The INCORRECT Statement is C
A combination of an ACE inhibitor and an angiotensin II receptor blocker is NOT preferred and is explicitly NOT recommended for diabetic nephropathy management. 1, 2, 3, 4
Why This is Incorrect
The most recent and authoritative guidelines uniformly recommend AGAINST dual RAS blockade (combining ACEi + ARB):
- KDIGO 2024 explicitly states: "We recommend avoiding any combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy in people with CKD, with or without diabetes (1B)" 3
- KDIGO 2022 reinforces: "ACEi or ARB monotherapy versus dual therapy (ACEi + ARB)" is not recommended 2
- ADA/KDIGO 2022 Consensus confirms single-agent therapy only 4
The evidence shows that dual RAS blockade increases risks (hyperkalemia, acute kidney injury, hypotension) without providing additional kidney or cardiovascular protection compared to monotherapy.
Why the Other Statements ARE Correct
A) Controlling Glycated Hemoglobin - CORRECT
Optimizing glucose control is a Grade A recommendation across all guidelines to reduce risk and slow progression of diabetic nephropathy 1, 5, 6, 7, 4
B) ACE Inhibitors Can Slow Progression - CORRECT
Either an ACEi OR an ARB (not both) is recommended:
- For albuminuria 30-299 mg/day: suggested (Grade C) 1
- For albuminuria >300 mg/day: strongly recommended (Grade A) 1, 6, 4
- Titrate to maximum tolerated dose for proven benefit 3, 4
D) Managing Comorbidities - CORRECT
Comprehensive management is essential 1, 4:
- Blood pressure optimization (Grade A)
- Statin therapy for cardiovascular protection
- SGLT2 inhibitors (now first-line for T2D with CKD, eGFR ≥20) 3, 4
- GLP-1 receptor agonists for additional glycemic/CV benefit 4
- Nonsteroidal MRA (finerenone) for persistent albuminuria 3, 4
- Monitor and manage CKD complications when eGFR <60 1
E) Kidney Transplantation - CORRECT
Transplantation is an established treatment option for selected patients with end-stage renal disease from diabetic nephropathy 8, 9. Diabetes is the leading cause of kidney failure requiring transplantation or dialysis worldwide 4.
Critical Clinical Pitfall
Never combine ACEi + ARB. If one class is not tolerated, substitute with the other—do not add it 1, 5, 6, 10. This is one of the most important evidence-based prohibitions in nephrology practice, with consistent Grade A/B evidence against combination therapy.