Progressive renal and cardiovascular disease: Optimal treatment strategies

able for truncal obesity and no hepatosplenomegaly or vascular bruits. He had intact sensation and motor function of all four extremities as well as normal deep tendon reflexes. Laboratory testing revealed a serum potassium of 4.8 mEq/L; BUN, 26 mg/dL; serum creatinine, 1.9 mg/dL; hematocrit, 38.8%; serum cholesterol, 287 mg/dL; 24-hour urinary protein, 3.6 g; and a creatinine clearance of 52 mL/min. His serum albumin was 2.2 g/dL. The urine sediment showed 0-2 red blood cells/high-power field and hyaline casts. Serum protein electrophoresis and urine protein electrophoresis did not reveal paraproteins. Serologic evaluation for other causes of renal dysfunction and proteinuria was negative. The purpose of the consultation was to recommend the optimal treatment strategy for treating the blood pressure and proteinuria and for inhibiting his progressive renal disease. CASE PRESENTATION A 54-year-old white man was referred by his internist for DISCUSSION evaluation of a serum creatinine of 1.9 mg/dL and nephroticDr. Matthew R. Weir (Head, Division of Nephrology, range proteinuria (3.6 g/24 h). The patient had an approximate 10-year history of non–insulin-dependent diabetes mellitus and and Director, Clinical Research Unit, Department of Meda 15-year history of hypertension. The patient also reported icine, University of Maryland School of Medicine, Baltithat he had a history of a mildly enlarged heart and an elevated more, Maryland, USA): This case exemplifies the probcholesterol level but denied previous visual abnormalities, lem that clinicians face in the management of patients chest pain, shortness of breath, or peripheral edema. He rewith hypertension and early renal insufficiency. What ported that he has always been stocky but had gained approxiis the best strategy for preventing progression of both mately 10 pounds during the previous year. He stated that atherosclerotic cardiovascular disease and chronic renal his glucose levels were reasonably controlled between 130-200 mg/dL with diet and oral medication, but that his blood presfailure? In my discussion, I will focus on the most relesure was hard to treat and his physician had prescribed many vant issues in the management of this patient. Among different medicines. these, I will review the concept of renal autoregulation On physical examination, he was a middle-aged, overweight because it provides a rationale for optimal levels of blood white male who was 5 10” tall and weighed 230 pounds. His pressure and for which medications might need to be blood pressure was 162/98 mm Hg and did not vary between prescribed. An understanding of renal autoregulation arms or with position. Funduscopic examination revealed arteriolar narrowing, a rare microaneurysm, and two small hemoralso provides a framework for understanding (1) the rhages in his left retina. His lungs were clear. Cardiovascular relationship between blood pressure and renal injury, examination disclosed normal carotid upstrokes, a regular (2) the option of intensive control of blood pressure, heart rate and rhythm, an S4 gallop, and 1 peripheral pulses and (3) the particular role of drugs that block the reninwithout pedal edema. His abdominal examination was remarkangiotensin-aldosterone system (RAAS). I will conclude with some comments about the importance of proteinThe Nephrology Forum is funded in part by grants from Amgen, uria as a prognostic and modifiable risk factor for cardioIncorporated; Merck & Co., Incorporated; Dialysis Clinic, Incorpovascular and renal disease progression and why preventing rated; and Bristol-Myers Squibb Company. renal failure is important for reducing the risk of cardio