Decreasing GFR in a Diabetic (6)

I would appreciate your advice about this 78 year old lady with IHD and NIDDM diagnosed 12 years ago. She was diagnosed with CKD stage 3 four years ago in 2006 (this is the first time her creatinine was elevated). Her renal function is steadily declining with a current eGFR of 32

PCR was 0.08 on 4/8/09 and an abdominal ultrasound scan showed normal kidneys in February 2006. Last HBA1c was 7.4 in July 09. BP is 138/78. She is almost stage 4 CKD

1) Should I refer her to a renal clinic?
2) Should I alter her medication (eg. Metformin)?
3) Do you have any other suggestions?

What further information would you seek before giving your opinion?

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Current Medications;

Aspirin 75mg OD, Simvastatin 10mg OD, Co-dydramol prn, Bumetamide 1mg OD, Allopurinol 300mg OD, Omeprazole 20mg OD, Amitriptyline 20mg nocte, Metformin 500mg TID, Lisinopril 10mg OD, Ferrous sulphate 200mg BD

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Her function is actually remarkably stable – losing 0.5mls/min/yr in terms of eGFR.

Her BP is close to adequate – target would be <130/80

She has no significant proteinuria on an ACEi.

She is appropriately on a statin, aspirin and ACEi.

The big issue is metformin. She is close to where Metformin should be stopped on the basis of absolute GFR, but she looks, on basis of all evidence, to be at low risk of progression in terms of renal disease. Stopping metformin will potentially de-stabilise her diabetic control and therefore a pragmatic approach would be to discuss the risk with her and leave her on Metformin.

However she should understand clearly that if she develops any intercurrent illness -especially vomiting or diarrhoea, she should stop both metformin and lisinopril until she has recovered.

I do not think there is any added value in her coming to a renal clinic.


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