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Chronic kidney disease referral — USMLE Step 3 MCQ

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HardInternal Medicine (chronic management)Chronic kidney disease referralUSMLE Step 3

A patient with stage G4 CKD has repeated serum bicarbonate values of 16–17 mEq/L, potassium 4.8 mEq/L, controlled blood pressure and no edema. What is the most appropriate management?

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Correct answer: E — Begin oral alkali therapy with bicarbonate, blood-pressure, and volume monitoring

The best answer is “Begin oral alkali therapy with bicarbonate, blood-pressure, and volume monitoring”. Persistent clinically important metabolic acidosis in advanced CKD can be treated with oral alkali after confirming the disorder and addressing causes. Therapy requires monitoring because sodium load or overcorrection can worsen blood pressure and volume status; this laboratory value alone is not a dialysis indication.

Reference: KDIGO 2024 Clinical Practice Guideline for Chronic Kidney Disease: https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf