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  Sunday, 13 May 2012
  3 Replies
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Dear exprts , I have a female patient , 63 years old , with longstanding DM type 2 for more than 20 years .the patient is coming presented by proteinuria 13 gm / day .  the patient was treated before from recurrent renal calculi and UTI . 4 months ago the patient creatinine was 1.5 mg/dl , and it gradually rises to 1.7 , 1.9 , 2.37 with one month interval between every reading . her medication described for her from another hospital  is as follows : ezapril 20 mg  3 tab/12 hr irbesartan 150 mg once / day iron supplement hypolipidemic drug regular insulin  metformin 500 mg once / day  my question is about the dose of ACEI IF IT SHOULD BE DECREASED OR NOT ? what about metformin ?    
12 years ago
Regardless of your course of action here, unless the patient is very hypertensive to explain such extreme proteinuria, it will be difficult to achieve major improvements in proteinuria in my opinion. I have been quite impressed with combining aldactone and ACE OR ARB, potassium permitting. I feel aldactone-based combinations are more effective that ACE+ARB or either added to DRI. One question I would have is whether this patient has ever been biopsied?
12 years ago
Dear Dr.Jordan
no biopsy was taken for the patient . also her BP is about 130 / 90 .
so you will decrease the dose of ACEI , for her creatinine rise or not?
do you prefer doing a biopsy for the patient despite this long standing diabetes suggesting diabetic nephropathy ?
metformin is ok with her?
12 years ago
Statistically, this is very likely to be diabetes, particularly if glycemia was not well managed. In general, it would be reasonable to biopsy a patient with very high-grade protein (>5 g / day) and diabetes in order to ensure another disease such as Membranous Nephropathy is not coexisting, as obviously this would have important treatment implications. As mentioned, I prefer aldactone and ACE or ARB rather than ACE/ARB together, potassium permitting. Metformin may be used with caution down to eGFR of 33 cc/min.

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