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Name: Denise Fields	DOB: 5/9/1985	Date: 11/20/23

Chief Compliant

“I’m here to follow up on the results of my labs”

History of Present Illness

A 38-year-old woman with type 2 diabetes mellitus (T2DM), hypertension (HTN), and dyslipidemia returns to her primary care physician (PCP) for a follow-up visit. At her routine physical examination 3 months ago, her annual nephropathy screening revealed a urine albumin-to-creatinine ratio (UACR) of 659 mg/g, which was elevated from the previous year’s screening that showed a mildly increased UACR of 145 mg/g and an SCr of 1.2 mg/dL. A second spot urine test from 1 week ago showed a persistently elevated UACR of 673 mg/g. She has returned to the office today to review her lab results and presents with no complaints. She brought with her a list of her medications and self-monitoring blood glucose readings.

Past Medical History

Medical Conditions: T2DM x 8 years, HTN x 6 years, Dyslipidemia x 5 years, seasonal allergies

Medications

Metformin 1000 mg PO twice daily

Semaglutide 0.5 mg mh injected subcutaneously once weekly

Hydrochlorothiazide 25 mg PO once daily

Atorvastatin 20 mg PO once daily

Mometasone 100 mcg two sprays in each nostril once daily prn allergies

Cetirizine 10 mg PO once daily prn allergies

Naproxen 220 mg PO twice daily prn headaches

Multivitamin PO once daily

Allergies

Seasonal: grass and pollen

Drug: NKDA

Family History

Mother: alive at age 62, has HTN and dyslipidemia

Father: passed at age 50 secondary to myocardial infarctions, had T2DM and CVD

Brother: alive at age 31, has T2DM

Social History

Education: high school graduate

Employment status: full time administrative assistant

Marital Status: married to husband, no children

Smoking Status: current 1 PPD smoker, decreased from last year (2 PPD)

Illicit Drugs: denies

ETOH: occasional consumption on weekends or when out with friends (1-2 beverages/week)

Review of Systems

Eyes: no vision changes

Cardiovascular: no chest pain or palpitations

Respiratory: no shortness of breath

Gastrointestinal: no polydipsia or polyphagia

Genitourinary: no polyuria

Musculoskeletal: no edema

Neurological: occasional headaches, generally associated with menstruation, no dizziness, fatigue, or sensory loss

Physical Examination

Constitutional: no acute distress

Neck/lymph nodes: supple without adenopathy or thyromegaly

HEENT: PEERLA, EOMI, negative for diabetic retinopathy; no retinal edema or vitreous hemorrhage; TMs intact; oral mucosa moist with no lesions

Cardiovascular: heart sounds normal, no murmurs, no bruits

Respiratory: clear, breath sounds normal

Gastrointestinal: soft NT/ND

Genitourinary: rectal exam deferred; recent PAP smear negative

Musculoskeletal: no CCE, normal ROM

Neurological: A&O x 3, CNs intact, normal DTRs

Skin: warm, dry, no rashes

Vitals 1

Height: 5 ft. 6 in. Weight: 191 lbs. BMI: 30.8 Systolic1: 148 Diastolic1: 84 Systolic2: 146 Diastolic2: 82 Pulse: 82 Resp:18 Temp: 37.5C O2SAT: 98%

Lab Reports (collected 1 week ago)

BMP LAB REPORT

Test Name	Patient Results	Reference Range	Unit
SODIUM	140	135 – 145	MEQ/L
POTASSIUM	3.9	3.5 – 5	MEQ/L
CHLORIDE	107	98 – 106	MEQ/L
CO2	26	22 -28	MEQ/L
BUN	29	8 – 20	MG/DL
CREATININE	1.6	0.6 – 1.2	MG/DL
GLUCOSE	196	65 – 99	MG/DL
CALCIUM	9.4	8.6 – 10.2	MG/DL
PHOSPHORUS	2.7	2.8 - 4.5	MG/DL

ESTIMATED GLOMERULAR FILTRATION RATE LAB REPORT

Test Name	Patient Results	Reference Range	Unit
eGFR	46.4	> 90	mL/min/1.73m2

CBC LAB REPORT

Test Name	Patient Results	Reference Range	Unit
WBC	9,500	4,000-10,000	cells/μL
HGB	12.2	12-17	g/dL
HCT	36.1%	36-51	%
MVC	79	79-97	fL
PLATELETS	148,000	150,000-400,000	cells/μL

HbA1C LAB REPORT

Test Name	Patient Results	Reference Range	Unit
HBA1C	8.2	<5.7	%

PREGNANCY TEST LAB REPORT

Test Name	Patient Results	Reference Range	Unit
HCG, qualitative	NEGATIVE	NEGATIVE

LIPID PANEL LAB REPORT

Test Name	Patient Results	Reference Range	Unit
TOTAL CHOLESTEROL	212	100 - 199	MG/DL
LDL, DIRECT	149	0 - 99	MG/DL
HDL	42	>39	MG/DL
TRIGLYCERIDES	149	0 - 149	MG/DL

