Nephrology

PCP submission

56-year-old male with HTN and DMII- poorly controlled  due to insurance changes with noncompliance (HbA1c 9.4, on insulin).

Creatinine 1.5 and eGFR 50 last month. Follow-up eGFR 43.

Resumed lisinopril 40mg (prior long-term regimen with HCTZ).  SBP ranging 150s-170s, max SBP 200 in office, asymptomatic.  

Should lisinopril be discontinued or should I consider additional antihypertensive medications? Options for imaging such as renal artery ultrasound or nephrology referral are limited.

Specialist response

If a patient like this presented to me, these would be my general thoughts: I suggest the following- 

1. With DM and CKD and HTN, ACEi or ARB will offer significant benefits over risks. As long as he is able to remain well hydrated and is able to get periodic chem-7 checks (every 3 months or so), I will continue ACEi. 
2. Confirm not taking NSAIDS. 
3. Of course, if insurance or other limitations are really restricting and if you have to prioritize one aspect of his care then I will focus on DM control as a renoprotective measure. Although, he will very likely need some antihypertensive agent. If follow up with chem-7 is not possible due to insurance then amlodipine will be an alternative antihypertensive to consider. 
4. Advise low salt diet 
5. Once he gets insurance then I suggest additional work up to include- renal US, urinalysis with sediment, and hepatitis panel, PTH, phosphorous, CBC, iron studies.