What is the management and treatment for an 84-year-old male with generalized edema, diminished foot sensation, and impaired renal function?

From the Guidelines

Management for this 84-year-old male with generalized edema, diminished foot sensation, and impaired renal function should focus on addressing both the edema and underlying causes, with initial treatment including a loop diuretic such as furosemide 20-40mg daily, careful monitoring of kidney function and electrolytes, and restriction of sodium intake to 2-3g daily and fluid intake to 1.5-2L per day. The patient's reduced kidney function, as indicated by a potential low eGFR, necessitates careful monitoring and potential adjustment of diuretic doses to avoid worsening renal function 1. Given the potential for diuretic resistance, especially in patients with significant impairment of renal function or perfusion, the use of intravenous diuretics, combination diuretic therapy, or diuretics with drugs that increase renal blood flow may be necessary 1.

Key Considerations

• Monitoring of daily electrolytes and renal function is crucial while administering intravenous diuretics or titrating heart failure medications 1.
• The patient should be evaluated for chronic kidney disease, and nephrology consultation is warranted given the reduced eGFR and creatinine levels.
• Diminished foot sensation suggests peripheral neuropathy, requiring neurological assessment and proper foot care to prevent complications.
• Daily weight monitoring can help track fluid status, and blood pressure control is essential, preferably with ACE inhibitors or ARBs if tolerated with his kidney function.
• Regular monitoring of renal function is crucial when using these medications, and evaluation for cardiac, hepatic, or other systemic causes of edema should be conducted through appropriate laboratory tests and imaging.

Treatment Approach

• Initial diuretic therapy with a loop diuretic such as furosemide, with doses adjusted based on patient response and renal function.
• Consideration of combination diuretic therapy or the use of diuretics with drugs that increase renal blood flow if diuretic resistance is encountered.
• Aggressive treatment of electrolyte imbalances and continued diuresis until fluid retention is eliminated, while carefully monitoring for hypotension and azotemia 1.
• Patient education on sodium and fluid restriction, daily weight monitoring, and the importance of adherence to the prescribed treatment regimen.

From the FDA Drug Label

5.3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].

The management and treatment for an 84-year-old male with generalized edema, diminished foot sensation, and impaired renal function should involve close monitoring of renal function while on lisinopril, as the patient is at risk of developing acute renal failure.

• Monitor serum potassium levels to avoid hyperkalemia, especially with concomitant use of potassium-sparing diuretics or in patients with diabetes.
• Adjust the dose of lisinopril according to the patient's renal function, and consider withholding or discontinuing therapy if a clinically significant decrease in renal function occurs.
• Avoid using lisinopril in patients who are hemodynamically unstable.
• Use with caution in patients with severe aortic stenosis or hypertrophic cardiomyopathy. 2

From the Research

Management and Treatment

The management and treatment of an 84-year-old male with generalized edema, diminished foot sensation, and impaired renal function can be complex and requires careful consideration of various factors.

• The patient's symptoms, such as generalized edema, may be indicative of acute heart failure (AHF) or other cardiovascular conditions 3, 4.
• Diuretic therapy is widely recommended in patients with AHF, with loop diuretics being the first-line treatment, especially intravenous furosemide 3.
• The dose and mode of administration of diuretics can vary depending on the patient's condition, with high-dose or low-dose therapy and continuous infusion or bolus administration being considered 3, 4, 5.
• In patients with impaired renal function, careful monitoring of serum electrolytes and kidney function is necessary during diuretic therapy 3, 6.
• Combination diuretic therapy, including thiazide diuretics and/or aldosterone antagonists, may be considered in patients with diuretic resistance or severe congestion 3, 4.
• The patient's diminished foot sensation may be related to underlying conditions such as diabetes or peripheral artery disease, which can affect treatment decisions 7.

Treatment Considerations

• The choice of diuretic and dose should be individualized based on the patient's condition, renal function, and response to treatment 4, 5.
• Patients with severely impaired kidney function may require higher doses of diuretics, up to 1000 mg per day, and close monitoring of renal function and electrolytes 4.
• The use of aldosterone antagonists, such as spironolactone, may be beneficial in patients with heart failure and reduced ejection fraction, but requires careful monitoring of potassium levels and renal function 3, 7.
• Thiazide diuretics can be helpful in combination with loop diuretics, especially in patients with residual congestion or impaired renal function 3, 6.