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Diabetic kidney disease with high predicted kidney failure risk — MSRA MCQ

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HardNephrologyDiabetic kidney disease with high predicted kidney failure riskMSRA

A 64-year-old man with type 2 diabetes, hypertension and diabetic kidney disease is reviewed in general practice. He takes ramipril 10 mg once daily and dapagliflozin 10 mg once daily; both are at the highest tolerated licensed doses. He is clinically euvolaemic, avoids NSAIDs and potassium-containing salt substitutes, and has no symptoms of urinary obstruction or systemic disease. His eGFR values have been 37, 36 and 36 mL/min/1.73 m² over 9 months. Two early-morning urine ACR measurements, 3 months apart, are 94 mg/mmol and 101 mg/mmol. Urine dipstick is negative for blood and urine culture is negative. BP is 126/74 mmHg, potassium is 4.6 mmol/L and bicarbonate is 24 mmol/L. The laboratory-reported 5-year Kidney Failure Risk Equation risk is 5.6%. 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: E — Refer for nephrology assessment while continuing current kidney-protective treatment

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

This patient should be referred for nephrology assessment. Although his eGFR is stable, blood pressure is controlled and there is no haematuria or evidence of obstruction, his 5-year Kidney Failure Risk Equation (KFRE) risk is 5.6%. NICE recommends specialist assessment when the 5-year risk of requiring renal replacement therapy is greater than 5%. His ACR is also above 70 mg/mmol, but NICE makes an exception to automatic referral for this finding when albuminuria is known to be caused by diabetes and is already appropriately treated. That exception does not override the separate KFRE referral criterion. He is already receiving optimised ACE-inhibitor and SGLT2-inhibitor therapy, so referral should not be deferred simply to observe response. B fails because KFRE exceeds the referral threshold. C is not the priority: there are no symptoms or findings suggesting renal outflow obstruction, and imaging is not required before referral on the basis of KFRE alone. D may appear attractive for residual albuminuria, but adding spironolactone is not the appropriate substitute for indicated specialist assessment and introduces hyperkalaemia risk alongside ramipril in CKD. E is incorrect because a stable eGFR below 45 mL/min/1.73 m² is not, by itself, an indication to stop a tolerated ACE inhibitor.

Reference: NICE NG203: Chronic kidney disease: assessment and management — Recommendations, section 1.5 Risk assessment, referral criteria and shared care (Published 25 August 2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Recommendations, section 1.5 Risk assessment, referral criteria and shared care (Published 25 August 2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Recommendations NICE NG203: Chronic kidney disease: assessment and management — Rationale and impact, risk assessment, referral criteria and shared care (Published 25 August 2021; checked 16 August 2026) — https://www.nice.org.uk/guidance/ng203/chapter/Rationale-and-impact