What is the diagnosis and management for a patient with elevated blood pressure, impaired fasting glucose, impaired renal function, and proteinuria?

Diagnosis and Management

This patient has chronic kidney disease (CKD) stage 3a with significant proteinuria (2+) and uncontrolled hypertension requiring immediate intensification of blood pressure control with uptitration of her ACE inhibitor or ARB to maximum tolerated dose, targeting BP <120/80 mmHg, along with quantification of proteinuria and nephrology referral. 1, 2

Diagnosis

This 66-year-old woman presents with multiple findings indicating chronic kidney disease with proteinuria:

• Elevated creatinine (1.3 mg/dL) indicates reduced glomerular filtration rate, likely CKD stage 3a 3
• Proteinuria 2+ on dipstick represents significant kidney damage requiring further evaluation 3, 1
• Uncontrolled hypertension (150/80 mmHg) despite current telmisartan/HCTZ therapy 1
• Diabetes with suboptimal glucose control (FBS 144.5 mg/dL) is a major risk factor for progressive kidney disease 3

The most likely diagnosis is diabetic nephropathy with hypertensive nephrosclerosis, given her diabetes, hypertension, and cardiovascular disease (on clopidogrel). 3, 4

Immediate Management Steps

1. Blood Pressure Optimization (Priority #1)

Target BP: <120/80 mmHg using standardized office measurements 1, 2

• Uptitrate telmisartan to maximum tolerated dose (80 mg daily) - the antiproteinuric effect is dose-dependent and not solely related to BP reduction 1, 2
• Current dose of 40 mg is subtherapeutic for proteinuria management 1
• Do not stop the ARB if creatinine increases up to 30% from baseline, unless progressive deterioration or refractory hyperkalemia occurs 1, 5, 6
• The HCTZ component (12.5 mg) may need adjustment based on volume status 1

2. Quantify Proteinuria

Obtain spot urine protein-to-creatinine ratio or albumin-to-creatinine ratio immediately 3, 1

• Dipstick 2+ suggests significant proteinuria (likely >1 g/day) 3
• Quantification is essential to determine disease severity and guide therapy 1, 2
• This should be done on at least two separate occasions 3

3. Calculate Estimated GFR

Use MDRD or CKD-EPI formula to estimate GFR 3

• Serum creatinine 1.3 mg/dL in a 66-year-old female likely indicates eGFR 40-50 mL/min/1.73 m² (CKD stage 3a) 3
• This confirms chronic kidney disease requiring nephrology referral 3

4. Nephrology Referral

Refer to nephrology immediately given: 3

• Proteinuria grade 2+ by dipstick 3
• Reduced renal function (creatinine >1.2 mg/dL) 3
• Progressive disease risk in diabetic patient 3

Consider renal biopsy if clinical course is atypical or if immunosuppressive therapy is being considered 3, 1

Additional Management Interventions

Dietary Sodium Restriction

Restrict sodium to <2.0 g/day (<90 mmol/day) 1, 2

• This enhances the antiproteinuric effect of RAS blockade 1, 2
• Further restriction may be needed if proteinuria persists despite medical therapy 1

Glycemic Control Optimization

Intensify diabetes management - current FBS 144.5 mg/dL indicates suboptimal control 3

• Consider increasing insulin glargine dose or adding prandial insulin 3
• Target HbA1c <7% to slow nephropathy progression 3

Monitor for Complications

Check serum potassium and creatinine within 1-2 weeks after uptitrating telmisartan 1, 6

• ARBs can cause hyperkalemia, especially with reduced GFR 6
• Accept creatinine increase up to 30% if stable 1, 5

Treat Asymptomatic Bacteriuria

Do NOT treat asymptomatic bacteriuria in this non-pregnant patient without urologic abnormalities - treatment does not improve outcomes and promotes resistance 3

Follow-up Timeline

• Recheck labs in 1-2 weeks: creatinine, potassium, spot urine protein-to-creatinine ratio 1
• Reassess BP in 2-4 weeks after medication adjustment 1
• Expect proteinuria improvement within 3 months, with minimum 50% reduction by 6 months 1
• If proteinuria persists >1 g/day after 3-6 months of optimal therapy (maximum dose ARB, BP <120/80, sodium restriction), consider immunosuppressive therapy in consultation with nephrology 1, 2

Critical Pitfalls to Avoid

• Do not stop telmisartan if creatinine rises modestly (up to 30%) - this is expected and acceptable 1, 5
• Do not undertitrate the ARB - maximum dose is required for antiproteinuric effect independent of BP control 1, 2
• Do not delay nephrology referral - this patient meets criteria for specialist evaluation 3
• Avoid NSAIDs - they can worsen renal function in patients on ARBs with compromised kidney function 6
• Monitor for hyperkalemia closely given ARB therapy and reduced GFR 6