A 55-year-old woman with hypertension and type 2 diabetes has proteinuria of 3.8 g/24 hours and eGFR 42 mL/min. She is already on ramipril 10 mg daily. Her blood pressure is 132/80 mmHg. According to KDIGO 2022 CKD guidelines, what additional agent has the strongest evidence to slow CKD progression in this patient?
- A Add an ARB (dual RAAS blockade with ramipril + candesartan)
- B Add finerenone (non-steroidal MRA)
- C Intensify blood pressure control with amlodipine
- D Add an SGLT2 inhibitor (dapagliflozin or empagliflozin) ✓
Explanation
KDIGO 2022 CKD guidelines recommend SGLT2 inhibitors (dapagliflozin per DAPA-CKD trial; empagliflozin per EMPA-KIDNEY trial) as a first-line addition to RAAS blockade for diabetic and non-diabetic CKD patients with uACR ≥ 200 mg/g and eGFR ≥ 20 mL/min. These trials showed significant reductions in composite kidney failure endpoints. Dual RAAS blockade (ACEi + ARB) is specifically contraindicated due to increased risk of AKI and hyperkalaemia (ONTARGET trial). Finerenone (FIDELIO-DKD, FIGARO-DKD) showed benefit but has a smaller evidence base than SGLT2i in CKD. Additional amlodipine alone does not address the proteinuric drive to progression.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.