A Caucasian Man with Newly Diagnosed Type 2 Diabetes and Renal Insufficiency, Part 1

Mr. Walker visited his physician a few days later at his wife's request and had an A1C measurement of 7.5%.

Despite his physician's recommendation at that time to go on medication to treat his diabetes, Mr. Walker insisted he felt fine and wanted to try diet and exercise to see if he could avoid medication. He stated that his wife, who also has type 2 diabetes, had the knowledge to help him with the changes.

In addition to his diabetes, Mr. Walker

• has a 17-year history of hypertension and dyslipidemia, neither of which were well-controlled until 3 years ago
• had a cardiac catheterization 3 years ago and was diagnosed with mild diffuse cardiovascular disease, but an intervention was not indicated at that time
• has stable angina
• was diagnosed with renal insufficiency 2 years ago

During the visit, Mr. Walker, who works as a construction supervisor, explained that he has had an increase in the amount of stress in his life during the past 6 months and that he has not been very successful at watching his diet. This has been putting a strain on his marriage and he states he now realizes he needs to get control of his diabetes in order to improve both his health and his marriage.

Case Details

Based on Mr. Walker’s initial presentation and laboratory values, what management recommendations, in addition to glycemic control, do you feel should be addressed at this visit?

1.    Add an agent to improve blood pressure management

2.    Optimize renal function

3.    Decrease cardiovascular disease risk

4.    Medical nutrition therapy

5.    All of the above

All management areas (glycemic control, blood pressure, renal function, cardiovascular risk, and medical nutrition therapy) need to be addressed for this patient.

Question 1 Explanation: Improved glycemic control

Glycemic control, blood pressure, renal function, cardiovascular risk, and medical nutrition therapy all need to be addressed.  

Mr. Walker’s A1C of 8.3% is above goal:

• American Diabetes Association (ADA) 2009 Clinical Practice Recommendations: <7.0%
• American College of Endocrinology (ACE)/American Association of Clinical Endocrinologists (AACE): ≤6.5%
• CADRE: The lowest A1C possible without unacceptable hypoglycemia, with action recommended at an A1C >7.0% (caution is recommended in children, the elderly, and higher risk populations)

Mr. Walker is not currently on a medication to treat his diabetes, so one should be prescribed at this visit.

Question 1 Explanation: Improved blood pressure control 

Glycemic control, blood pressure, renal function, cardiovascular risk, and medical nutrition therapy all need to be addressed.  

Although Mr. Walker is currently on two medications, an ACE inhibitor and a thiazide diuretic, his blood pressure is above the level recommended. 

Guidelines for patients with a systolic blood pressure of 130 to 139 mmHg and a diastolic blood pressure of 80 to 89 mmHg are to initiate lifestyle modification with  

• increased physical activity
• weight loss
• reduced sodium intake
• an emphasis on increased consumption of fruits, vegetables, and low fat dairy products
• moderation in alcohol consumption 

Because Mr. Walker has renal insufficiency, and tight blood pressure control may slow the progression of his kidney disease, lifestyle modification may not be enough and another medication should be added. 

Question 1 Explanation: Optimizing renal function

Glycemic control, blood pressure, renal function, cardiovascular risk, and medical nutrition therapy all need to be addressed.

It will be important to optimize Mr. Walker’s renal function, as it will slow the progression of his existing nephropathy. This can be achieved with excellent glycemic and blood pressure control. 

Question 1 Explanation: Decreasing cardiovascular risk

Glycemic control, blood pressure, renal function, cardiovascular risk, and medical nutrition therapy all need to be addressed.

Mr. Walker is currently taking simvastatin 40 mg daily for his dyslipidemia.

Because improving his glycemic control will likely improve his lipid parameters, it is acceptable to keep him on his current statin medication and reassess his need for additional medication at a follow-up visit.  

Optimizing Mr. Walker’s blood pressure will also reduce his cardiovascular disease risk.

Question 1 Explanation: Medical nutrition therapy 

Glycemic control, blood pressure, renal function, cardiovascular risk, and medical nutrition therapy all need to be addressed.

Mr. Walker needs multiple dietary changes due to his obesity, diabetes, hypertension, cardiovascular disease, and kidney disease. He and his wife need education from a registered dietitian to assist them in planning meals that meet all of his dietary needs. Mr. Walker should be encouraged to share meal planning responsibilities, which may reduce some of the stress in their marriage.