CASE PRESENTATION: Diabetes Mellitus Type 2, Hypertension, Proteinuria, Edema' - PowerPoint PPT Presentation

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CASE PRESENTATION: Diabetes Mellitus Type 2, Hypertension, Proteinuria, Edema'

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Division of Nephrology and Hypertension. Director CME, Department of Medicine ... Lungs Clear to auscultation. CVS RR, Rate 82, S1 S2 normal. No S3, S4, murmurs ... – PowerPoint PPT presentation

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Title: CASE PRESENTATION: Diabetes Mellitus Type 2, Hypertension, Proteinuria, Edema'


1
CASE PRESENTATIONDiabetes Mellitus Type 2,
Hypertension, Proteinuria, Edema.
  • Vinod Prasad M.D
  • PGY2, Internal Medicine.
  • Allan B Schwartz M.D
  • Professor of Medicine
  • Division of Nephrology and Hypertension
  • Director CME, Department of Medicine
  • Drexel University College of Medicine.

2
A 53 year old obese AAF
  • Type 2 DM x 15 years
  • HTN x 15 years
  • Hyperlipidemia x 3 years
  • Diabetic proliferative retinopathy
  • Diabetic neuropathy x 1 year
  • Proteinuria
  • Asthma x 35 years

3
ROS - positives
  • Diminished visual acuity both eyes
  • Class 1 dyspnea on exertion
  • Numbness and tingling in both legs
  • Bilateral ankle swelling
  • Leg claudication

4
Medications
  • Cardizem CD 240 mg qd
  • Lasix 80 mg bid
  • Kdur 20 meq qd
  • Pravachol 30 mg qd
  • Insulin 70/30 20u qam and 10u qpm
  • Albuterol MDI
  • Prempro 0.625 mg qd
  • Allergic to penicillin.

5
Social history
  • No tobacco, No ETOH, no IVDA
  • On disability
  • Lives with grandchildren
  • Family history
  • Mother has DM and HTN
  • Father died of MI in his 60s.

6
Physical exam
  • Temp - 98 F, HR - 82/min, bp -180/90, RR- 16.
  • Obese - 5 2, 224 lbs. BMI - 41, NAD.
  • HENT Visual acuity 3/20 both eyes
  • Fundus microaneurysms, hemorrhages, hard
    exudates, neovascularization.
  • Neck bilateral carotid bruits

7
Physical.. continued
  • Lungs Clear to auscultation
  • CVS RR, Rate 82, S1 S2 normal. No S3, S4,
    murmurs
  • Abdomen Obese, Soft, no palpable masses, BS
  • Extremities 2 to 3 edema bilateral up to
    knees
  • Neuro Decreased vibration and fine touch
    sensation below knees bilateral.

8
Labs
  • Creatinine 1.1, 1.2 mg/dl
  • 24 hour urine protein 1800 mg
  • Creatinine clearance 45 ml/min.
  • HbA1c 8.6

9
Enrolled in IDNT study
  • Double blinded study protocol
  • Irbesartan, Amlodipine or placebo in addition to
    standard therapy.
  • Medications titrated for control of bp, edema and
    blood sugar for 2 years
  • Lasix increased to 160 mg tid.
  • Clonidine 0.05 mg bid metolazone 5 mg qd were
    added in addition to study medication.

10
Follow up
11
Follow up
12
Next 2 years
  • Progressive loss of renal function - doubling of
    serum creatinine.
  • Increasing proteinuria nephrotic range.
  • Refractory edema.

13
Questions
  • Explain patients blood pressure response
    variance with proteinuria and creatinine
    clearance ?
  • Why was the edema difficult to control?
  • Why did the serum creatinine double during the 2
    year period?
  • What would you have done next to manage the
    patient?

14
Next step
15
  • Taken off the study protocol in 5/00.
  • The code was broken revealed that the study
    drug was Amlodipine.
  • Started on open labeled irbesartan 75 mg qd and
    titrated up to 150 mg bid.

16
Follow up
17
Follow up
18
Next 4 years
  • Proteinuria lt200 mg/24 hours
  • Edema responsive
  • Creatinine improved / stable.

19
Questions
  • What is the reason for the impressive
    proteinuria response?
  • Why did the edema disappear ?
  • Why did the creatinine clearance improve /
    stabilize ?
  • Compare the bp control with the Amlodipine
    regimen ( non dihydropyridine Ca channel Blocker)
    vs the Irbesartan regimen ( Angiotensin receptor
    blocker).

20
Thank you.
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