A patient with type 2 diabetes has eGFR 38 mL/min/1.73m² and urine ACR 280 mg/g. HbA1c is 8.1%. According to current KDIGO 2022 and ADA 2024 guidelines, which combination of agents is MOST appropriate to slow CKD progression?
- A Metformin + sulfonylurea
- B ARB + GLP-1 agonist only
- C ACE inhibitor + SGLT2 inhibitor (e.g., dapagliflozin) + finerenone ✓
- D Insulin + ACE inhibitor
Correct answer: C. ACE inhibitor + SGLT2 inhibitor (e.g., dapagliflozin) + finerenone
Explanation
KDIGO 2022 guidelines for CKD in type 2 diabetes recommend a 'four-pillar' approach: RAS blockade (ACEi/ARB), SGLT2 inhibitor (dapagliflozin or empagliflozin), and now finerenone (a non-steroidal MRA shown in FIDELIO-DKD and FIGARO-DKD trials to independently reduce CKD progression and CV events). Metformin is safe down to eGFR 30 but does not slow CKD progression. GLP-1 agonists reduce albuminuria but are secondary agents. The triple combination of RASi + SGLT2i + finerenone is the current evidence-based nephroprotective standard.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.