From the Guidelines
The patient requires immediate nephrology referral for comprehensive kidney disease management, given the presence of moderate to severe chronic kidney disease (CKD) with a glomerular filtration rate (GFR) of 31-33 mL/min, indicating stage 3b CKD, alongside hyperglycemia and metabolic alkalosis. The elevated BUN (blood urea nitrogen) and creatinine levels, along with the reduced GFR, suggest significant kidney impairment. The patient also has hyperglycemia with glucose levels consistently elevated at 109-124 mg/dL, and metabolic alkalosis as indicated by the elevated CO2 (bicarbonate) levels 1. The electrolyte panel shows normal sodium and calcium levels, with slightly fluctuating potassium levels that remain within or near normal range. Treatment should include:
- Blood pressure control, likely with an ACE inhibitor or ARB if not contraindicated, as suggested by the 2020 KDIGO clinical practice guideline for diabetes management in chronic kidney disease 1.
- Diabetes management to achieve better glycemic control, with consideration of the patient's CKD stage and the potential benefits and risks of intensive glycemic control, as discussed in the 2020 standards of medical care in diabetes 1.
- Dietary modifications including sodium, potassium, and protein restriction, as recommended for patients with CKD to slow disease progression and manage complications 1. Regular monitoring of kidney function and electrolytes is essential, and medications that are nephrotoxic should be avoided, with drug dosages adjusted based on reduced kidney function 1. Addressing modifiable risk factors such as smoking cessation and weight management is also crucial to slow CKD progression and reduce cardiovascular risk, which is significantly elevated in patients with kidney disease 1.
From the Research
Laboratory Results Analysis
The provided laboratory results show several abnormal values, including:
- High glucose levels (124,109)
- High BUN levels (53,58,36)
- High creatinine levels (1.5,1.6,1.0)
- Low glomerular filtration rate (33,31)
- High CO2 levels (32,33,35)
Relationship to Kidney Function
According to 2, the relationship between glucose levels and kidney function is significant. The study introduces the concept of "dglucose" (2h-postprandial glucose - Fasting glucose), which relates to renal function changes measured by serum creatinine levels or estimated glomerular filtration rate.
Management of Hyperglycemia in Kidney Disease
Studies 3, 4, and 5 discuss the management of hyperglycemia in patients with kidney disease. 3 emphasizes the importance of choosing drugs with proven cardio-renal benefits, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. 4 reviews metabolic changes in kidney impairment and treatment options for diabetic patients with chronic kidney disease. 5 defines a safe and effective dose regimen for metformin in moderate and severe chronic kidney disease.
Treatment Options
Treatment options for patients with kidney disease and hyperglycemia include: