A 55-year-old diabetic man presents with progressive CKD stage G4A3 (eGFR 24 mL/min, UACR 650 mg/g). BP 142/88 mmHg on maximum-dose ACE inhibitor. HbA1c 7.1% on insulin. According to KDIGO 2022 and recent FIDELIO-DKD/FIGARO-DKD trial data, which agent should be added to further reduce CKD progression?
- A Amlodipine
- B Spironolactone
- C Finerenone ✓
- D Furosemide
Explanation
Finerenone (non-steroidal selective mineralocorticoid receptor antagonist) was shown in the FIDELIO-DKD trial to significantly reduce the composite kidney outcome (40% decline in eGFR, kidney failure, renal death) and cardiovascular events in patients with diabetic kidney disease already on RAAS blockade. Unlike steroidal MRAs (spironolactone, eplerenone), finerenone has higher selectivity and lower risk of hyperkalemia and gynecomastia. KDIGO 2022 guidelines now recommend finerenone for CKD patients with T2DM, eGFR ≥25, and UACR ≥30 mg/g despite ACEi/ARB. Spironolactone has limited trial data for DKD and higher side effect burden.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.