UA LAB REPORT

Test Name	Patient Results	Reference Range	Unit
pH	5.2	5 - 7.5
SPECIFIC GRAVITY	1.020	1.001-1.029
URINE COLOR	YELLOW	YELLOW
APPEARANCE	CLEAR	CLEAR
PROTEIN	325	< 20	mg/dL
GLUCOSE	1+ GLUCOSE	NEGATIVE
KETONES	NEGATIVE	NEGATIVE
BLOOD	NEGATIVE	NEGATIVE
LEUKOCYTE ESTERASE	NEGATIVE	NEGATIVE
NITRITE	NEGATIVE	NEGATIVE
BILIRUBIN	NEGATIVE	NEGATIVE
UROBILINOGEN	0.2	0.2 - 1	mg/dL
WBC	3-4	0 - 5	hpf
RBC	0	0 - 2	hpf
EPITHELIAL CELLS	0	0 - 10	hpf
CASTS	NONE SEEN	NONE SEEN
BACTERIA	NONE SEEN	NONE SEEN

MICROALBUMIN TO CREATINE RATIO LAB REPORT

Test Name	Patient Results	Reference Range	Unit
MACR	673	< 30	MG/G

URIC ACID LAB REPORT

Test Name	Patient Results	Reference Range	Unit
URIC ACID	6.2	2.3 - 7	MG/DL

ALBUMIN LAB REPORT

Test Name	Patient Results	Reference Range	Unit
ALBUMIN	3.4	3.5 - 5.5	G/DL

Assessment

1. CKD with albuminuria (G3bA3) with inappropriate medication dosing

Supporting Evidence:

Subjective: patient does not report any complaints

Objective: worsening of SCr to 1.6 from 1.2 a year ago, eGFR of 42 mL/min (stage 3 CKD), MACR/UACR 673 up from 659 3 months ago and 145 1 year ago, CrCl = 53 mL/min

(ActualBW = 87 kg, IBW = 59.3 kg, AdjBW = 70.4 kg)

Non-pharmacologic options:

A. remove nephrotoxic agents

B. Dietary recommendations

- diet high in vegetables, fruit, whole grain, fiber, plant based proteins, unsaturated fats and nuts; low in processed meats, refined carbohydrates, and sweetened beverages

- dietary protein should be 0.8g/kg daily

- restrict sodium to < 2000 mg/day

C. Weight reduction

D. Physical exercise

E. Smoking cessation

Pharmacologic options:

A. Blood pressure management: the patient is currently above goal of < 130/80 on HCTZ therapy

Hydrochlorothiazide (current therapy)

Pros: currently tolerating therapy, efficacy with CrCl > 25-30 mL/min, first line therapy for HTN

Cons: electrolyte disturbances

ACE inhibitor (lisinopril)

Pros: slows the progression of kidney disease, first line in patients with CKD and diabetes with albuminuria

Cons: may increase SCr if not stable (AKI risk), cough, hyperkalemia, angioedema risk

ARB (losartan)

Pros: slows the progression of kidney disease, first line in patients with CKD and diabetes with albuminuria

Cons: may increase SCr if not stable (AKI risk), hyperkalemia, angioedema risk

CCB (amlodipine)

Pros: recommended first line therapy for most patients, no monitoring required, well tolerated

Cons: risk of edema (may be issue in patient with volume regulation issues)

B. Glycemic management: the patient is above A1c goal of 8.2% with metformin and Ozempic

Metformin

Pros: first line therapy for management of T2DM, oral medication, well tolerated

Cons: GI upset common, lactic acidosis, renal dose adjusted

GLP-1 RA (semaglutide/Ozepmic)

Pros: recommended after metformin and SGLT2 in patients with CKD, weight loss

Cons: GI adverse effects, injectable, risk of pancreatitis

SGLT-2 inhibitor

Pros: recommended first-line therapy for patient with CKD and diabetes over GLP1-RA, slows the progression of kidney disease, may lower BP

Cons: electrolyte disturbances, increased urination, risk of infection, require hydration

Insulin

Pros: safe in patients with CKD, but not recommended in patients until non-insulin therapy has been trialed or optimized if A1c < 10%

Cons: injectable, weight gain

C. Smoking cessation: patient willingness to quit was not assessed, but patient self-decreased smoking to 1 PPD

Dual NRT (Patch + gum or lozenge)

Pros: first line therapy, easy to use, dual target approach

Cons: should be paired with behavioral therapy, patch can cause skin irritation

Varenicline

Pros: first line therapy, flexible quit date strategy, oral therapy

Cons: should be paired with behavioral therapy, vivid dreams, psychiatric considerations, renal dose adjustment in severe kidney patient (not this patient)

D. Dyslipidemia management: patients LDL is 149 mg/dL on moderate intensity statin therapy and lifetime ASCVD risk score is 50%

Statins (atorvastatin)

Pros: first line medication of choice for all patients

Cons: myalgias/muscle weakness, rare rhabdomyolysis

E. Inappropriate medications/dosing: medication dosing should be continually assessed in patients with CKD and nephrotoxic agents should be avoided

Naproxen

- NSAID therapy is nephrotoxic and is known to worsen kidney impairment and increase the risk of AKI. It should be avoided in all patients with CKD

