dyslipidemia albuminuria

1. CASE
CASE STUDY

2. BACKGROUND
• A 60-year-old man with type 2 diabetes mellitus was seen for
an annual physical examination at his primary care provider's
office.
• The patient does not exercise regularly and admits to
frequent dietary indiscretions.

3. • Although he denies chest discomfort or shortness of breath,
the patient has recently noticed mild swelling of his feet at
the end of the day.
• He is concerned and asks for an opinion regarding his
condition.

4. MEDICAL HISTORY
• The patient had a history of type 2 diabetes mellitus for 20
years, hypertension for 10 years, and dyslipidemia for 8 years.
• He had laser photocoagulation for diabetic retinopathy twice
in the past 3 years.
• His right hip was replaced with a total joint prosthesis for
severe osteoarthritis 3 years ago.

5. CURRENT MEDICAL TREATMENT
• His hyperglycemia has been treated with a combination of
metformin 1000 mg twice daily and lispro insulin 5 units
before meals.
• For hypertension, he takes hydrochlorothiazide 25 mg every
morning, ramipril 5 mg every morning, and amlodipine 5 mg
at bed time.
• The patients dyslipidemia has been treated with atorvastatin
10 mg at bedtime. He takes a baby aspirin 75 mg daily for
"cardioprotection„.

6. We should always ask patients about family history….

7. FAMILY HISTORY
• The patient's father had high blood pressure and died at age
59 years from a myocardial infarction.
• His mother (age 83 years) has arthritis and type 2 diabetes
mellitus. She was recently diagnosed as having chronic kidney
disease caused by diabetes mellitus and may require dialysis
in the future.
• He has 2 younger sisters. Although both sisters are apparently
healthy, one is obese and her blood glucose level was mildly
elevated on a recent evaluation.

8. SOCIAL HISTORY
• The patient has worked as an attorney for 34 years.
• His job is stressful and he handles high-profile cases for the
firm.
• He was divorced 3 years ago and has 2 adult children.
• He drinks 2 to 3 glasses (8 ounces each) of beer on most days.
• He denies ever using illicit drugs.

9. The findings of a physical examination showed the
following:
body mass index, 31 kg/m2;
blood pressure, 150/88 mm Hg;
heart rate, 92 beats/minute and regular;
respiratory rate, 17 breaths/minute
body temperature, 37°C.
his lungs are clear to auscultation.

10. Cardiac examination results showed systolic ejection murmur at
the left sternal border.
The patient has no hepatosplenomegaly or abdominal
tenderness.
• His prostate is mildly enlarged, and
• Fecal stool examination is negative for occult blood.
• Edema is noted from the feet to mid-calf and is approximately
1+ in severity.

11. Which lab tests will you order for this patient?

12. LABORATORY STUDIES-
ARE THESE RESULTS WITHIN THE NORMAL RANGE?????
Laboratory testing reveals the following serum values:
creatinine, 1.1 mg/dL;
potassium, 5.2 mEq/L;
fasting glucose, 188 mg/dL;
albumin, 3.7 g/dL;
• Total cholesterol, 210 mg/dL;
• High-density lipoprotein (HDL) cholesterol, 28 mg/dL;
• Triglycerides, 248 mg/dL;
• Low-density lipoprotein (LDL) cholesterol, 154 mg/dL;
• hemoglobin A]c, 8.4%;
• hemoglobin, 15.1 g/dL; and hematocrit, 45%.

13. • A urinalysis shows proteinuria (2+) but no blood, cells, or
casts.
• The calculated glomerular filtration rate is 74 mL/min.
• His urinary albumin-to-creatinine ratio is 453 mg/g.

14. Which imaging tests will you order for this patient?
• CT?
• MRI?
• ECG?
• ECHO?
• Abdomen USG?

15. An electrocardiogram is performed and reveals left
ventricular hypertrophy

16. • The left ventricle hypertrophies in response to pressure
overload secondary to conditions such as aortic stenosis and
hypertension.
• This results in increased R wave amplitude in the left-sided
ECG leads (I, aVL and V4-6) and increased S wave depth in the
right-sided leads (III, aVR, V1-3).

17. IMPRESSION AND DIAGNOSIS
• The patient is a 60-year-old man with type 2 diabetes
mellitus, hypertension, and dyslipidemia.
• Based on the National Kidney Foundation staging system for
chronic kidney disease (CKD), this patient has stage 2 CKD.
• The presence of albuminuria in this case is an indicator of
kidney damage and high cardiovascular risk.
• He is also at high risk based on his family history (eg, heart
disease, diabetes mellitus, and renal failure) and lifestyle
factors (eg, high stress, lack of exercise, and poor diet).

18. IMPRESSION AND DIAGNOSIS
• The renal diagnosis is probable diabetic nephropathy, based
on the patient's typical presentation: longstanding diabetes,
diabetic retinopathy, and proteinuria with a bland urinary
sediment.
• If the ultrasound examination shows no such structural
abnormalities and is typical of diabetes mellitus, as indicated
by normal or enlarged kidneys, then a diagnosis of diabetic
nephropathy can be presumed.
• Renal biopsy is generally reserved for atypical findings, such as
hematuria or lack of proteinuria or retinopathy, in a patient
with diabetes with decreased kidney function.

19. • Electrocardiographic examination indicates the patient has
left ventricular hypertrophy, which increases his risk for heart
failure, ischemic events, and arrhythmias.
• Cardiac dysfunction, in addition to diabetic nephropathy, may
contribute to development of edema.
• An echocardiogram to evaluate cardiac function and structure
should also be considered.

20. • He has no obvious symptoms of cardiac ischemia but has
multiple major risk factors (including CKD) and evidence for
atherosclerosis (carotid bruit).
• Because "silent ischemia" is common in patients with
diabetes, noninvasive stress testing should be considered if
this patient develops any suggestive symptoms or before he
begins an exercise program.

21. TREATMENT PLAN
• It is essential to intensify risk factor management with this
patient. Blood pressure should be treated to the current goal
of less than 130/80 mm Hg.
• Several strategies should be used: increase ramipril to 10 mg
every morning and switch to a loop diuretic (furosemide 40
mg every morning to better control edema). The amlodipine
could be increased to 10 mg every hour of sleep. Because
dihydropyridine calcium antagonists can increase proteinuria,
particularly if blood pressure is not adequately controlled, the
patient could also be switched to a different type of calcium
channel blocker.

22. • The statin dose should be increased and the LDL cholesterol
goal of less than 100 mg/dL should be achieved.
• However, newer guidelines indicate that even lower levels
(LDL cholesterol <70 mg/dL) are desirable in high-risk
patients.

23. • For his dyslipidemia, including low HDL cholesterol and high
triglycerides, lifestyle factors should also be addressed:
reduce intake of alcohol, fat, and calories.
• Limitation of salt intake would help lower the patient's blood
pressure and, because of the diabetes and proteinuria
diagnosis, he should avoid a high-protein intake.

24. TREATMENT PLAN
• Although his ability to walk may be limited by arthritis, the
patient should be counseled to pursue other types of physical
activity, such as swimming.
• Before he begins this type of exercise program, noninvasive
cardiac stress testing should be considered. These lifestyle
changes will help the patient control glycemia and lose
weight.
• If kidney function deteriorates further, metformin should be
discontinued because of the risk of lactic acidosis.

25. What do we have to monitor during treatment of this
patient?

26. • ……..
• Lipid profile, liver profile
• Serum potassium should be careflilly monitored while
increasing the angiotensin-converting enzyme inhibitor.
• However, also increasing the loop diuretic will help to prevent
worsening of hyperkalemia.

27. Thank you for your attention