A 55-year-old man comes to the office for a routine checkup. The patient was diagnosed with type 2 diabetes mellitus 3 years ago, and treatment was initiated with metformin and lifestyle modification. Liraglutide was added to his medical regimen a year ago due to inadequate glycemic control. The patient reports no symptoms other than the occasional "feelings of low blood sugar" when he skips a meal. Blood glucose readings during those episodes have been 60-70 mg/dL. He also takes atorvastatin for hyperlipidemia and low-dose aspirin. The patient smoked a pack of cigarettes daily for 30 years but quit when he was diagnosed with diabetes. He does not use alcohol or recreational drugs. Blood pressure is 128/80 mm Hg, pulse is 76/min, and respirations are 14/min. BMI is 27.5 kg/m². Physical examination shows normal heart and lung sounds and normal pulses in the extremities. There are no lower extremity ulcers or calluses, and vibration and sensory function is intact. Pressure testing with a 10-g monofilament is normal. Laboratory results are as follows: Urinalysis is negative for protein, glucose, cells, or casts, and ECG shows no abnormalities. Which of the following is the most appropriate next step in management of this patient?

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Explanation: Diabetic kidney disease (DKD) is a common complication in patients with longstanding diabetes. Patients can develop proteinuria and progressive renal dysfunction. Rising serum creatinine occurs late in the disease; therefore, it is critical to assess urinary protein (ie, albumin) excretion as a more sensitive marker for early DKD. Normal albumin excretion is <30 mg/day. Patients are diagnosed as having moderately increased albuminuria (previously known as microalbuminuria) with excretion of 30-300 mg/day and severely increased albuminuria (previously known as overt proteinuria) with excretion >300 mg/day. Ordinary (dipstick) urinalysis is insensitive for early nephropathy and may not be positive until albumin excretion is >300 mg/day. Options for screening include: 24-hour urine albumin: Gold standard test but cumbersome and often incorrectly collected by patients Spot urine albumin: Easy to obtain but accuracy varies with fluid intake and urinary output Urine albumin/creatinine ratio (untimed): Corrects for fluid balance and improves accuracy compared to spot sample and therefore the most preferred and practical test Patients with type 1 diabetes should be screened for early DKD starting 5 years after diagnosis. In contrast, patients with type 2 diabetes often have hyperglycemia (and glomerular injury) for years before diagnosis and should therefore be screened yearly beginning at the time of diagnosis. (Choice A) ACE inhibitors (eg, lisinopril) and angiotensin II receptor blockers are the preferred medications for hypertension in patients with diabetes and for normotensive patients with DKD. However, they are not recommended for normotensive patients without DKD. (Choice C) This patient has good overall glycemic control. Although he has hypoglycemic symptoms when he misses a meal, his glucose at these times is not significantly low. Liraglutide has a low risk of severe hypoglycemia and should be continued. (Choice D) This patient has a small elevation in triglycerides of minimal clinical significance. Niacin can lower triglycerides but is not proven to reduce the risk of cardiac events in patients on statin therapy. (Choice E) This patient is at risk for coronary artery disease but has good glycemic and blood pressure control and is on statin and antiplatelet therapy. No changes in management are necessary regardless of findings on stress testing. Screening asymptomatic patients for coronary disease is not recommended. Educational objective: Patients with diabetes should be screened yearly for diabetic kidney disease with a urine albumin/creatinine ratio. Serum creatinine and dipstick urine protein testing have low sensitivity and are not recommended for screening. References: Diabetic kidney disease: diagnosis, treatment, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/31194487) Update on diabetic nephropathy: core curriculum 2018. (http://www.ncbi.nlm.nih.gov/pubmed/29398179)

A 55-Year-Old Man Comes to the Office for a Routine