Prasad.ppt

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Prasad.ppt

  1. 1. CASE PRESENTATION: Diabetes Mellitus Type 2, Hypertension, Proteinuria, Edema. Vinod Prasad M.D PGY2, Internal Medicine. Allan B Schwartz M.D Professor of Medicine Division of Nephrology and Hypertension Director CME, Department of Medicine Drexel University College of Medicine.
  2. 2. A 53 year old obese AAF … <ul><li>Type 2 DM x 15 years </li></ul><ul><li>HTN x 15 years </li></ul><ul><li>Hyperlipidemia x 3 years </li></ul><ul><li>Diabetic proliferative retinopathy </li></ul><ul><li>Diabetic neuropathy x 1 year </li></ul><ul><li>Proteinuria </li></ul><ul><li>Asthma x 35 years </li></ul>
  3. 3. ROS - positives <ul><li>Diminished visual acuity both eyes </li></ul><ul><li>Class 1 dyspnea on exertion </li></ul><ul><li>Numbness and tingling in both legs </li></ul><ul><li>Bilateral ankle swelling </li></ul><ul><li>Leg claudication </li></ul>
  4. 4. Medications <ul><li>Cardizem CD 240 mg qd </li></ul><ul><li>Lasix 80 mg bid </li></ul><ul><li>Kdur 20 meq qd </li></ul><ul><li>Pravachol 30 mg qd </li></ul><ul><li>Insulin 70/30 – 20u qam and 10u qpm </li></ul><ul><li>Albuterol MDI </li></ul><ul><li>Prempro 0.625 mg qd </li></ul><ul><li>Allergic to penicillin. </li></ul>
  5. 5. Social history <ul><li>No tobacco, No ETOH, no IVDA </li></ul><ul><li>On disability </li></ul><ul><li>Lives with grandchildren </li></ul><ul><li>Family history </li></ul><ul><li>Mother has DM and HTN </li></ul><ul><li>Father died of MI in his 60s. </li></ul>
  6. 6. Physical exam <ul><li>Temp - 98 F, HR - 82/min, bp -180/90, RR- 16. </li></ul><ul><li>Obese - 5’ 2”, 224 lbs. BMI - 41, NAD. </li></ul><ul><li>HENT – Visual acuity 3/20 both eyes </li></ul><ul><li>Fundus – microaneurysms, hemorrhages, hard exudates, neovascularization. </li></ul><ul><li>Neck – bilateral carotid bruits + </li></ul>
  7. 7. Physical.. continued <ul><li>Lungs – Clear to auscultation </li></ul><ul><li>CVS – RR, Rate 82, S1 S2 normal. No S3, S4, murmurs </li></ul><ul><li>Abdomen – Obese, Soft, no palpable masses, BS + </li></ul><ul><li>Extremities – 2 to 3 + edema bilateral up to knees </li></ul><ul><li>Neuro – Decreased vibration and fine touch sensation below knees bilateral. </li></ul>
  8. 8. Labs <ul><li>Creatinine – 1.1, 1.2 mg/dl </li></ul><ul><li>24 hour urine protein – 1800 mg </li></ul><ul><li>Creatinine clearance – 45 ml/min. </li></ul><ul><li>HbA1c – 8.6 </li></ul>
  9. 9. Enrolled in IDNT study <ul><li>Double blinded study protocol </li></ul><ul><li>Irbesartan, Amlodipine or placebo in addition to standard therapy. </li></ul><ul><li>Medications titrated for control of bp, edema and blood sugar for 2 years </li></ul><ul><li>Lasix increased to 160 mg tid. </li></ul><ul><li>Clonidine 0.05 mg bid & metolazone 5 mg qd were added in addition to study medication. </li></ul>
  10. 10. Follow up 3+ 2+ 3+ 2 to 3+ Edema 110/70 146/86 136/84 180/90 BP 03/00 12/99 03/99 04/98
  11. 11. Follow up 25 39 35 45 Cr Clearance ml/min 4350 1989 1605 1800 24 urine protein mg 2.8 1.3 1.6 1.1 Creatinine mg/dl 03/00 12/99 03/99 04/98
  12. 12. Next 2 years <ul><li>Progressive loss of renal function - doubling of serum creatinine. </li></ul><ul><li>Increasing proteinuria – nephrotic range. </li></ul><ul><li>Refractory edema. </li></ul>
  13. 13. Questions <ul><li>Explain patient’s blood pressure response variance with proteinuria and creatinine clearance ? </li></ul><ul><li>Why was the edema difficult to control? </li></ul><ul><li>Why did the serum creatinine double during the 2 year period? </li></ul><ul><li>What would you have done next to manage the patient? </li></ul>
  14. 14. Next step …
  15. 15. <ul><li>Taken off the study protocol in 5/00. </li></ul><ul><li>The code was broken – revealed that the study drug was Amlodipine. </li></ul><ul><li>Started on open labeled irbesartan 75 mg qd and titrated up to 150 mg bid. </li></ul>
  16. 16. Follow up trace trace 1 to 2+ 0 trace Edema 120/80 130/80 110/80 140/60 120/70 BP 3/04 3/03 01/02 03/01 11/00
  17. 17. Follow up 26 20 20 25 23 Cr Clearance ml/min 30 150 100 150 50 24 urine protein mg 2.2 2.0 2.1 1.9 2.1 Creatinine mg/dl 3/04 3/03 01/02 03/01 11/00
  18. 18. Next 4 years <ul><li>Proteinuria <200 mg/24 hours </li></ul><ul><li>Edema responsive </li></ul><ul><li>Creatinine improved / stable. </li></ul>
  19. 19. Questions <ul><li>What is the reason for the impressive proteinuria response? </li></ul><ul><li>Why did the edema disappear ? </li></ul><ul><li>Why did the creatinine clearance improve / stabilize ? </li></ul><ul><li>Compare the bp control with the Amlodipine regimen ( non dihydropyridine Ca channel Blocker) vs the Irbesartan regimen ( Angiotensin receptor blocker). </li></ul>
  20. 20. Thank you.

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