Goals of therapy: Slowing progression and dyslipidemias

Abstract

A 47-year-old man with type 2 diabetes mellitus with no evidence of retinopathy, hypertension, chronic kidney disease (CKD) stage 3, and congestive heart failure (CHF) presents for a follow-up visit at the clinic. Recently, he developed fatigue and shortness of breath with effort. He takes lisinopril 20 mg daily, metoprolol 50 mg twice a day, and a nightly subcutaneous shot of 30 U of insulin glargine. On physical examination, he is afebrile, heart rate is 83 bpm, and BP is 163/89 mmHg. His physical examination is normal other than a S4 and a displaced PMI. His serum creatinine is 1.8 mg/dl (6 months ago it was noted to be 1.5 mg/dl); a hemoglobin A1C is 8.8 %. The rest of his chemistries are within normal range. His hemoglobin is 8.9 g/dl. Both platelet and white cell counts are normal. His urinanalysis reveals 2+ protein with a urine protein:creatinine ratio of 1.8 g/g of creatinine. On ECG, voltage criteria for LVH are met. What are the risk factors for progression of CKD in this patient? How can these risk factors be controlled and what other agents may be added to his medication regimen? What is the optimal blood pressure goal?