Sick Day Rules Triple Therapy AKI Prevention — ESENeph MCQ

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EasyAcute Kidney InjurySick Day Rules Triple Therapy AKI PreventionESENeph

A 64-year-old woman with CKD G4 (eGFR 22 mL/min/1.73m2) is on ramipril, dapagliflozin, and finerenone. She develops diarrhoea and vomiting for 48 hours. Her potassium rises to 6.8 mmol/L and creatinine from 220 to 450 umol/L. Which concept describes the medication management she should have implemented?

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Correct answer: D — Use temporary sick-day medication holds

Sick day rules require temporary cessation of medications that can cause or worsen AKI during acute illness (dehydration, vomiting, diarrhoea, sepsis, fever). The commonly cited mnemonic is SADMANS: SGLT2 inhibitors, ACE inhibitors, Diuretics, Metformin, ARBs, NSAIDs, Sulphonylureas. Finerenone (nsMRA) should also be paused as it causes hyperkalaemia, which is exacerbated by AKI. This patient's triple combination (RASi + SGLT2i + nsMRA) creates significant hyperkalaemia risk during volume depletion. All three should have been temporarily stopped at onset of GI illness. Patient education about sick day rules is a critical component of CKD self-management.

Reference: NICE 2021 – NG203; KDIGO 2024 – CKD Guideline; Think Kidneys 2020 – Sick Day Rules: https://www.nice.org.uk/guidance/ng148/chapter/recommendations