Proteinuria in Type 2 Diabetic (5)

This 63 year old gentleman is a type II diabetic with treated hypertension.  He attended for review 2 weeks ago and had an ACR sent as part of his diabetes care.  The urinary ACR was high with an albumin of 166, creatinine of 2.91 and ACR of 57.4.  The ACR was repeated with an MSU – the MSU was negative with no evidence of red cells.

When I saw the patient today I changed him on to gliclazide from pioglitazone, along with his metformin, and aim to titrate this up to try and get better diabetic control.  The patient is on an ACEi and his BP today was 132/78.

Looking back in the patient’s record he has had problems with right hydronephrosis, left sided renal calculi and a previous renogram showed some scarring. Since then he has had some episodes of renal colic and received lithotripsy in 20 years ago. He has not been troubled by renal colic recently.

My enquiry really is to get some advice as to whether an ACR at this level in this situation requires any further investigation or input from the renal service? Or should we continue to monitor and control his BP? Also at what level would you want to see someone with a high ACR?

What further information would you seek before giving your opinion?

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Medications;
Zopiclone, Quinine, Metformin, Sildenafil, Glicazide, Amlodipine, Fosinopril, Co-codamol, Bendroflumethiazide, Atorvastatin, Aspirin, Diclofenac

A summary of the results for this patient;

Urine 2 years ago – ACR 12.5 mg/mmol
Urine 2 weeks ago – ACR 57.3
Urine today – ACR 55.2

Blood Today – Urea 5.0 / Creatinine 72 / eGFR> 60 / Sodium 138 / Potassium 4.0 /  HBA1c  8.1

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Assuming there is no microscopic haematuria, then I think it is fair to assume that the raised ACR is due to diabetic nephropathy.  At that level, I would be looking to improve his BP further – ideally a target of 125/75 to be sure we match current recommendations.  The ACEi is indicated as he is a diabetic with proteinuria.  In some patients adding in an ARB may improve BP and reduce proteinuria further. (Controversial whether that improves outcomes though).

I would have some concerns about a diabetic patient (albeit good renal function) on the combination of an ACEi, Metformin and regular NSAIDs. Essentially he must discontinue the ACEi and NSAID in the event of any intercurrent illness such as diarrhoea, vomiting or fever. I would review whether he needs regular NSAID.


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