Clinical Management and Pharmacotherapy
This domain tests medication and treatment decisions across the CKD continuum, from albuminuria to dialysis and transplant - when to start, when to stop, and what to monitor.
Slow progression: the four-pillar approach
For CKD with albuminuria: maximally tolerated ACE inhibitor or ARB (never both together); an SGLT2 inhibitor (dapagliflozin or empagliflozin) down to eGFR 20; finerenone, a nonsteroidal mineralocorticoid receptor antagonist, when albuminuria persists despite those two and potassium allows; and a GLP-1 receptor agonist such as semaglutide, which reduced kidney outcomes in the FLOW trial. Blood pressure target is systolic <120 mmHg when tolerated using standardized office measurement.
Manage the complications
Anemia: correct iron deficiency first (TSAT <20% or ferritin <100 ng/mL in non-dialysis CKD), then an ESA or HIF prolyl hydroxylase inhibitor; target hemoglobin about 10–11.5 g/dL and never intentionally normalize it. CKD-MBD: lower phosphate toward the normal range with diet and binders, use active vitamin D and calcimimetics for secondary hyperparathyroidism. Give sodium bicarbonate when serum bicarbonate is persistently below 18 mEq/L. High-intensity statin for adults ≥50 with CKD.
Worked example
A patient with G3b A3 on maximized lisinopril has potassium 5.3 mEq/L. Stopping the ACE inhibitor is the wrong answer. Correct sequence: add an SGLT2 inhibitor, which blunts hyperkalemia; review diet and loop diuretic dose; add finerenone with potassium monitoring if albuminuria persists; use a potassium binder rather than abandoning RAAS blockade.
Traps that cost marks
ACE inhibitor plus ARB is not recommended. An ESA given without iron repletion fails. Phosphate binders are not indicated for isolated mild hyperphosphatemia without sustained elevation.