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Schwinghammer’s Pharmacotherapy Casebook: A Patient­Focused Approach, 12th Edition

Chapter 55: Progressive Kidney Disease: It Was Only a Matter of Time Level III

Christie Schumacher

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LEARNING OBJECTIVES
After completing this case study, the reader should be able to:

Identify risk factors for progression of chronic kidney disease (CKD) in persons with diabetes.

Design an individualized care plan, including lifestyle modifications and pharmacotherapy, for persons with diabetes and CKD.

Identify clinical and laboratory parameters used to evaluate progression of CKD and the efficacy and safety of related medication therapy.

Summarize counseling points for non­pharmacologic and pharmacologic management options for persons with CKD.

PATIENT PRESENTATION
Chief Complaint

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

HPI

A 38­year­old woman with type 2 diabetes mellitus (T2DM), hypertension (HTN), and dyslipidemia returns to her primary care physician (PCP) for a
follow­up visit. At her routine physical examination 3 months ago, her annual nephropathy screening revealed a urine albumin­to­creatinine 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 self­monitoring blood glucose readings.

PMH

T2DM × 8 years

HTN × 6 years

Dyslipidemia × 5 years

Seasonal allergies

FH

Father had T2DM and cardiovascular disease (CVD) and passed away at age 50 secondary to a myocardial infarction (MI); mother (age 62) has HTN and
dyslipidemia; brother (age 31) also has T2DM.

SH
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The patient is an Hill. All Rights Reserved.
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assistant with of Use • drug
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reports occasional alcohol consumption on weekends or when out with
friends (one to two alcoholic beverages per month). She smokes one pack per day (ppd); decreased from previously reported two ppd last year. No
history of illicit drug use.
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Father had T2DM and cardiovascular disease (CVD) and passed away at age 50 secondary to a myocardial infarction (MI); mother (age 62) has HTN and
dyslipidemia; brother (age 31) also has T2DM.

SH

The patient is an administrative assistant with prescription drug benefits. She reports occasional alcohol consumption on weekends or when out with
friends (one to two alcoholic beverages per month). She smokes one pack per day (ppd); decreased from previously reported two ppd last year. No
history of illicit drug use.

Meds

Metformin 1000 mg PO twice daily

Semaglutide 0.5 mg subcutaneously every 7 days

Hydrochlorothiazide 25 mg PO daily

Atorvastatin 20 mg PO daily

Mometasone two sprays (100 mcg) in each nostril once daily PRN allergies

Cetirizine 10 mg PO daily PRN allergies

Naproxen 220 mg PO twice daily PRN headaches

Multivitamin PO daily

All

NKDA, seasonal allergies to grass and pollen

ROS

Occasional headaches, generally associated with menstruation; no c/o polyuria, polydipsia, polyphagia, sensory loss, or visual changes

No chest pain, palpitations, dizziness, edema, fatigue, or SOB

Physical Examination

Gen

No acute distress

VS

BP 148/84 mm Hg (R arm), repeat BP 146/82 mm Hg (L arm), HR 82 bpm, RR 18, T 37.5°C; Wt 191 lb (87 kg), Ht 5′6″ (168 cm)

Skin

Warm, dry, no rashes

HEENT

PERRLA, EOMI, negative for diabetic retinopathy; no retinal edema or vitreous hemorrhage

TMs intact

Oral mucosa moist with no lesions

Neck/Lymph Nodes
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Lungs/Thorax
 PERRLA, EOMI, negative for diabetic retinopathy; no retinal edema or vitreous hemorrhage
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Oral mucosa moist with no lesions

Neck/Lymph Nodes

Supple without adenopathy or thyromegaly

Lungs/Thorax

Clear, breath sounds normal

CV

Heart sounds normal, no murmurs, no bruits

Abd

Soft NT/ND

Genit/Rect

Rectal exam deferred; recent Pap smear negative

MS/Ext

No CCE, normal ROM

Neuro

A&O × 3; CNs intact; normal DTRs

Labs (1 Week Ago, Fasting)

Na 140 mEq/L Hgb 12.2 g/dL Fasting lipid profile

K 3.9 mEq/L Hct 36.1% T. chol 212 mg/dL

Cl 107 mEq/L WBC 9.5 × 103/mm3 Trig 149 mg/dL

CO2 26 mEq/L Plt 148 × 103/mm3 LDL 140 mg/dL

BUN 29 mg/dL Ca 9.4 mg/dL HDL 42 mg/dL

SCr 1.6 mg/dL Phos 2.7 mg/dL Alb 3.4 g/dL

Glu 196 mg/dL Uric acid 6.2 mg/dL

A1C 8.2% eGFR 46.4 mL/min/1.73 m2

UA (1 Week Ago)

pH 5.2, 1+ glucose, (–) ketones, 3+ protein, (–) leukocyte esterase and nitrite; (–) RBC; 3–4 WBC/hpf, UACR 673 mg/g

