Kidney Disease, Chronic

KIDNEY DISEASE, CHRONIC 51A

A 58-year-old obese woman with hypertension, type 2 diabetes mellitus, and chronic kidney disease (CKD) is admitted to the hospital after a right femoral neck fracture sustained in a fall. Recently, she has been complaining of fatigue and was started on epoetin alfa subcutaneous injections. Her other medications include an angiotensin-converting enzyme (ACE) inhibitor, a β-blocker, a diuretic, calcium supplementation, and insulin. On review of systems, she reports mild tingling in her lower extremities. On examination, her blood pressure is 148/60 mm Hg.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Hypertension; diabetes mellitus; anemia, responsive to epoetin alfa injections; lower extremity tingling suggestive of neuropathy

How to think through: What are the likely contributors to this patient’s CKD? (Hypertension, leading to glomerulosclerosis or to renal artery stenosis [or both], along with diabetic nephropathy, both likely contribute. Obesity-related kidney disease presents a third, independent possibility.) What studies would be appropriate? (Urinalysis with microscopy, urine protein measurement, renal ultrasonography.) How can urine protein be estimated? (The ratio of spot urine protein to urine creatinine approximates the number of grams of protein lost per day. A ratio >3.5 indicates nephrotic range proteinuria, which would be unexpectedly high for the above causes.) Is a renal biopsy needed? (No. In the absence of unexpected findings on the above studies or an unexpected course, the diagnosis of CKD is based on epidemiologic risk factors.) What treatments are known to slow the progression of CKD? (ACE inhibitor or angiotensin receptor blocker [ARB]; control of hypertension with a goal systolic blood pressure of ≤130 mm Hg; optimal control of diabetes.) What are the important aspects of management of this patient’s CKD while she is in the hospital? (Adjustment of all medication dosing. Monitoring of electrolytes, weight, volume status, input and output. Avoidance of nonsteroidal antiinflammatory drugs.)