Chronic kidney disease — KFP-style written assessment

KFP 1 (10 marks)

A 61-year-old woman attends for a diabetic annual review. Type 2 diabetes for 9 years, HbA1c 7.8%. Blood pressure today 152/88 mmHg. Laboratory results: eGFR 68 ml/min/1.73 m², urine ACR 12 mg/mmol on a random sample. She takes metformin 1 g twice daily. ^[24]

1. What additional test confirms or excludes albuminuria, and why? (2) ^[24]
2. Classify her CKD status using CGA once albuminuria is confirmed. (3) ^[24]
3. State her blood pressure target and first-line antihypertensive class with titration instruction. (3) ^[24]
4. Which therapy class should be added next for kidney protection, and what trial justifies it? (2) ^[9]

Model answers

1. An ACR between 3 and 70 mg/mmol must be checked on a subsequent early-morning sample; a repeat is not required if the initial value is 70 mg/mmol or more. Urine ACR is used rather than protein:creatinine ratio because of greater sensitivity for low-level proteinuria. ^[24]
2. With confirmed ACR 3 mg/mmol or more she has clinically important proteinuria: cause = diabetic kidney disease (presumed, after considering other causes), GFR category G2 (60–89 ml/min/1.73 m²), albuminuria category A2 (3–30 mg/mmol) — moderate risk on the heat map. The combination rule matters: reduced GFR and increased ACR multiply adverse-outcome risk. ^[24]
3. Target clinic systolic 120–139 mmHg with diastolic below 90 (ACR under 70 mg/mmol). First-line is an ACE inhibitor or ARB — indicated for diabetes with ACR 3 mg/mmol or more — titrated to the highest licensed dose she can tolerate, checking potassium and eGFR 1–2 weeks after starting and after each dose increase. ^[24]
4. Add an SGLT2 inhibitor as an add-on to optimised standard care: DAPA-CKD showed dapagliflozin 10 mg reduced the primary composite of sustained ≥50% eGFR decline, end-stage kidney disease, or renal/cardiovascular death by 39% (HR 0.61; NNT 19), with identical effects in participants with and without type 2 diabetes. ^[9]