A 60-year-old man with diabetic nephropathy has eGFR 32 mL/min and urine ACR 620 mg/g. He is on maximum-dose ACE inhibitor. Per KDIGO 2022 guidelines, which therapy should be ADDED to provide additional renoprotection?

• A Spironolactone (steroidal MRA) to replace ACE inhibitor
• B ARB added on top of ACE inhibitor (dual RAS blockade)
• C Amlodipine to achieve additional BP lowering only
• D Finerenone (non-steroidal mineralocorticoid receptor antagonist) ✓

Explanation

The FIDELIO-DKD and FIGARO-DKD trials established finerenone (non-steroidal, selective MRA) as an evidence-based add-on therapy to RAS blockade in CKD with type 2 diabetes — reducing composite kidney and cardiovascular outcomes. KDIGO 2022 guidelines recommend finerenone for T2D with CKD, eGFR ≥25, and ACR ≥30 mg/g on maximum-tolerated RAAS blockade. Dual RAS (ACE inhibitor + ARB) is explicitly contraindicated per ONTARGET due to increased AKI and hyperkalaemia. Steroidal MRAs (spironolactone) have excess hyperkalaemia risk in CKD.

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

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Written and medically reviewed by the StethoPrep medical team.