Metformin

- metformin should be renal dose adjusted based on eGFR due to risk of accumulation in kidney impairment increasing the risks of adverse effects including GI upset and lactic acidosis

- based on this patients eGFR the recommended daily dose is 1000mg/day

Plan

1. CKD with albuminuria (G3bA3) with inappropriate medication dosing

Goals: management of CKD is focused on the management of risk factors for progressive kidney disease: obesity, elevated BP (goal BP < 130/80), hyperglycemia (goal A1c < 7%), smoking, dyslipidemia, nephrotoxic medications

Nonpharmacologic Recommendation:

A. remove nephrotoxic agents

B. Dietary recommendations

- diet high in vegetables, fruit, whole grain, fiber, plant based proteins, unsaturated fats and nuts; low in processed meats, refined carbohydrates, and sweetened beverages

- dietary protein should be 0.8g/kg daily

- restrict sodium to < 2000 mg/day

C. Weight reduction

D. Physical exercise

E. assess willingness to quit smoking and discuss smoking cessation options

Pharmacologic Recommendation:

A. initiate lisinopril 5 mg by mouth once daily and continue hydrochlorothiazide 25 mg by mouth once daily

B. initiate canagliflozin 100 mg by mouth daily, decrease metformin to 500 mg by mouth twice daily, and continue semaglutide 0.5 mg injected subQ once weekly

C. increase atorvastatin to 40 mg by mouth once daily

D. discontinue naproxen 220 mg twice daily PRN and initiate acetaminophen 500 mg 1-2 tablets every 6 hours prn

E. continue all other medications as prescribed

Rationale:

A. an ACE inhibitor or ARB would be appropriate for BP lowering renal protection in the setting of CKD with albuminuria. Hydrochlorothiazide should also be continued because her BP is well above goal and patient likely needs combination therapy. Dose of lisinopril should be titrated slowly to a max of 40 mg/day

B. SGLT2 inhibitor therapy should be prioritized in combination with metformin in patients with diabetes and CKD over GLP-1RA therapy. SGTL2 inhibitor therapy may also reduce the patients BP. Metformin dose must be reduced due to renal impairment to a max of 1000mg/day. May consider increasing semaglutide to 1 mg at this time but with other changes today, it might be best to wait for follow up

C. patient has a high risk of lifetime ASCVD and many risk factors for CV disease. The patient is currently on moderate intensity statin therapy and LDL is 149 mg/dL. The patient would benefit from an increase to high intensity therapy and my benefit from targeting a max dose of atorvastatin 80 mg/day

D. naproxen is nephrotoxic and should be avoided, if the patient has not failed acetaminophen this would be an appropriate switch, if there is inadequate relief the patient should follow up with PCP for further assessment

E. patients current medications are dose appropriately considering the patients renal function and do not have disease interactions to be concerned about

Toxicity Monitoring:

· ACEi/ARB: patients’ potassium is 3.9 mEq/L and SCr 1.6 both can be increased with the initiation of therapy

· BMP in 7-10 days

· SGLT-2: transient increase in eGFR, especially in combination with ACE/ARB initiation; risk of electrolyte abnormalities

· BMP in 7-10 days

Therapeutic Efficacy Monitoring:

· CKD progression: monitor renal function and albuminuria

· BMP and MACR every 3-6 months

· HTN

· monitor BP at each encounter and at home daily

· T2DM

· A1c every 3 month until at goal x 2 then every 6 months

· SMBG daily

· Dyslipidemia: monitor for improvement in lipid panel

· FLP in 4-8 weeks

Patient Education:

· You have been diagnosed with a condition called chronic kidney disease or CKD. This can happen because of long-term uncontrolled diabetes, high blood pressure, certain medications, and other factors. Having CKD means that your kidneys are not able to filter the waste in your body as well anymore. Some medications will need to be changed to prevent build up or further damage to your kidneys. Our goal is preventing the further progression of the kidney disease and lower the risk of further complications. We will need to closely monitor your kidney function and labs moving forward to identify any progression early. It is important to consult your provide before taking any new medications since they may cause further damage to your kidneys.

· Stop taking naproxen or other NSAIDS to prevent damage to your kidneys, instead take acetaminophen 500 mg 1-2 tablets every 6 hours as needed, do not take more than 4000 mg of acetaminophen per day. Contact your provider if your headaches are not relieved

· Your metformin dose will need to be reduced since your kidney aren’t able to clear the medication as well anymore, which increases your risk of side effects with the medication.

· Canagliflozin is a new medication which can help lower you blood sugar and blood pressure. This medication also helps prevent the worsening of your kidney function. it may cause you to go to the bathroom more often and should be taken in the morning. It is important to stay hydrated while taking this medication because it increases the sugar in your urine which can increase your risk of urinary tract infections. Report any signs of infection to your doctor.

· Lisinopril is a new medication which will help lower your blood pressure and prevent progression of your kidney disease. This medication may cause an allergic reaction of the face which can lead to swelling of the face or tongue, if this occurs go directly to the ED. Let your provider know if you develop a dry cough on this medication and if you plan to become pregnant

Follow up:

Follow up in 1 week to repeat labs and then every 3 months.