A 58-year-old man with a history of type 2 diabetes mellitus comes to the office for a follow-up visit. Medical history also includes hypertension, hyperlipidemia, coronary artery disease, and osteoarthritis. He has diabetic nephropathy with a baseline creatinine of 2.0-2.5 mg/dL. The patient's mobility is impaired due to right knee osteoarthritis and diabetic neuropathy. Medications include acetaminophen, insulin, metoprolol, valsartan, chlorthalidone, aspirin, and atorvastatin.
Blood pressure is 159/102 mm Hg and pulse is 68/min. BMI is 36 kg/m². Physical examination shows 2+ bilateral lower extremity edema.
Laboratory results are as follows:
Which of the following is the best next step in management of this patient?

Question

A 58-year-old man with a history of type 2 diabetes mellitus comes to the office for a follow-up visit. Medical history also includes hypertension, hyperlipidemia, coronary artery disease, and osteoarthritis. He has diabetic nephropathy with a baseline creatinine of 2.0-2.5 mg/dL. The patient's mobility is impaired due to right knee osteoarthritis and diabetic neuropathy. Medications include acetaminophen, insulin, metoprolol, valsartan, chlorthalidone, aspirin, and atorvastatin.
Blood pressure is 159/102 mm Hg and pulse is 68/min. BMI is 36 kg/m². Physical examination shows 2+ bilateral lower extremity edema.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_990b_d6b2_853d_5333ee6190b6_MD0002_00 This patient has uncontrolled hypertension despite multiple antihypertensive medications. In addition, he is at increased risk for complications due to underlying diabetes and chronic kidney disease (CKD). Patients with CKD should have a target blood pressure of <140/90 mm Hg, and many experts recommend even more aggressive control. ACE inhibitors and angiotensin II receptor blockers (ARBs) (eg, valsartan) are first-line antihypertensive agents in patients with proteinuric CKD (ie, proteinuria >500 mg/day). For patients who have persistent hypertension despite first-line therapy, a diuretic or non-dihydropyridine calcium channel blocker (eg, diltiazem, verapamil) may be added. Diuretics are especially useful for patients with edema (such as this patient) as euvolemia can increase the effectiveness of other antihypertensives. However, thiazide diuretics (eg, chlorthalidone) are less effective in patients with creatinine clearance <30 mL/min/1.73 m²; these patients should be transitioned to loop diuretics (eg, furosemide). If loop diuretics alone are ineffective at improving edema, a thiazide may be added again to improve diuresis. The addition of furosemide would likely reduce this patient's mild hyperkalemia as well. (Choices A and D) This patient is appropriately on an ARB (valsartan). There is little benefit in substituting an ACE inhibitor (eg, lisinopril) for an ARB beyond cost considerations and a slightly reduced rate of symptomatic hypotension. Adding an ACE inhibitor to an ARB is not recommended as combined therapy is associated with an increased risk of hypotension and hyperkalemia. (Choices B and E) Calcium channel blockers (eg, amlodipine) and aldosterone antagonists (eg, spironolactone) are excellent options for third- or fourth-line therapy in proteinuric CKD. However, non-dihydropyridine blockers are preferred over dihydropyridines due to their effect on proteinuria. Also, aldosterone antagonists may worsen this patient's hyperkalemia. Educational objective: In patients with hypertension and proteinuric chronic kidney disease, diuretics can correct edema and increase the effectiveness of other antihypertensive medications. Loop diuretics are more effective than thiazide diuretics in patients with creatinine clearance <30 mL/min/1.73 m². ² __________ References: Thiazide diuretics in advanced chronic kidney disease. (http://www.ncbi.nlm.nih.gov/pubmed/22951101) 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). (http://www.ncbi.nlm.nih.gov/pubmed/24352797)

A 58-Year-Old Man with a History of Type 2 Diabetes