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CDE Diabetes

Practice Exam: Chronic Kidney Disease in Diabetes (Chapter 29 – 2025 Update)

Diabetes remains the leading cause of kidney failure in Canada. The 2025 Guidelines Update represents a significant evolution in care, moving beyond simple glucose control to a “kidney-protective” strategy that utilizes newer pharmacotherapies to delay progression and reduce cardiovascular risk.

This practice exam tests your ability to apply the latest screening protocols, diagnostic criteria, and the expanded treatment algorithms for patients with varying stages of renal impairment.

Key Concepts Covered in This Exam:

  • Screening & Diagnosis: Mastering the criteria for diagnosing Chronic Kidney Disease (CKD) using the Urine Albumin-to-Creatinine Ratio (UACR) and eGFR, and distinguishing persistent albuminuria from transient causes.

  • Renoprotective Pharmacotherapy: Applying the updated recommendations for SGLT2 inhibitors as a foundational treatment for delaying CKD progression, even in patients without optimal glycemic control.

  • Non-Steroidal MRAs: Identifying the specific indications for finerenone (a non-steroidal mineralocorticoid receptor antagonist) in patients with Type 2 diabetes and CKD who remain at risk despite standard-of-care treatment.

  • RAAS Blockade: Reviewing the use of ACE inhibitors or ARBs for albuminuric patients and the critical caution against using them in combination.

  • “Sick Day” Management: Recognizing when to temporarily pause medications (like SADMANS) to prevent acute kidney injury during intercurrent illness.

1. Case: A patient with CKD has metabolic acidosis with serum bicarbonate of 16 mmol/L. What treatment is recommended?

2. The guideline states that management of CKD in diabetes should now consider ‘goal-directed medical therapy’ similar to which other condition?

3. When should potassium be rechecked after initiating or doubling an ACEi or ARB dose?

4. When should potassium be rechecked after initiating an nsMRA (finerenone)?

5. According to the 2025 guidelines, CKD in diabetes is defined as:

6. Case: A 55-year-old patient with newly diagnosed type 2 diabetes asks when they should start CKD screening. According to the guidelines, when should screening begin?

7. Case: A patient with diabetic nephropathy is being considered for finerenone. What serum potassium level is required before initiating this nsMRA?

8. What 5-year KFRE (Kidney Failure Risk Equation) score is an indication for nephrology referral?

9. According to the guideline, what factors suggesting kidney disease may be unrelated to diabetes should prompt consideration of alternative diagnoses?

10. According to the guidelines, what percentage of SGLT2 is responsible for glucose resorption in the kidney?

11. Case: A clinician is counselling a patient about why SGLT2 inhibitors are still recommended at low eGFR despite reduced glucose-lowering effect. What is the key message?

12. Case: A healthcare team discusses whether to add quadruple therapy (RAASi + SGLT2i + GLP1-RA + nsMRA) for persistent nephropathy. What does the guideline state about this approach?

13. What is the blood pressure treatment target for people with diabetes according to the guidelines?

14. What is the ACR threshold for diagnosing A2 albuminuria (microalbuminuria) in people with diabetes according to Diabetes Canada?

15. In the FIDELITY pooled analysis, what was the improvement in the composite kidney outcome with finerenone?

16. According to the guideline’s recommended sequencing, which therapy should be started first for cardiorenal protection?

17. The guideline discusses potassium bioavailability. Which food source has the highest potassium absorption rate?

18. Case: A patient develops hyperkalemia. Which potassium binder has the fastest onset of action?

19. Which two phenotypes of kidney disease in diabetes are described in the guidelines?

20. The guidelines define ‘rapid progression of loss of kidney function’ as:

21. Case: A quality improvement team reviews why people with CKD who develop hyperkalemia often have RAASi discontinued. According to the guideline, what is the concern with this practice?

22. According to the guidelines, approximately what percentage of people on dialysis have diabetes?

23. According to the guideline, what is the emerging evidence regarding dietary potassium restriction from fruits and vegetables in earlier CKD stages?

24.

  1. At what uACR level does the guideline suggest referral to nephrology for assessment of possible kidney biopsy if albuminuria persists after adding 2+ nephroprotective classes?

25. Case: A research team is reviewing why Diabetes Canada maintains an ACR cutoff of 2 mg/mmol versus KDIGO’s 3 mg/mmol. What is the guideline’s rationale?

26. Case: A patient has diabetes and an eGFR of 55 mL/min/1.73 m² with uACR of 25 mg/mmol. How often should eGFR and uACR be assessed?

27. Case: A patient with type 1 diabetes diagnosed at age 8 asks when CKD screening should begin. What is the recommendation?

28. In the FLOW study with semaglutide, what was the reduction in the primary kidney outcome compared to placebo?

29. According to the guidelines, which tests should be used to screen for CKD in people with diabetes?

30. In the meta-analysis of 5 SGLT2i trials (n=20,387), what was the reduction in risk of kidney failure in people with advanced diabetic kidney disease?

31. Case: A patient with type 2 diabetes and diabetic nephropathy asks about using both ACEi and ARB together for additional benefit. What does the guideline recommend?

32. Case: A patient on an ACEi develops moderate hyperkalemia (K = 5.7 mmol/L). According to the algorithm, what is the recommended approach?

33. How many drug classes now show evidence of kidney and cardiovascular benefit for people with CKD in diabetes?

34. According to the guideline, what is the relationship between cardiovascular outcomes and progressive loss of kidney function in people with CKD?

35. Case: A patient with CKD has a creatinine-based eGFR of 52 mL/min/1.73 m² but is a competitive bodybuilder with high muscle mass. What test should be considered?

36. What is the normal kidney function as measured by eGFR?

37. What is the classification for severe hyperkalemia according to the guidelines?