BCACP Renal Disease and Chronic Kidney Disease Management — Questions and Answers
Question 1: A pharmacist is reviewing the medication list of a patient with CKD Stage 3b (eGFR 35 mL/min/1.73 m²). The patient is taking metformin 1000 mg twice daily for type 2 diabetes. What action should the pharmacist recommend?
- Continue metformin at the current dose without any modifications
- Discontinue metformin immediately as it is absolutely contraindicated below eGFR 60
- Reduce metformin dose and continue with more frequent monitoring of renal function (Correct answer)
- Switch to a sulfonylurea such as glibenclamide (glyburide) as the safer alternative
Correct answer: Reduce metformin dose and continue with more frequent monitoring of renal function
Per FDA labeling updated in 2016 and KDIGO/ADA guidelines, metformin can be continued with dose reduction and increased monitoring when eGFR is 30–45 mL/min/1.73 m² (CKD Stage 3b). At eGFR 35, continuing at a reduced dose with close renal monitoring is appropriate. Metformin is contraindicated below eGFR 30 due to lactic acidosis risk. Glyburide is actually more dangerous in CKD due to active metabolite accumulation causing hypoglycemia.
Question 2: A patient with type 2 diabetes has an eGFR of 38 mL/min/1.73 m² and a urine albumin-to-creatinine ratio (UACR) of 350 mg/g. Which pharmacological intervention has demonstrated slowing of CKD progression specifically in patients with diabetic kidney disease at this stage?
- Adding a calcium channel blocker (amlodipine) as the primary kidney-protective agent
- Initiating a SGLT-2 inhibitor (e.g., empagliflozin or dapagliflozin) in addition to RAAS blockade (Correct answer)
- Starting high-dose loop diuretic therapy to reduce proteinuria
- Discontinuing all antihypertensive medications to avoid renal hypoperfusion
Correct answer: Initiating a SGLT-2 inhibitor (e.g., empagliflozin or dapagliflozin) in addition to RAAS blockade
SGLT-2 inhibitors (empagliflozin, dapagliflozin) have demonstrated robust cardiorenal protection in patients with CKD and type 2 diabetes in landmark trials (CREDENCE, DAPA-CKD, EMPA-KIDNEY). They are now recommended by KDIGO 2022 as add-on therapy to RAAS blockade (ACE inhibitor or ARB) in patients with eGFR ≥20 and UACR ≥200 mg/g to slow CKD progression. CCBs do not slow CKD progression independently. Loop diuretics reduce volume but not proteinuria as a primary mechanism.
Question 3: A patient with Stage 4 CKD (eGFR 22 mL/min/1.73 m²) develops anemia with a hemoglobin of 9.8 g/dL. Iron studies show ferritin of 85 ng/mL and transferrin saturation (TSAT) of 18%. What is the most appropriate initial treatment for this patient's anemia of CKD?
- Start erythropoiesis-stimulating agent (ESA) immediately without iron repletion
- Transfuse packed red blood cells as the first-line intervention
- Initiate IV iron supplementation to optimize iron stores before or alongside ESA therapy (Correct answer)
- No treatment is needed until hemoglobin falls below 8 g/dL
Correct answer: Initiate IV iron supplementation to optimize iron stores before or alongside ESA therapy
KDIGO guidelines recommend iron supplementation when ferritin is <500 ng/mL and TSAT is <30% in CKD patients with anemia. Optimizing iron stores should precede or accompany ESA initiation to ensure adequate substrate for erythropoiesis and to minimize ESA dose needed. IV iron is preferred in non-dialysis CKD stages 4–5 when oral iron is insufficient or not tolerated. ESA monotherapy without iron correction is suboptimal and risks poor response.
Question 4: A patient with CKD Stage 4 develops hyperphosphatemia (serum phosphorus 6.8 mg/dL) despite dietary phosphate restriction. Which phosphate binder is most appropriate for a patient who also has hypercalcemia (serum calcium 10.8 mg/dL)?
- Calcium carbonate
- Calcium acetate
- Sevelamer carbonate (Correct answer)
- Either calcium carbonate or calcium acetate, as calcium binders are preferred in CKD
Correct answer: Sevelamer carbonate
Sevelamer (a non-calcium, non-aluminum phosphate binder) is preferred when the patient has hypercalcemia, because calcium-based binders (carbonate or acetate) would worsen hypercalcemia and increase the risk of vascular calcification and calciphylaxis. KDIGO guidelines recommend avoiding calcium-based binders in patients with persistent hypercalcemia, arterial calcification, or adynamic bone disease. Sevelamer also has the added benefit of lowering LDL cholesterol.
Question 5: A patient with CKD Stage 3a starts lisinopril 10 mg daily for proteinuria reduction. At a follow-up visit 2 weeks later, creatinine has increased from 1.4 to 1.7 mg/dL (eGFR decreased from 52 to 43 mL/min/1.73 m²). What is the most appropriate clinical response?
- Immediately discontinue lisinopril permanently as it is causing kidney damage
- Continue lisinopril if the creatinine rise is less than 30% from baseline — this hemodynamic effect is expected (Correct answer)
- Switch to a calcium channel blocker instead, as ACE inhibitors are contraindicated in proteinuric CKD
- Add an ARB to the ACE inhibitor to provide additive kidney protection
Correct answer: Continue lisinopril if the creatinine rise is less than 30% from baseline — this hemodynamic effect is expected
An initial creatinine rise of up to 30% from baseline after initiating an ACE inhibitor or ARB in CKD is expected and acceptable — it reflects efferent arteriolar dilation reducing intraglomerular pressure, which is the desired nephroprotective mechanism. Discontinuing RAAS blockade for this hemodynamic effect would deprive the patient of proven long-term kidney protection. Greater than 30–35% rise or rises accompanied by hyperkalemia warrant dose reduction or temporary hold. Dual RAAS blockade (ACE + ARB) is not recommended due to increased risk of hyperkalemia and acute kidney injury.
Question 6: Which of the following correctly describes CKD Stage G3b A3 according to the KDIGO 2012 classification?
- eGFR 30–44 mL/min/1.73 m² with urine albumin-to-creatinine ratio ≥ 300 mg/g (severely increased albuminuria) (Correct answer)
- eGFR 45–59 mL/min/1.73 m² with urine albumin-to-creatinine ratio < 30 mg/g (normal albuminuria)
- eGFR 15–29 mL/min/1.73 m² with urine albumin-to-creatinine ratio 30–300 mg/g (moderately increased albuminuria)
- eGFR < 15 mL/min/1.73 m² with any level of albuminuria
Correct answer: eGFR 30–44 mL/min/1.73 m² with urine albumin-to-creatinine ratio ≥ 300 mg/g (severely increased albuminuria)
KDIGO classifies CKD using GFR categories (G1–G5) and albuminuria categories (A1: <30 mg/g, A2: 30–300 mg/g, A3: >300 mg/g). G3b = eGFR 30–44 mL/min/1.73 m², and A3 = urine ACR ≥300 mg/g (severely increased or nephrotic-range proteinuria). This combination places the patient at high-to-very-high risk for CKD progression and cardiovascular events, warranting aggressive risk factor management.
BCACP Renal Disease and Chronic Kidney Disease Management
A pharmacist is reviewing the medication list of a patient with CKD Stage 3b (eGFR 35 mL/min/1.73 m²).
The patient is taking metformin 1000 mg twice daily for type 2 diabetes.
What action should the pharmacist recommend?