CASE STUDY

A 60-YEAR-OLD MAN WITH TYPE 2 DIABETES,

HYPERTENSION, DYSLIPIDEMIA, AND ALBUMINURIA

Katherine Tuttle, MD

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

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.
CURRENT MEDICAL TREATMENT
His hyperglycemia has been treated with a combination of metformin 1000 mg twice daily, glargine insulin
18 units every hour of sleep, 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 81 mg daily for cardioprotection. Although he used nonsteroidal antiinflammatory agents for arthritis in the past, the patient
has not taken these agents since his hip replacement.
REVIEW OF SYSTEMS
The patient has gained 15 pounds over the past 18
months and relates the weight gain to beginning
insulin therapy. He fatigues easily. The patient has no
headaches, visual disturbances, or transient ischemic

S34

attack symptoms. He denies shortness of breath, chest

pain, palpitations, or syncope. He reports no history of
nausea, vomiting, abdominal pain, or change in bowel
habits. He experiences nocturia 2 to 3 times per night
and hesitancy with voiding. The patient suffers pain in
his left hip when he walks or stands for prolonged
periods. These symptoms limit his ability to exercise.
FAMILY HISTORY
The patients 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.
SOCIAL HISTORY
The patient has worked as an attorney for 34 years.
He was a federal prosecutor until 5 years ago, when he
joined a large firm where he oversees the criminal defense
section. 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.
PHYSICAL EXAMINATION
The findings of a physical examination showed the
following: patient alert and cooperative; weight, 205
pounds; height, 68 inches; body mass index, 31
kg/m2; blood pressure, 150/88 mm Hg; heart rate, 92
beats/minute and regular; respiratory rate, 17
breaths/minute; and body temperature, 37C.
Funduscopic examination reveals scars from prior laser
therapy and some additional neovascularization in the
right eye. He has a right carotid bruit and no jugular
venous distension. His lungs are clear to auscultation.
Cardiac examination results showed an S4 gallop and
a systolic ejection murmur at the left sternal border.
The patient has no hepatosplenomegaly or abdominal
tenderness. His prostate is mildly enlarged, and the

Vol. 5 (1A)

January 2005

CASE STUDY

fecal stool examination is negative for occult blood.

Edema is noted from the feet to mid-calf and is
approximately 1+ in severity. He has decreased sensation to microfilament testing on the soles of both feet.
LABORATORY STUDIES
Laboratory testing reveals the following serum values: creatinine, 1.1 mg/dL; potassium, 5.2 mEq/L;
bicarbonate, 21 mEq/L; blood urea nitrogen, 28
mg/dL; 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 A1c, 8.4%;
hemoglobin, 15.1 g/dL; and hematocrit, 45%.
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.
An electrocardiogram is performed and reveals left
ventricular hypertrophy.
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 Kidney Disease Outcomes
Quality Initiative 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).
The renal diagnosis is probable diabetic nephropathy, based on the patients typical presentation: longstanding diabetes, diabetic retinopathy, and
proteinuria with a bland urinary sediment. Although
he does not currently use nonsteroidal anti-inflammatory agents, past use could have contributed to kidney
damage. Given the patients prior use of these drugs
and his enlarged prostate and associated symptoms, a
renal ultrasound should be performed to evaluate for
occult structural kidney disease, such as obstruction or
papillary necrosis. 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.

Advanced Studies in Medicine

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. 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.
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 or a blocker. 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. 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 patients
blood pressure and, because of the diabetes and proteinuria diagnosis, he should avoid a high-protein intake.
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. Examinations show evidence for type IV renal
tubular acidosis (mild hyperkalemia and nonanion gap
acidosis); some experts would discontinue metformin at
this point. Serum potassium should be carefully monitored while increasing the angiotensin-converting
enzyme inhibitor. However, also increasing the loop
diuretic will help to prevent worsening of hyperkalemia.

S35