Transcript Diapositiva 1

77-year-old woman with long-standing osteoarthritis, a 20-year history of
hypertension and a 3-year history of type 2 diabetes presents for a routine
office visit. She admits frustration at not being able to meet A1c goals in the
past. She admits to being generally weaker during the past year, during
which time she has suffered 2 falling episodes without true syncope or
vertigo. The patient denies chest pain, palpitations or dyspnea but admits to
occasional ankle swelling. Prior glycated hemoglobin (A1c) levels have been
in the 7.0-8.1% range.
Medications: metformin 1,000 mg twice daily, naproxen 440 mg twice daily
and lisinopril 5 mg once daily.
Review of systems: significant for chronic hip and knee pains but is
otherwise negative except as above.
Somewhat frail-appearing elderly woman in no acute distress.
PERRLA: fundi benign
Neck: thyroid nonenlarged; no masses, lymphadenopathy, abnormal pulses
or bruits
Lungs: clear
Cardiovascular: regular rate and rhythm; no murmurs or S3 gallop
Abdomen: soft; nontender; no masses or organomegaly
Extremities: no cyanosis or clubbing; there is trace to 1+ ankle edema
bilaterally
Neurological: intact, including cranial nerves and reflexes
Skin: no lesions or rash; resolving bruise over her
Psychiatric: oriented x4 and fluent; MMSE not performed
Family History: Father died with a stroke at age 71 and her mother died at
age 75 with long-standing heart failure; sister has diabetes.
Social History: Widow, retired bookkeeper with 5 grown children; nonsmoker
and nondrinker. Lives alone and administers her own medications.
Stages of Chronic Kidney Disease and Prevalence in Adults
Abboud H and Henrich W. N Engl J Med 2010;362:56-65
Chronic kidney disease has recently been recognized as
a public health problem; it is estimated that by 2030,
more than 2 million people in the United States will need
dialysis or transplantation for kidney failure. Currently,
approximately 19 million adults in the United States are
in the early stages of the disease, defined by either a
GFR of less than 60 ml per minute per 1.73 m2 of bodysurface area or the presence of kidney damage,
regardless of the cause, for three or more months.
ACE Inhibition versus Angiotensin-Receptor Blockade in Progressive Nephropathy Associated
with Type 2 Diabetes
Mitch W. N Engl J Med 2004;351:1934-1936
A 54-year-old woman with an 11-year history of type
2 diabetes presents for care. She was first noted to
have proteinuria 4 years earlier; her serum
creatinine level then was 1.1 mg per deciliter (97
µmol per liter). Her urinary protein excretion has
progressively increased to 2.8 g per 24 hours, and
her serum creatinine level to 3.1 mg per deciliter
(274 µmol per liter). The estimated glomerular
filtration rate (GFR) is 26 ml per minute per 1.73 m2
of body-surface area. Her blood pressure is 155/90
mm Hg, and the glycated hemoglobin level is 7.6 mg
per deciliter. The medications she is currently taking
include an oral hypoglycemic agent, an angiotensinconverting–enzyme (ACE) inhibitor, a statin, and a
thiazide diuretic. How should her case be managed?
Major Causes of Severe Chronic Kidney Disease
Abboud H and Henrich W. N Engl J Med 2010;362:56-65
Cardiovascular Disease in Patients with Chronic Kidney Disease
Abboud H and Henrich W. N Engl J Med 2010;362:56-65
Diagnosis
1.
Hypertension
2.
Diabetes Mellitus Type 2
3.
Osteoarthritis