Urine Hcg: Negative

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Assessment Page 3 / 5
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A 38­year­old woman with diabetes diagnosed today with CKD and overt macroalbuminuria complicated by inadequately managed co­conditions.
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UA (1 Week Ago) Access Provided by:

pH 5.2, 1+ glucose, (–) ketones, 3+ protein, (–) leukocyte esterase and nitrite; (–) RBC; 3–4 WBC/hpf, UACR 673 mg/g

Urine Hcg: Negative

Assessment

A 38­year­old woman with diabetes diagnosed today with CKD and overt macroalbuminuria complicated by inadequately managed co­conditions.

QUESTIONS
Collect Information

1.a. What objective information indicates the presence of CKD in this patient?

1.b. What additional information is needed to fully assess this patient’s CKD and other diseases that may contribute to CKD?

Assess the Information

2.a. Assess the severity of CKD based on the subjective and objective information available. Calculate eGFR and CrCl in this patient based on her most
recent labs using the CKD­EPI and Cockcroft­Gault equations.

2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, efficacy, safety, and
patient adherence.

Develop a Care Plan

3.a. What are the goals of pharmacotherapy for CKD in this case?

3.b. What nondrug therapies might be useful for this patient’s CKD?

3.c. What feasible pharmacotherapeutic alternatives are available for treating this patient’s CKD and other diseases that may contribute to CKD?

3.d. Create an individualized, patient­centered, team­based care plan to optimize medication therapy for this patient’s CKD and other drug therapy
problems. Include specific drugs, dosage forms, doses, frequency, and durations of therapy.

Implement the Care Plan

4.a. What information should be provided to the patient to enhance adherence, optimize efficacy, and minimize adverse effects?

4.b. Describe how care should be coordinated with other healthcare providers.

Follow­Up: Monitor and Evaluate

5 . Explain how to monitor and evaluate the care plan for medication appropriateness, effectiveness, safety, and patient adherence by using clinical and
laboratory data, patient feedback, and other information.

SELF­STUDY ASSIGNMENTS

1 . Discuss the role of diuretic therapy in patients with normal kidney function compared to those with eGFR values <30 mL/min/1.73 m2.

2 . Explain the proposed rationale for the nephroprotective effects of sodium­glucose cotransporter­2 (SGLT2) inhibitors.

3 . Describe the role of finerenone, a nonsteroidal mineralocorticoid receptor antagonist, in reducing CKD progression and cardiovascular events in
clinical practice.

CLINICAL PEARL
The American2023­10­29
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REFERENCES
3 . Describe the role of finerenone, a nonsteroidal mineralocorticoid receptor antagonist, in reducing CKD progression and cardiovascular events in
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CLINICAL PEARL
The American Diabetes Association (ADA) recommends that a sodium­glucose cotransporter­2 inhibitor be initiated in patients with T2DM and CKD to
reduce chronic kidney disease progression and cardiovascular events.

REFERENCES

1. American Diabetes Association. Standards of medical care in diabetes—2022. Diabetes Care. 2022;45(Suppl 1):S1–S264. [PubMed: 34964812]

2. Kidney Disease: Improving Global Outcomes (KDIGO) 2020 clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int.
2020;98:S1–S115. [PubMed: 32998798]

3. Kidney Disease: Improving Global Outcomes (KDIGO) 2012 clinical practice guideline for the evaluation and management of chronic kidney disease.
Kidney Int. 2013;3:S1–S150.

4. Kidney Disease: Improving Global Outcomes (KDIGO) 2021 clinical practice guideline for the management of blood pressure in chronic kidney
disease. Kidney Int. 2021;99:S1–S87. [PubMed: 33637192]

5. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention,
detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association
Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269–1324. [PubMed: 29133354]

6. National Kidney Foundation. Frequently asked questions about GFR estimates. Available at: https://www.kidney.org/sites/default/files/docs/12­10­
4004_abe_faqs_aboutgfrrev1b_singleb.pdf . Accessed March 11, 2022.

7. Grundy SM, Stone NJ, Bailey AL, et al. 2018 ACC/AHA/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of
blood cholesterol: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines. J
Am Coll Cardiol. 2019;73:e285–e350. [PubMed: 30423393]

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