A 63-year-old male with long-standing poorly controlled diabetes and hypertension presents for evaluation. Laboratory results reveal serum creatinine 180 umol/L, eGFR 36 mL/min/1.73m2, and a spot urinary albumin-to-creatinine ratio (uACR) of 420 mg/g. Which class of antihypertensive agents is primarily indicated to slow the progression of diabetic nephropathy?

Answer and explanation

Correct answer: A. Angiotensin-Converting Enzyme Inhibitors (ACEi) or ARBs

  1. Step 1: In patients with diabetic kidney disease and albuminuria (uACR > 300 mg/g), ACE inhibitors or ARBs are the first-line antihypertensive agents.
  2. Step 2: By selectively dilating the efferent renal arteriole, they reduce intraglomerular capillary hydrostatic pressure and proteinuria, significantly slowing the progression of renal disease.
Answer
Angiotensin-Converting Enzyme Inhibitors (ACEi) or ARBs.
Why not the others: 'Thiazide diuretics' lower systemic blood pressure but do not possess unique renoprotective intraglomerular hemodynamics; 'Dual renin-angiotensin blockade' (combining ACEi and ARB or direct renin inhibitors) is strictly contraindicated due to increased rates of hyperkalemia, acute kidney injury, and syncope; 'Alpha-1 antagonists' lack renal protective outcomes.

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