Image Quizzes

Pruritus and pitting edema

Reviewed by Romesh K. Khardori, MD, PhD

Clinical Photography, Central Manchester University Hospitals NHS Foundation Trust, UK/Science Source

A 47-year-old Black man presents with shortness of breath, pruritus, and pitting edema of the bilateral extremities, which have been present for 6 weeks. He has a 7-year history of type 2 diabetes, hypertension, and hyperlipidemia, as well as a 30–pack-year history of smoking. His blood pressure is 160/95 mm Hg, heart rate is 97 beats/min (regular rate and rhythm), and respiration is 26 breaths/min. He also has proliferative retinopathy. He is 5 ft 10 in and weighs 220 lb (BMI 31.6). He is taking metformin 2550 mg/d. Other medications include simvastatin 20 mg, amlodipine 10 mg, and hydrochlorothiazide 25 mg. He admits to being nonadherent to his medication regimen. A year ago, his estimated glomerular filtration rate (eGFR) was 66 mL/min/1.73 m2 and he had 1+ proteinuria.

Laboratory tests reveal hemoglobin of 8.7 g/dL, creatinine of 3.4 g/dL, eGFR of 32 mL/min/1.73 m2, serum albumin of 3.3 g/dL, A1c of 8.8%, low-density lipoprotein of 143 mg/dL, high-density lipoprotein of 43 mg/dL, random glucose of 186 mg/dL, albumin-creatinine ratio of 3250 mg/g, calcium of 8.7 mg/dL, phosphorus of 4.2 mg/dL, plasma parathyroid hormone of 77 pg/mL, and C-reactive protein of 12.

In summary, this patient has normal albumin levels and increased proteinuria with decreased eGFR. His glucose level and A1c are not controlled. In addition, he has anemia, a low serum albumin level, and edema.

This patient has diabetic nephropathy and is at risk for a cardiovascular event because of his eGFR and long history of diabetes, hypertension, tobacco use, and hyperlipidemia. Intervention to control these risk factors should start immediately to prevent progression to chronic kidney disease (CKD).

In patients with diabetic nephropathy, how should glycemic control be maintained?

Insulin

Metformin and a sodium-glucose cotransporter 2 inhibitor

A sulfonylurea and a glucagon-like peptide 1 receptor antagonist

Insulin and a sodium-glucose cotransporter 2 inhibitor

The 2020 Kidney Disease Improving Global Outcomes (KDIGO) diabetes management in CKD guideline states that most patients with diabetic nephropathy and an eGFR ≥ 30 mL/min/1.73 m 2 benefit from treatment with both metformin and a sodium-glucose cotransporter 2 (SGLT2) inhibitor, which have been demonstrated to offer substantial benefits in reducing the risks for diabetic nephropathy and cardiovascular disease.

In patients who do not reach individualized targets with metformin and an SGLT2 inhibitor, or who are unable to use these medications, a long-acting glucagon-like peptide 1 (GLP-1) receptor antagonist may be used.

Metformin should be administered with caution to patients with CKD because it may increase the risk for lactic acidosis. It is contraindicated in patients with an eGFR < 30, but this patient's eGFR is adequate. Many clinicians might use a lower metformin dosage (1500 mg) as a precaution. Given how high his A1c is, adding a GLP-1 receptor antagonist is probably going to be needed because an SGLT2 inhibitor is only intermediate in terms of glucose reduction.

For control of his hypertension, the American Diabetes Association recommends either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) as first-line treatment. However, one agent alone is unlikely to control this patient's hypertension. At his level of eGFR, a thiazide diuretic is unlikely to be very effective. Therefore, a loop diuretic should be initiated with the ACE inhibitor or ARB, especially because he has edema.

Romesh K. Khardori, MD, PhD, Professor, Department of Internal Medicine, Division of Diabetes, Endocrine, and Metabolic Disorders, Eastern Virginia Medical School; EVMS Medical Group, Norfolk, Virginia

Romesh K. Khardori, MD, PhD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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