What is the management for an 84-year-old male with hyperglycemia, elevated Blood Urea Nitrogen (BUN), and impaired renal function?

From the Guidelines

This patient requires immediate medical attention for acute kidney injury and hyperglycemia, and should be referred to the emergency department or nephrology for urgent evaluation. The management of this patient should prioritize the prevention of further kidney deterioration and the control of blood glucose levels.

Initial Management

• Initial management should include intravenous fluid administration (normal saline at 100-150 mL/hour) to improve kidney perfusion,
• temporary discontinuation of potentially nephrotoxic medications (such as NSAIDs, ACE inhibitors, ARBs),
• and close monitoring of electrolytes, particularly potassium, as recommended by 1.

Glycemic Control

• For the elevated glucose, regular insulin may be needed based on blood glucose levels, with careful monitoring to avoid hypoglycemia,
• and the patient's medication list should be reviewed and adjusted based on renal function, with appropriate dose reductions for renally cleared drugs, as suggested by 1.

Renal Function Monitoring

• A comprehensive metabolic panel, urinalysis, and renal ultrasound should be ordered to determine the cause of kidney dysfunction,
• and serum creatinine and potassium should be monitored after initiation of treatment with an ACE inhibitor or ARB, MRA, or diuretic, as recommended by 1.

Long-term Management

• The patient should be managed with a multimodal approach, including antihypertensive treatments and closer control of glycaemia,
• with the goal of slowing down the progression of diabetic chronic kidney disease (DCKD) and reducing cardiovascular complications and mortality, as recommended by 1.

Medication Adjustment

• The use of ACE inhibitors or angiotensin antagonists (sartans) is recommended for patients with DCKD,
• as they have been shown to decrease mortality, slow down the progression of DCKD to end-stage renal failure, and reduce glomerular hyperfiltration and its consequences, as suggested by 1.

Lifestyle Modifications

• The patient should be advised to make lifestyle modifications, including dietary changes and increased physical activity,
• to help control blood glucose levels and slow down the progression of kidney disease, as recommended by 1.

Regular Follow-up

• The patient should have regular follow-up with a healthcare provider to monitor kidney function, blood glucose levels, and blood pressure,
• and to adjust the treatment plan as needed to prevent further kidney deterioration and cardiovascular complications, as recommended by 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management of Hyperglycemia and Impaired Renal Function

The management of an 84-year-old male with hyperglycemia, elevated Blood Urea Nitrogen (BUN), and impaired renal function involves several key considerations:

• Evaluating the cause of reduced kidney function to determine if it is due to chronic kidney disease or acute kidney injury (AKI) 2
• Assessing the patient's clinical history, medication, and laboratory values to provide a first suspicion diagnosis 2
• Conducting further investigations, such as abdominal sonography, urinary sediment, and proteinuria, to confirm the diagnosis 2
• Referring the patient to a nephrologist for further evaluation and management, especially if there is no obvious cause of AKI or if the patient has severe renal insufficiency with rapid progression of kidney failure 2, 3

Role of Nephrologist Referral

Referral to a nephrologist is crucial for patients with elevated serum creatinine levels, as it can lead to:

• Identification and treatment of reversible causes of renal failure 3
• Slowing the rate of decline associated with progressive renal insufficiency 3
• Management of coexisting conditions associated with chronic renal failure 3
• Facilitating efficient entry into dialysis programs for patients who may benefit 3

Treatment Options

Treatment options for patients with chronic kidney disease (CKD) may include:

• Renin-angiotensin system (RAS) blockers, such as angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), to slow the progression of CKD and manage hypertension and albuminuria 4, 5
• Monitoring of serum creatinine and urine output to diagnose and stage acute kidney injury (AKI) 6

Considerations for Advanced Renal Dysfunction

For patients with advanced CKD, the use of RAS blockers may be beneficial, but the evidence is limited, and the risk of hyperkalemia or acute renal decline must be carefully considered 5