Mr. G is a 65 year old man
who has a 15 year history of type 2 diabetes. He has an elevated creatinine
level of 3.3mg/dl and evidence of increasing proteinuria. He is currently
being managed with 20mgs of lisinopril for his hypertension. Measurement of 24
hour urinary protein has been in the nephrotic range. He has worsening
hypertension despite increasing therapy. Your next step would be:
1.Institute
a restricted protein diet.
2.
Increase the dose of the ACE inhibitor.
3.
Referral to a nephrologist.
4.
Add another antihypertensive agent.
A
restriction in dietary protein has been shown to be beneficial in patients
with type 1 diabetes and proteinuria, this is not the most appropriate
intervention in this scenario. In people with moderate proteinuria and
diabetes implementing treatment with an ACE inhibitor or increasing the dose
of the ACE inhibitor can slow the progression of their nephropathy. Mr. G has
nephrotic range proteinuria and evidence of significantly impaired renal
function. A referral to a nephrologist is the most appropriate intervention in
this case.
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