A 65-year-old man with CKD stage 3b (eGFR 38 mL/min) and T2DM presents with worsening proteinuria (urine ACR 620 mg/g). He is already on maximum dose ACE inhibitor and blood pressure is well controlled at 128/76 mmHg. According to the FIDELIO-DKD and FIGARO-DKD trial evidence, which additional agent significantly reduces CKD progression and cardiovascular events in diabetic kidney disease?

• A Add losartan (ARB) for dual RAAS blockade
• B Add spironolactone for additional antiproteinuric effect
• C Add finerenone (non-steroidal mineralocorticoid receptor antagonist) ✓
• D Add aliskiren (direct renin inhibitor)

Explanation

The FIDELIO-DKD and FIGARO-DKD trials demonstrated that finerenone, a selective non-steroidal MRA, significantly reduced CKD progression (primary outcome in FIDELIO) and cardiovascular events (FIGARO) in T2DM patients with CKD already on RAAS inhibition. Unlike spironolactone, finerenone has lower risk of hyperkalaemia and gynaecomastia. Dual RAAS blockade (ACEi + ARB or aliskiren) is contraindicated due to increased AKI and hyperkalaemia risk without CV benefit.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.