Disclaimer: The following guide is my best guess on what content will be on the exam. I do not know what exactly will be on the exam but I have helped over a thousand health care professionals pass the exam.

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Chapter 29 2025 Update- Chronic Kidney Disease in Diabetes
Importance: High- Re-read a few times, be familiar with chapter
Approximate time recommended: 230 minutes

I have highlighted what I think will be important for the exam. However you should read the entire chapter. All areas in grey (key messages and recommendations) are also important for the exam. Note that 2026 is the first time this chapter is on the test so I am less sure

Under the heading of: Practical Tips

Memorize Figure 1, the screening recommendations have changed so please see the 2025 updated Screening cheat sheet for details

ACE inhibitors/ACEi (ramipril, perindopril, and other medications that end with-PRIL) and Angiotensin Receptor Blockers/ARB (telmisartan , valsartan, and other medications that end with -SARTAN) is suggested to be first line therapy for cardiorenal protection. Past ACEi/ARB there is no evidence to suggest that one of the remaining classes (GLP1-RA such as Ozempic (semaglutide), SGLT-2i such as Jardiance (empagliflozin), nsMRA such as Kerendia (finerenone)) should be second line, therefore you can choose the agent based on factors like glycemic control, weight loss, and avoidance of certain side effects.

I don’t think you need to know the doses but you do need to know which class of medications are good for what situations.

Under the heading of: Introduction

Know the definition of kidney disease for a person with diabetes which is:

1) A persistent ACR > 2.0 mg/nmol in two urine samples over three months. The reason two samples are required is that ACR can fluctuate for a variety of reasons such as exercise, illness, and menstruation so two urine samples are required to confirm. In real life, you should check off the random urine albumin to creatinine ratio (ACR) vs the 24 hour. When I have accidently checked off the 24 hours ACR on the lab requisition I have gotten an earful of complaints from my patients on how inconvenient it is to carry a bucket of their own urine with them all day.

2) A persistent eGFR <60 ml/min over three months. Lab typically calculate the eGFR for you now but if you have a patients who are extremely under or over weight (this makes the standard calculation inaccurate) you may want to calculate it yourself using a eGFR calculator,  I like to use this one- https://globalrph.com/medcalcs/creatinine-clearance-multi-calc/

3) Or Both 

Know that kidney disease is the most common complication of diabetes, with about 50% of people with diabetes developing kidney disease during their lifetime.

Know that the risk factors for developing diabetic nephropathy are hyperglycemia,
hypertension, dyslipidemia, obesity, smoking, and genetics.

Normal kidney function is 120ml/min. Depending on your lab, it may only indicate renal function is low if the eGFR is below 60 ml/min. Giving patients a normal number is important for give a frame of reference. If I told you your exam score was 70 points you may think you did well until I tell you that the class average was 120 points. This could convince your patients to adhere to your recommendations on hyperglycemia, hypertension, dyslipidemia, obesity and smoking.

Under the heading of: Screening for Kidney Disease—Loss of Kidney Function

I would be familiar with Figure 2 but I wouldn’t memorize it.

Under the heading of: Risk Prediction in Individuals With Diabetes and CKD

Decreases in eGFR or increases of ACR  is closely linked to an increase atherosclerotic cardiovascular diseases and progression to end stage kidney disease. This highlights the importance of treatment.

Know what the KRFE is and the variables it uses to calculate risk.

Treatment

SLGT-2i are pills (most of which are generic now, which means that are a more affordable option) that help with weight loss (by urinating out sugar, patients lose calories leading to weight loss) and glycemic control (also by urinating out sugar). This class includes medications like Invokana (canagliflozin), Jardiance (empagliflozin) and Forxiga (dapagliflozin). SGLT-2i- seem to help the kidney by reducing tubular workload, glomerular pressure, and inflammation.  On recent exams both the brand name and generic names of medications are listed in the questions.

GLP1-RAs are subcutaneous injections, the newer GLP1-RAs are once weekly injections and are the most commonly used (such as Ozempic (semaglutide) and Mounjaro (dulaglutide)). Older GLP1-RAs were given daily (such as Victoza (liraglutide) and Byetta (exenatide). They are basically stomach hormones that reduce appetite (causing weight loss) and reduce glucagon secretion (which improves blood sugar, the weight loss also helps with the blood sugar). In not completely known how GLP-1RAs benefit the kidney but they seem to have beneficial effects on the RAAS system (same as ACE-1/ARB) and induce natriuresis. They are generally expensive without coverage.

