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Chronic kidney disease with persistent severe albuminuria — MSRA MCQ

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HardNephrologyChronic kidney disease with persistent severe albuminuriaMSRA

A 49-year-old woman is reviewed in general practice following CKD surveillance. She has hypertension but no diabetes, cardiovascular disease, systemic inflammatory symptoms or family history of kidney disease. She takes ramipril 10 mg once daily, the highest tolerated licensed dose. She avoids NSAIDs and potassium-containing salt substitutes. Her eGFR values have been 72, 70 and 71 mL/min/1.73 m² over 10 months. Two early-morning urine ACR measurements, taken 3 months apart, are 74 mg/mmol and 79 mg/mmol. Urine dipstick is negative for blood on both occasions, and urine culture is negative. Her BP is 128/76 mmHg, potassium is 4.5 mmol/L, and her laboratory-reported 5-year Kidney Failure Risk Equation risk is 3.9%. What is the most appropriate next management plan?

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

Reveal the answer and explanation

Correct answer: B — Refer for specialist kidney assessment while continuing current blood-pressure and renin–angiotensin system treatment

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

She should be referred for specialist kidney assessment. NICE recommends referral for adults with CKD and an ACR of 70 mg/mmol or more, unless the albuminuria is known to be caused by diabetes and the person is already appropriately treated. Her ACR is persistently above this threshold, she does not have diabetes, and the result has already been confirmed on two early-morning specimens. Her low KFRE risk does not override a separate referral criterion. A is attractive because a KFRE above 5% is a referral trigger, but it is not the sole trigger. B is inappropriate because ramipril is already at the highest licensed tolerated dose and her BP is within the NICE target for ACR of 70 mg/mmol or more. D is not indicated: she has no haematuria, and albuminuria alone is not a criterion for urgent urological cancer referral. E would be reasonable for an isolated or unconfirmed abnormal ACR, but persistent severe albuminuria has already been demonstrated.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations, section 1.5.5 (2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Recommendations, sections 1.6.1–1.6.5 (2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations