What is the management plan for a patient with Diabetes Mellitus (DM) and Hypertension (HT) presenting with edema, poor glycemic control (HbA1c 9.8%), Impaired Renal Function (eGFR 56 ml/min/1.73 m²), significant albuminuria, and moderate Non-Proliferative Diabetic Retinopathy (NPDR)?

Management Plan for a 50-year-old Lady with DM, HT, Edema, and Diabetic Complications

The patient requires a comprehensive treatment strategy focusing on glycemic control, blood pressure management, albuminuria reduction, and addressing diabetic retinopathy to reduce risks of kidney disease progression and cardiovascular complications. 1

Glycemic Control

• Implement intensive glycemic control targeting HbA1c <7.0% to decrease microvascular complications 1
• For this patient with type 2 diabetes and eGFR of 56 ml/min/1.73m²:
  • Start or continue metformin (can be used with eGFR ≥30 ml/min/1.73m²) 1
  • Add SGLT2 inhibitor as first-line therapy (can be initiated with eGFR ≥20 ml/min/1.73m²) for both glycemic control and renoprotection 1
  • Consider adding GLP-1 receptor agonist if glycemic targets not achieved with metformin and SGLT2 inhibitor 1
• Monitor blood glucose regularly and adjust insulin regimen if needed, with careful attention to hypoglycemia risk in the setting of CKD 2

Blood Pressure Management

• Initiate or optimize ACE inhibitor or ARB therapy and titrate to the highest tolerated dose, as the patient has both hypertension and albuminuria 1
• Target blood pressure <130/80 mmHg 1
• Monitor serum creatinine and potassium within 2-4 weeks after starting or changing dose of ACEi/ARB 1
• Continue ACEi/ARB unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase 1
• Add dihydropyridine calcium channel blocker and/or diuretic if needed to achieve blood pressure target 1
• Consider mineralocorticoid receptor antagonist (such as finerenone) for resistant hypertension and additional renoprotection given the significant albuminuria 1

Management of Albuminuria and CKD

• The patient has Stage 3a CKD (eGFR 56 ml/min/1.73m²) with moderate albuminuria (A2 category) requiring specific interventions 1
• Maximize RAS blockade with ACEi/ARB as the cornerstone of therapy for albuminuria 1
• SGLT2 inhibitor is strongly recommended for renoprotection in this patient 1
• Reduce dietary sodium intake to <2.3 g/day to optimize effectiveness of antihypertensive medications 1
• Monitor kidney function and albuminuria every 3-6 months 1
• Screen annually for progression of kidney disease by assessment of eGFR and urinary albumin:creatinine ratio 1

Management of Diabetic Retinopathy

• Refer to ophthalmologist for management of moderate NPDR 1
• Recommend annual dilated eye examinations by an ophthalmologist 1
• Tight glycemic and blood pressure control are essential for preventing progression of retinopathy 1, 3
• Note that diabetic retinopathy severity is a prognostic factor for CKD progression, warranting closer monitoring of renal function 4

Lipid Management

• Start or continue statin therapy for cardiovascular risk reduction 1
• Target LDL-C based on cardiovascular risk assessment 1
• Consider more intensive lipid-lowering therapy given the presence of multiple risk factors (diabetes, hypertension, CKD, and retinopathy) 1

Lifestyle Modifications

• Provide structured education on diabetes self-management 1
• Recommend moderate-intensity physical activity for at least 150 minutes per week 1
• Advise dietary modifications including sodium restriction (<2.3 g/day), moderate protein intake, and appropriate carbohydrate management 1
• Encourage weight management if overweight or obese 1
• Advise smoking cessation if applicable 1

Follow-up and Monitoring

• Regular risk factor reassessment every 3-6 months 1
• Monitor blood pressure, glycemic control, kidney function, and albuminuria 1
• Schedule follow-up eye examination in 6-12 months or sooner if visual symptoms develop 1
• Evaluate for signs of fluid overload and adjust diuretic therapy as needed to manage edema 1
• Screen for other diabetes complications including neuropathy 1

Pitfalls and Caveats

• Be cautious with metformin dose adjustment based on eGFR 1
• Monitor for hyperkalemia when using ACEi/ARB, especially in combination with mineralocorticoid receptor antagonists 1
• Avoid combination therapy with ACEi and ARB as it can be harmful 1
• Watch for orthostatic hypotension with aggressive blood pressure control, particularly in patients with diabetic autonomic neuropathy 1
• Be aware that diabetic retinopathy and nephropathy may not always progress at the same rate, especially in type 2 diabetes 5