AYYH is a 42-year-old male with type 2 diabetes and chronic kidney disease (“CKD") for follow-up today. His home blood pressure ranges from 140-160/80-90 mmHg, heart rate 70-80 beats per minute. His latest glycated haemoglobin A1c ("HbA1c") is 6.5% (target set by doctor: < 7%), estimated glomerular filtration rate ("eGFR") 55 mL/min/1.73m2 (ref. > 60 mL/min/1.73m2) and a urine albumin-to-creatinine ratio ("UACR") of 24 mg/mmol (ref. <1 mg/mmol). He is currently taking metformin 500 mg BD and gliclazide 80 mg BD for his diabetes. 

a) Using the cause, GFR category, and albuminuria category ("CGA"), what is his current stage of CKD? (1 mark) 

b) AYYH reads on the internet saying metformin is not suitable for patients with impaired renal function. How would you respond? (2 marks) 

c) Devise a treatment plan, with monitoring parameters, to optimise his diabetic control, CKD progression and/or blood pressure. (4 marks) 

d) Three months later, AYYH presents at your pharmacy counter requesting to purchase paracetamol. He explains that he tested positive for COVID-19 four days ago using a rapid antigen test ("RAT"). He reports feeling tired and nauseous. 

Upon further questioning, AYYH reveals that his fluid and food intake have been reduced over the past few days, and his urine output has been noticeably less than usual. He is currently taking enalapril 10 mg daily (increased from 5 mg daily last week), empagliflozin 10 mg daily, gliclazide 80 mg BD, and metformin 500 mg BD. 

You suspect that AYYH is experiencing acute kidney injury ("AKI"). What are the potential causes of AKI? (2 marks) 

e) Describe the appropriate course of action for a community pharmacist in this situation. (2 marks) 

f) Your pharmacy is recently collaborating with the Hospital Authority to manage patients with chronic diseases. Devise a comprehensive sick-day management plan for AYYH to minimise the risk of similar events occurring in the future. 

(4 marks)