CASE 4 Progressive Diabetic Nephropathy Case Description

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This 39-yr-old woman was diagnosed with type 1 diabetes mellitus at the age of 7 yr, during an evaluation for chicken pox. Presenting symptoms included weight loss and frequent urination and was found to be in ketoacidosis. Complications from diabetes at present include neuropathy, nephropathy, and proliferative retinopathy. Her only other medical problem is hypertension.

Her proteinuria was initially diagnosed in 1980 (age 20) on a routine urinalysis when hospitalized for a staphylococcal infection following a spider bite. A 24 urine for protein was 2.16 g. Her serum creatinine and iothlamate clearance were 0.8 mg/dL and 111 mL/ min/1.73 m2, respectively.

During this time, the patient was changed from a one injection daily insulin regimen to a two injection daily lente program. Despite this change, her hyperglycemia persisted, and her physician added regular insulin (LR-0-LR-0 program). In 1983, she was started on an MDI program, leading to improvement in glycemic control with a glycosylated hemoglobin of 8.3%. Monthly blood pressure measurements remained below 140/90 mm Hg.

In October 1981, she first noticed right ankle edema. She was initially treated with hydrochlorothiazide and later was switched to furosemide. Follow-up testing in 1986 showed a creatinine of 1.7 mg/dL, an increase from previous measurements of 1.5 mg/ dL (1984) and 1.4 mg/dL (1985). In 1987, enalapril therapy was initiated for persistent proteinuria and mild hypertension. With the combination of furosemide and enalapril, her blood pressure control improved. In 1991, her creatinine remained stable at 1.9 with an iothalamate clearance of 45 mL/min/1.73 m2.

She returned in the mid-1990s after some time lost to follow-up because she married and moved. She had remained on the combination of enalapril and furosemide. From 1995 to the present, she has remained on these two agents. Over this time period, her mean glycosylated hemoglobin was 8.4%, blood pressure remained within normal range (108/ 74-126/82 mmHg), and her urinary albumin levels fluctuated from 418 to 1116 mg/24 h. Her level of renal function has remained relatively constant with iothalamate clearances of 47 mL/min/1.73 m2 in 1997 and 45 mL/min/1.73 m2 in 1999.

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