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CKD Stage 4 Management — RACP Adult Medicine MCQ

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HardNephrologyCKD Stage 4 ManagementRACP Adult Medicine

A 55-year-old with CKD G4, diabetes and marked albuminuria is taking ramipril. He presents with dyspnoea, oedema, BP 165/100 mmHg, potassium 5.8 mmol/L and bicarbonate 16 mmol/L; ECG is normal and there is no uraemic encephalopathy or pericarditis. Which initial renal strategy best addresses the current physiology?

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

Reveal the answer and explanation

Correct answer: B — Begin IV loop diuresis, manage persistent acidosis and repeat potassium, bicarbonate, creatinine and congestion assessment promptly

Explanation lettering: E = shown as D · D = shown as E

B is correct. This patient needs prompt treatment of sodium and fluid excess, metabolic acidosis and hyperkalaemia; a loop diuretic is appropriate for congestion at low GFR, and alkali can be considered for persistent bicarbonate 16 mmol/L while sodium load and volume are monitored. C predictably worsens hyperkalaemia. D uses an eGFR number rather than refractory hyperkalaemia, acidosis, overload or uraemic complications to trigger dialysis. E does not remove renin–angiotensin effects or decongest the patient. A may have long-term cardiorenal value if clinically suitable, but it is not rescue therapy for this presentation. Whether ramipril is temporarily held depends on serial potassium, kidney function and response rather than an automatic permanent withdrawal.

Reference: Kidney Health Australia: Chronic Kidney Disease Management in Primary Care, 5th edition: https://kidney.org.au/health-professionals/ckd-management-handbook/ Australian RACP: Divisional Written Examination: https://www.racp.edu.au/trainees/examinations/divisional-written-examination