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65-year-old man with a history of diabetes mellitus type 2, hypertension, and obesity comes to your clinic for a 3-month follow-up visit. He was diagnosed with DM 15 years ago and HTN 20 years ago. He has no complaints and no episodes of hypoglycemia. He is eating better and has lost 10 lb in the last 1 year. On physical examination his BMI is 32, and BP 130/75. He has a normal heart examination. His foot examination demonstrates peripheral neuropathy with abnormal monofilament testing. His blood sugars have been better controlled in the last 6 months and his last HbA1C is 7.0%, which is an improvement from a previous 9.2%. Other test results include CBC with hemoglobin 11.0, normal WBC and platelets, creatinine 1.2, and glomerular filtration rate (GFR) 55. He has normal sodium, potassium, and calcium. Urine dipstick shows negative protein and urine microalbumin with 60 mg/g creatinine that has persisted for 6 months despite blood pressure control with a thiazide diuretic. His LDL is at goal. His last dilated eye examination showed nonproliferative retinopathy.

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1. What complications is this patient at risk for given his chronic kidney disease (CKD)?

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2. What are the common risk factors for CKD?

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3. How do you screen for and decrease risk for complication of CKD?

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Answers

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  1. Patient has CKD stage 3 given his GFR of 55. He is at risk for certain complications including anemia, metabolic acidosis, vitamin D deficiency, hyperparathyroidism, and metabolic bone disease.

  2. Age is probably the most common risk factor for CKD as the GFR peaks at age 30 and slowly declines at a rate of 1 mL/min per year. However, diabetes and HTN, the 2 most common reasons for patients to develop atherosclerotic coronary heart disease, also account for most of the cases of CKD and the need for dialysis in the United States. Other risk factors include African ancestry, autoimmune diseases, autosomal dominant polycystic kidney disease (APKD), a history of acute renal failure, and chronic urinary tract infections, among many others.

  3. Patient has multiple risk factors for the development of CKD including his age, diabetes, and hypertension. Moreover, he has evidence of microvascular complications from diabetes including neuropathy and retinopathy that makes the presence of nephropathy very likely. He has been screened appropriately with urine microalbumin measurements that have been confirmed on more than 1 occasion. In addition to treating his diabetes and HTN, the patient should be started on an ACE inhibitor or an angiotensin receptor blocker (ARB) that will help delay the progression of his kidney disease.

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Patient's increased blood sugars and high blood pressures have injured and destroyed nephrons over time. For many years, his “healthy” nephrons likely maintained a normal GFR by hyperfiltration and hypertrophy. However, these maladaptive responses are not enough anymore as evidenced by his declining GFR ...

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