The nsMRA (non-steroidal Mineral Receptor Antagonists) class currently has one medication, a pill called Kerendia (finerenone) related to MRAs like spironolactone. Kerendia has anti-inflammatory and antifibrotic effects on the kidneys. Kerendia costs about $3.50 per day so a 100 day supply would roughly be $350.

Under the heading of: Approach to Managing People With CKD From Diabetes

Memorize Figure 6

Under the heading of: Management of Hyperkalemia in People With Diabetes and
CKD

CKD, RAAS (ACEi and ARB) inhibitors and msRNAs can increase the risk of hyperkalemia.

Be familiar with Table 8. In most provinces the upper limit of normal is 5.0 mmol/L.

Know what to do for mild, moderate and severe hyperkalemia.

For the Hyperkalemia Supplement 

Know that hyperkalemia can increase the risk of mortality, hospitalizations and ICU admissions.

Under the heading of: Risk Factors for Hyperkalemia and Strategies for Management

Know that medical conditions such as heart failure and diabetes can increase the risk for hyperkalemia.

Know that RAAS can increase the risk of hyperkalemia but discontinuing them permanently may lead worse outcomes. To summarize Table 3 I would say to know that RAAS inhibitors (meds that end with -pril and -sartan), MRA (meds that end with- one), beta-blockers (meds that end with -olol), and NSAIDS can lead to hyperkalemia. You could memorize Table 3 but I think there are other parts of the guidelines that are more valuable to memorize.

I wouldn’t bother with memorizing the natural supplements that increase potassium for the exam as you already have a different chapter with a list of supplements. However, some of the natural supplements listed in this chapter are commonly used. If your patient is hyperkalemic, you should review if they are using herbal products from this list. Ginseng and hawthorn are commonly used Asian herbal products. My late grandmother (who also had type 2 diabetes) used them all the time.

I wouldn’t memorize any of the nutrition figures, you already have so much other stuff to memorize! I would know that in general, bananas, oranges, tomatoes, and potatoes are high in potassium. In general, the more your process them (i.e. tomatoes to tomato soup to V-8 drink) the higher the potassium. Know that half salt is high in potassium.

I wouldn’t memorize the individual hyperkalemia medications as there are enough diabetes medications to memorize. However, I would be familiar with Figure 7.

 

Practice Questions

Lee is a 30 year old female with type 2 diabetes who is busy hotel manager. Her target A1c is 7% (0.07) and her previous A1c three months ago was 8.7% (0.087). Her ACR three months ago was 20.2 mg/mmol. Her BMI is 40.2 and she is interested in better glycemic control and weight loss. She is on Glucophage (metformin) 1000mg twice daily, Coversyl (perindopril) 2mg  and Crestor (rosuvastatin) 40mg. She recently goes for lab work and the results are below:

A1c= 8.9% (0.089)
eGFR= 63 ml/min
ACR= 22.5 mg/mmol

You discuss that she has:

A) No kidney disease as her eGFR is 65 ml/min and she should be continued to be screened yearly
B) No kidney disease as her ACR is 20.2 mg/mmol and 22.5 mg/mmol and she should be continued to be screened yearly
C) She has kidney disease as her eGFR is 65 ml/min and she should be started on renal protective therapy
D) She has kidney disease as her ACR is 20.2 and 22.5 and she should be started on renal protective therapy and referred to a specialist

Lee asks for a recommendation on a medication for diabetes and kidney disease. You suggest:

A) Micardis (telmisartan)
B) Kerendia (finerenone)
C) Ozempic (semaglutide)
D) Invokana (canagliflozin)

You have a patient, Ryder, who has chronic hyperkalemia. Today you get his lab work which shows he currently has a K+ of 5.1 mmol/L. He takes Diovan (valsartan) 160 mg daily for kidney protection. He calls you as he is camping and is very hungry but doesn’t have a lot of food choices . You suggest that he:

A) Call 911 as he is severely hyperkalemic and needs to be hospitalized
B) Suggest consuming an orange
C) Suggest consuming a cup of orange juice
D) Suggest consuming a cup of dried oranges sweetened with orange concentrate syrup.

After a few months Ryder sees you for follow up after complaints of muscle weakness, heart palpitations, vomiting and nausea. You order stat labwork and it comes back with a potassium of 6.1 mmol/L. You suggest:

A) That he has mild hyperkalemia and to continues his Diovan (valsartan)
B) That he has moderate hyperkalemia and to continue his Diovan (valsartan) and refer him to a renal dietitian
C) That he has moderate hyperkalemia, so he should hold his Diovan (valsartan) and refer him to a renal dietitian
D) That he has severe hyperkalemia, so he should hold his Diovan (valsartan) and go to the emergency department