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LEARNING OBJECTIVES

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

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  • Discuss various methods for estimating creatinine clearance and glomerular filtration rate.

  • Differentiate AKI from CKD.

  • Identify risk factors for progression of renal disease.

  • Recommend nonpharmacologic and pharmacologic interventions to alter the rate of progression of renal disease.

  • Recognize and treat potential comorbid or pathologic conditions that are frequently associated with chronic renal insufficiency.

  • Educate patients about the common medications prescribed for chronic renal insufficiency.

  • Provide recommendations for renal disease therapy during pregnancy.

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PATIENT PRESENTATION

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Chief Complaint

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“I’m here to check the results of my labs.”

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HPI

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Christine Karter-Davis is a 38-year-old woman with type 2 diabetes mellitus who returns to her PCP for a follow-up visit. At her routine physical examination 3 months ago, her annual kidney screening revealed 3+ protein and an ACR of 659 mg/g in spot urine collection. This is elevated from last year’s screening which showed mildly increased albumin and SCr elevation of 1.2 mg/dL. A follow-up appointment was scheduled 6 weeks ago, and a second spot urine test showed persistent elevation of ACR 615 mg/g. Complete laboratory workup was ordered at that time along with a 24-hour urine collection (conducted 1 week ago). She has returned to the office today to review the results of this testing.

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A pleasant woman with no current medical complaints, Ms Karter-Davis arrives in the office today with a printout of her home blood glucose monitor readings. Review of the report shows only six tests in the last month, all between 6:00 am and 7:00 am. From her past pregnancy she is known to have an aversion to needles, and on questioning reveals that she hates the lancing device, and the finger pricks really hurt so she does not test very often. She has started a new regimen of daily vitamin D and aspirin because she heard that it was good for her. She also shows you her new pill organizer (Dosette pack) that she picked up at the pharmacy on the way to the office. She says that with the new vitamins she has been forgetting to take some of her medications but feels that the pill organizer will help her remember.

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PMH

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  • Type 2 DM × 8 years (history of gestational diabetes with use of insulin required)

  • HTN × 6 years

  • Dyslipidemia × 5 years

  • Gastric ulcer treated several years ago with H. pylori regimen (antibiotics and PPI)

  • Appendectomy at age 16

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FH

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Father had DM and CHD and died at age 50 secondary to MI; mother (age 62) has HTN and dyslipidemia. Brother (age 31) has DM, and two sisters (age 27 and 29) have no known medical problems other than obesity.

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SH

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