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Chapter 23: Slowing the Progression of Chronic Kidney Disease

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A 61-year-old woman with a medical history notable for hypertension and diabetes mellitus type 2 presents to nephrology clinic for routine follow-up of stage 4 CKD secondary to diabetic nephropathy. She is doing well overall. Her medication regimen includes metoprolol 50 mg twice daily, lisinopril 20 mg daily, and insulin. Her BP in the office is 138/86 mm Hg, heart rate is 78 beats/min; her physical examination is otherwise unremarkable.

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Her laboratory test results reveal a stable serum creatinine of 1.87 mg/dL, potassium 4.7 mmol/L, bicarbonate 21 mmol/L, and a glucose of 178 mg/dL. She has a spot ACR of 470 mg/g. What would be the most important change to make in clinic today?

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A. Increase metoprolol dose

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B. Start sodium bicarbonate

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C. Add metformin

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D. Increase lisinopril dose

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The answer is D. In this case, the patient has diabetic nephropathy and has persistent microalbuminuria on RAAS blockade. The most important intervention would be to increase her RAAS inhibitor to maximally suppress her proteinuria. Her blood pressure is at goal by ACCORD standards, and increasing the metoprolol dose the same antiproteinuric effects seen with RAAS blockade. Control of blood glucose in type 2 diabetes has not been definitively linked with improved renal outcomes. Her mild metabolic acidosis does not require therapy.

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A 41-year-old man is seen in the office for his annual physical examination. He has a medical history that includes hypertension and gout. His only new medical problem is some anterior knee pain that started about 4 months ago. He has been treating it with ibuprofen 800 mg two to three times daily. His other daily medications include losartan, amlodipine, and allopurinol.

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His physical examination shows a BP of 151/88 mm Hg and a heart rate of 81 beats/min. His right knee is without erythema and he has no point tenderness, but pain is elicited with passive and active extension. Examination is otherwise notable for only trace peripheral edema. Including referral for imaging studies to specifically evaluate his knee pain, which of the following would also be indicated?

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A. Serum uric acid

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B. Dual-energy X-ray absorptiometry (DEXA) scan

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C. Serum creatinine

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D. Urine sodium

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The answer is C. In this case, the chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) in association with worsening control of hypertension may signal a decline in renal function. The monitoring of renal function in certain high risk patient subgroups is useful in order ...

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