Hello,

That level of proteinuria is indeed very substantial. I do not disagree that more intensive ACE inhibition might indeed be warranted. Do you know his level of kidney function (e.g. his serum creatinine or eGFR level)? Has he had a kidney ultrasound and do you know his kidney sizes? Knowing these might make it more clear why the physician might have been reluctant to increase therapy further at this stage. Nevertheless, I do not disagree with your suggestion, especially if your dad is a high-functioning 90 year-old man where you would would consider treating more aggressively.

Feel free to return with more information.

Dr. Jordan Weinstein, MD
Division of Nephrology, St. Michael's Hospital
Assistant Professor of Medicine
University of Toronto

So far, my father has not had any tests other than blood work. I talked to him today and convinced him he should see a nephrologist, even if it is just to get some peace of mind. He is also going to have labs run again to see if the last test was a fluke. He is still very vital and goes out almost every day with his camera. Everyone thinks he is 20 tears younger than he really is. I got his lab work records.

Microalb/Creat Ratio - 2/20/13 - 1234, 6/5/13 - 445, 12/9/13 - 710, 6/10/14 - 783, 8/13/15 - 513, 2/17/16 - 726, 9/16/16 - 1918, 3/18/17 - 1576, 9/30/17 - 4305

Creatinine - 12/9/13 - 1.3, 6/10/14 - 1.3, 7/10/14 - 1.3, 12/10/14 - 1.3, 2/16/15 - 1.3, 8/13/15 - 1.2, 9/30/17 -1.3

Est GFR - 12/9/13 - 52, 6/10/14 - 52, 7/10/14 - 52, 12/10/14 - 52, 2/16/15 - 52, 8/13/15 - 57, 9/30/17 - 52

His glucose level on 9/30/17 was 123, which is about how it has been for the last 3-4 years, it did get up to 257 in early 2015, but he brought it down to 115 later that year. His triglycerides were 173. All other categories, including blood pressure were within normal ranges.

Hello again,

I would think an intensification of the ACE inhibitor is warranted. He appears to have high-grade proteinuria that my well be do to an underlying glomerulonephritis (GN). In some cases, non-specific treatment (with ACE inhibitors or ARBs plus mineralocorticoid receptor antagonists) might be helpful alone. Otherwise, a renal biopsy might be needed to clarify which GN is present and whether immunotherapy is needed. Suffice it to say, all of the above should be discussed with a nephrologist and all the risk/benefits discussed and considered before acting.

Regard,

Dr. Jordan Weinstein