Optimal Four-Pillar CKD Management — ESENeph MCQ

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ModerateDiabetic Kidney DiseaseOptimal Four-Pillar CKD ManagementESENeph

A 55-year-old man with CKD G4 and type 2 diabetes is on the maximum four-pillar regimen (Ramipril, Dapagliflozin, Finerenone, Semaglutide). His HbA1c is 52 mmol/mol, BP 118/72, potassium 4.6, uACR has fallen from 120 to 25 mg/mmol. Is any further escalation of therapy needed?

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Correct answer: B — Continue the current four-pillar regimen

This patient is on all four evidence-based pillars of CKD management per KDIGO 2024: RASi, SGLT2i, nsMRA, and GLP-1 RA. His parameters are excellent – HbA1c at target, BP well below 120 systolic, potassium safe, and albuminuria reduced by >75%. No further escalation is needed. All agents should be continued as their benefits are ongoing. Stopping SGLT2i after albuminuria improvement would risk disease progression. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: KDIGO 2024 – CKD Guideline: https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf