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Four Pillar Sequencing CKD — ESENeph MCQ

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ModerateChronic Kidney DiseaseFour Pillar Sequencing CKDESENeph

A 40-year-old woman with CKD G3b and type 2 diabetes is on the maximum four-pillar regimen. Her clinician asks about the order in which these agents should ideally be started. According to KDIGO 2024, what is the recommended sequencing?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — RASi first (for albuminuria/hypertension), then SGLT2i (add early regardless of glycaemia), then Finerenone (if persistent albuminuria with T2D), then GLP-1 RA (if glycaemic targets unmet)

KDIGO 2024 recommends a stepwise approach: (1) RASi (ACEi or ARB) is the foundational first-line agent for proteinuric/hypertensive CKD; (2) SGLT2i should be added early as a second agent – its benefits are independent of glycaemia; (3) Finerenone (nsMRA) is added if albuminuria persists despite RASi + SGLT2i in T2D, with normal potassium; (4) GLP-1 RA is added if glycaemic targets are not met despite metformin + SGLT2i, or if weight management is needed. This is the optimal sequencing, though clinical circumstances may vary.

Reference: KDIGO 2024 – CKD Guideline