A 63-Year-Old Man, Who Was Diagnosed with Type 2 Diabetes

question 541

Multiple Choice

A 63-year-old man, who was diagnosed with type 2 diabetes mellitus 8 years ago, comes to the office for a follow-up appointment.  Over the last 2 weeks, he has noticed mild swelling in his legs, as well as fatigue.  He has had no shortness of breath, orthopnea, nausea, vomiting, or diarrhea.  Over the past year, the patient was found to have albuminuria on 2 separate visits.  Three months ago, blood pressure was 122/78 mm Hg, serum creatinine was 1.2 mg/dL, urine albumin-to-creatinine ratio was 250 mg/g, and hemoglobin A1c was 7.2%.  Lisinopril was initiated a year ago and the dose was increased 3 months ago.  The patient has had no recent viral illnesses or taken any new medications.  Current medications include low-dose aspirin, atorvastatin, lisinopril, and glargine insulin.  The patient does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 155/95 mm Hg and pulse is 85/min.  Auscultation of the heart and lungs shows no abnormalities.  The abdomen is nontender and no costovertebral angle tenderness.  The patient has 2+ pitting edema of the bilateral lower extremities.
Laboratory results are as follows:
Hemoglobin A1c is 7.5%.  A renal ultrasonogram shows symmetric, normal-sized kidneys with no evidence of hydronephrosis.  Which of the following is the next most appropriate step in management of this patient?

• A)Adjust insulin dose for strict glycemic control and follow-up in several weeks
• B)Discontinue lisinopril and initiate valsartan
• C)Discontinue lisinopril and repeat laboratory testing in several weeks
• D)Discuss ultrasound-guided renal biopsy
• E)Obtain duplex Doppler ultrasonography of the renal arteries

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