SOAP Note: Diabetic Nephropathy with Uncontrolled Hypertension and Anemia
Subjective
- 55-year-old male with bilateral paresthesias in fingers and toes (likely diabetic neuropathy)
- Currently on multiple antihypertensive and antidiabetic medications
Objective
- BP: 170/100 mmHg (severely uncontrolled despite dual therapy)
- FBS: 8.12 mmol/L (146 mg/dL) - suboptimal glycemic control
- Creatinine: 200 μmol/L (2.26 mg/dL) - Stage 3b CKD (eGFR approximately 30-35 mL/min/1.73m²)
- Hemoglobin: 109 g/L (10.9 g/dL) - anemia of chronic kidney disease
- Urinalysis: Albuminuria, glucosuria, hyaline casts 6-8/lpf
- Current medications: Losartan 100mg daily, amlodipine 10mg daily, febuxostat 40mg daily, metformin 500mg BID, dapagliflozin 10mg, glimepiride + metformin combination
Assessment
This patient has diabetic nephropathy with severely uncontrolled hypertension requiring immediate medication intensification, not emergency IV therapy, as he lacks acute end-organ damage symptoms. 1, 2
Primary Problems:
- Stage 3b CKD with diabetic nephropathy - evidenced by elevated creatinine, albuminuria, and diabetes
- Uncontrolled hypertension (170/100 mmHg on dual therapy) - requires triple therapy
- Suboptimal diabetes control - FBS 8.12 mmol/L with glucosuria
- Anemia of CKD - Hgb 109 g/L
- Diabetic peripheral neuropathy - bilateral paresthesias
Critical Medication Issues:
- STOP metformin immediately - contraindicated with eGFR <30-35 mL/min/1.73m² due to lactic acidosis risk
- STOP glimepiride - high hypoglycemia risk with renal impairment
- Continue dapagliflozin cautiously - monitor closely as efficacy decreases with eGFR <45 mL/min/1.73m²
Plan
1. Blood Pressure Management - Target <130/80 mmHg 3, 4
Add a thiazide-like diuretic (chlorthalidone 12.5-25mg daily or indapamide 1.25-2.5mg daily) as third-line agent immediately. 3 The patient is already on maximal doses of losartan (ARB) and amlodipine (dihydropyridine CCB), representing appropriate first-line combination therapy for diabetic nephropathy. 3
Rationale: Triple therapy with ARB + CCB + thiazide-like diuretic is the recommended escalation pathway for uncontrolled hypertension in diabetes with CKD. 3 Thiazide-like diuretics (chlorthalidone, indapamide) are preferred over hydrochlorothiazide for superior cardiovascular event reduction. 3
If BP remains uncontrolled after 2-4 weeks on triple therapy, add spironolactone 12.5-25mg daily (monitor potassium closely given ARB use and renal impairment). 3
Monitor: Recheck BP in 2 weeks, then monthly until target achieved. 4 Check renal function and potassium 2-4 weeks after adding diuretic or spironolactone. 3, 4
2. Diabetes Management - Target FBS <7.0 mmol/L, HbA1c <7%
STOP metformin 500mg BID immediately - absolute contraindication with eGFR <30-35 mL/min/1.73m² due to lactic acidosis risk. 4
STOP glimepiride combination - sulfonylureas carry excessive hypoglycemia risk in renal impairment and do not provide cardiovascular or renal protection. 3
Continue dapagliflozin 10mg daily - SGLT2 inhibitors provide renoprotection and cardiovascular benefit in diabetic CKD, though glucose-lowering efficacy diminishes with eGFR <45 mL/min/1.73m². 3 Monitor for volume depletion given concurrent diuretic use.
Add basal insulin (e.g., insulin glargine 10 units subcutaneously at bedtime, titrate by 2 units every 3 days based on FBS) - safest option for glycemic control in advanced CKD without hypoglycemia risk of sulfonylureas. 3
Alternative: Consider DPP-4 inhibitor (linagliptin 5mg daily - no dose adjustment needed in CKD) if patient refuses insulin. 3
3. Renal Function Monitoring
Monitor eGFR and urine albumin-to-creatinine ratio every 3 months. 4 The patient has diabetic nephropathy with Stage 3b CKD requiring close surveillance.
Counsel patient to temporarily hold losartan and diuretics during acute illness with volume depletion (vomiting, diarrhea, fever) to prevent acute kidney injury. 4, 5
Avoid NSAIDs completely - nephrotoxic in CKD. 4
4. Anemia Management
Check iron studies, vitamin B12, folate, and consider erythropoietin level. Anemia of CKD typically develops when eGFR <45 mL/min/1.73m². 4
If iron deficient, supplement with oral or IV iron. If erythropoietin deficiency confirmed, consider erythropoiesis-stimulating agent (ESA) therapy targeting Hgb 100-115 g/L (avoid >120 g/L due to cardiovascular risk). 4
5. Diabetic Neuropathy Management
Optimize glycemic control - primary intervention for diabetic neuropathy. 3
Consider gabapentin 100-300mg at bedtime (renally dose-adjusted) or pregabalin 25-75mg BID for symptomatic relief of paresthesias. Avoid starting at full doses given renal impairment.
Screen for orthostatic hypotension - measure BP supine and after 3 minutes standing to assess for autonomic neuropathy. 4
6. Cardiovascular Risk Reduction
Initiate high-intensity statin therapy (atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily) if not already on one - this patient has diabetes with CKD, qualifying as very high cardiovascular risk. 3, 4
Aspirin 81mg daily for primary prevention given diabetes with additional cardiovascular risk factors (hypertension, CKD, age >50). 3
Lifestyle modifications: Sodium restriction <2g/day, 150 minutes moderate-intensity aerobic activity weekly, weight optimization if overweight. 3, 4
7. Follow-up Schedule
- 2 weeks: Recheck BP, renal function, potassium, FBS
- 4 weeks: Reassess BP control, adjust medications if needed
- 3 months: HbA1c, lipid panel, urine albumin-to-creatinine ratio, eGFR, CBC
Critical Pitfalls to Avoid:
- Do NOT use IV antihypertensives - this patient has severe asymptomatic hypertension without acute end-organ damage (hypertensive urgency, not emergency). Oral intensification is appropriate. 1, 2
- Do NOT continue metformin - lactic acidosis risk is real with eGFR <30-35 mL/min/1.73m²
- Do NOT rapidly lower BP >25% in first 24-48 hours - risk of ischemic complications in chronic hypertension 1
- Monitor potassium closely when combining ARB + spironolactone in CKD - hyperkalemia risk 3, 4