BCACP Renal Disease and Chronic Kidney Disease Management

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?

Accepted Answer

Reduce metformin dose and continue with more frequent monitoring of renal function

Answer

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?

Accepted Answer

Initiating a SGLT-2 inhibitor (e.g., empagliflozin or dapagliflozin) in addition to RAAS blockade

Answer

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?

Accepted Answer

Initiate IV iron supplementation to optimize iron stores before or alongside ESA therapy

Answer

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)?

Accepted Answer

Sevelamer carbonate

Answer

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?

Accepted Answer

Continue lisinopril if the creatinine rise is less than 30% from baseline — this hemodynamic effect is expected

Answer

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.

BCACP - Board Certified Ambulatory Care Pharmacist Exam Practice Test

BCACP - Board Certified Ambulatory Care Pharmacist Exam Practice Test

BCACP Renal Disease and Chronic Kidney Disease Management