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?

See more of the history or available results?

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

Now consider which one of these three options to go for: 

  1. Give Advice
  2. See in Outpatients non-urgently
  3. Send this patient to us now!

Write your advice

Now read what the expert wrote

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.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below

Things to read:

[To do list; picture]

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?

See more of the history or available results?

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

Now consider which one of these three options to go for: 

  1. Give Advice
  2. See in Outpatients non-urgently
  3. Send this patient to us now!

Write your advice

Now read what the expert wrote

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.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below

Things to read:

[To do list; picture]