incorrect because potassium is not above 5.5 mmol/L and the eGFR fall is modest. C correctly up-titrates but delays mandatory post-adjustment monitoring. D applies an inappropriate withholding threshold; withholding is indicated when potassium exceeds 5.5 mmol/L, with restart when it is 5.0 mmol/L or lower.

Reference: Finerenone for treating chronic kidney disease in type 2 diabetes: Recommendations (Published 23 March 2023; updated September 2024) — https://www.nice.org.uk/guidance/ta877/chapter/1-recommendations Kerendia 10 mg film-coated tablets: Summary of Product Characteristics (Updated April 2026) — https://www.medicines.org.uk/emc/product/13437/smpc