Clinical Scenario: Managing Progressive CKD in a Patient with Diabetes
Patient Profile
Name: Maria Rodriguez
Age: 62 years
Occupation: Retired elementary school teacher
Initial Presentation
Maria is a 62-year-old woman with a 15-year history of type 2 diabetes who presents to her primary care physician for routine follow-up. Her recent lab work shows worsening kidney function with an eGFR of 38 mL/min/1.73m² (CKD Stage 3b), down from 45 mL/min/1.73m² six months ago. Her urine albumin-to-creatinine ratio (UACR) is 320 mg/g, indicating moderate albuminuria.
Medical History
•Type 2 diabetes mellitus (15 years)
•Hypertension (12 years)
•Hyperlipidemia
•Obesity (BMI 32 kg/m²)
•Diabetic retinopathy (mild)
Current Medications
•Metformin 1000 mg twice daily
•Glipizide 10 mg daily
•Lisinopril 20 mg daily
•Atorvastatin 40 mg daily
•Aspirin 81 mg daily
Recent Laboratory Results
•HbA1c: 7.8%
•Serum creatinine: 1.6 mg/dL (baseline 1.3 mg/dL six months ago)
•eGFR: 38 mL/min/1.73m² (CKD-EPI)
•UACR: 320 mg/g
•Potassium: 4.8 mEq/L
•Hemoglobin: 11.2 g/dL
•Calcium: 9.2 mg/dL
•Phosphorus: 4.0 mg/dL
•PTH: 85 pg/mL (slightly elevated)
•Vitamin D (25-OH): 22 ng/mL (insufficient)
Clinical Assessment
Maria reports increasing fatigue over the past few months. She has been monitoring her blood glucose at home with readings ranging from 130-180 mg/dL. Her blood pressure today is 142/88 mmHg. She admits to occasional dietary indiscretions and has been less active due to knee pain from osteoarthritis.
Management Challenges
Challenge 1: Medication Adjustments
Issue: Metformin is generally not recommended at full dose when eGFR falls below 45 mL/min/1.73m², and is contraindicated below 30 mL/min/1.73m².
Solution:
•Reduce metformin to 500 mg twice daily
•Consider adding an SGLT2 inhibitor (e.g., empagliflozin) which has proven reno-protective effects in diabetic kidney disease
GLP-1 receptor agonists can help patient as well with weight management , diabetes control and has reno-protective effects as well
•Monitor kidney function more frequently (every 3 months)
Challenge 2: Blood Pressure Control
Issue: Target BP for patients with diabetes and CKD is <130/80 mmHg. Maria’s current BP is above target.
Solution:
•Increase lisinopril to 40 mg daily if tolerated
•Consider adding a long-acting calcium channel blocker (e.g., amlodipine 5 mg daily)
•Emphasize sodium restriction (<2 g/day)
•Recommend home BP monitoring with a target of <130/80 mmHg
Challenge 3: CKD Progression
Issue: Maria’s kidney function is declining at a concerning rate.
Solution:
•Refer to nephrology for co-management
•Optimize RAAS blockade with careful monitoring of potassium and creatinine
•Educate about avoiding nephrotoxins (NSAIDs, certain antibiotics)
•Implement comprehensive lifestyle modifications
Challenge 4: Early CKD Complications
Issue: Maria is showing early signs of CKD-related complications (anemia, vitamin D deficiency, secondary hyperparathyroidism).
Solution:
•Start vitamin D supplementation (ergocalciferol 50,000 IU weekly for 8 weeks, then monthly)
•Monitor hemoglobin quarterly; consider erythropoiesis-stimulating agents if hemoglobin drops below 10 g/dL
•Monitor calcium, phosphorus, and PTH levels regularly
•Consider nephrology referral for management of CKD-MBD
Interdisciplinary Care Plan
Primary Care Provider
•Coordinate overall care
•Adjust medications for diabetes and hypertension
•Monitor for complications
•Provide regular follow-up (every 3 months)
Nephrologist
•Evaluate for secondary causes of kidney disease
•Manage CKD-specific complications
•Plan for future renal replacement therapy if needed
•Co-manage with primary care
Certified Diabetes Educator
•Provide education on diabetes self-management
•Assist with glucose monitoring
•Advise on dietary modifications for both diabetes and CKD
Dietitian
•Design a renal-diabetic diet plan
•Provide education on sodium, potassium, and phosphorus restriction
•Ensure adequate protein intake without excess
Pharmacist
•Perform medication reconciliation
•Adjust medication dosages based on kidney function
•Monitor for drug interactions
Patient Education and Self-Management
Key Education Points
1.Understanding CKD: Explain the nature of diabetic kidney disease and its progression
2.Medication Adherence: Emphasize the importance of taking medications as prescribed
3.Diet: Provide specific guidance on a renal-diabetic diet
4.Monitoring: Teach home monitoring of blood pressure and blood glucose
5.Red Flags: Educate about warning signs requiring immediate medical attention
Self-Management Goals
1.Maintain blood glucose between 100-180 mg/dL
2.Achieve home blood pressure readings <130/80 mmHg
3.Limit sodium intake to <2 g/day
4.Engage in physical activity for 30 minutes, 5 days per week
5.Monitor weight and report gains >2 kg in 3 days
Follow-Up and Outcomes
Three-Month Follow-Up
•eGFR stabilized at 39 mL/min/1.73m²
•UACR decreased to 220 mg/g
•BP improved to 128/76 mmHg
•HbA1c improved to 7.2%
•Patient reports increased energy levels
Six-Month Follow-Up
•eGFR stable at 40 mL/min/1.73m²
•UACR further decreased to 180 mg/g
•BP maintained at 126/74 mmHg
•HbA1c stable at 7.0%
•Vitamin D levels normalized
•PTH decreased to 65 pg/mL
Key Lessons for Clinical Practice
1.Early Intervention: Prompt action when kidney function declines can slow progression
2.Medication Optimization: SGLT2 inhibitors and RAAS blockers provide renoprotection
3.Multidisciplinary Approach: Coordinated care between primary care and nephrology improves outcomes
4.Patient Engagement: Involving patients in their care plan enhances adherence
5.Regular Monitoring: Frequent assessment allows for timely interventions
Discussion Points for Healthcare Providers
1.At what point should primary care physicians refer patients with CKD to nephrology?
2.How can communication between primary care and nephrology be optimized?
3.What strategies can improve patient adherence to complex medication regimens?
4.How should medication adjustments be prioritized in patients with multiple comorbidities?
5.What role do newer agents (SGLT2 inhibitors, GLP-1 receptor agonists) play in managing diabetic kidney disease?