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Case Spotlight

Nephrology

General

Summary

  • 56 year old male with poorly controlled HTN and type 2 diabetes with new worsening kidney function.
  • PCP asked for advice on management and workup of new worsening kidney function since options for imaging such as renal artery ultrasound or nephrology referral are limited.
  • Specialist recommended ACEi or ARB and said that if insurance and other limitations are restricting care, the PCP should focus on diabetes control and advising the patient to be on a low-salt diet.
  • Specialist also recommended additional workup to include renal US, urinalysis with sediment, and hepatitis panel, PTH, phosphorous, CBC and iron studies once the patient gets insurance.

eConsult transcript

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 patient is 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 them to follow a 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.

Tags: insurance, noncompliance, poorly controlled, co-morbidities