MKSAP: 65-year-old man with chronic kidney disease

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 65-year-old man is evaluated during a follow-up visit for stage G3b/A3 chronic kidney disease due to diabetic nephropathy. He reports doing well with good baseline exercise tolerance and no shortness of breath. Medical history is also significant for type 2 diabetes mellitus and hypertension. Medications are basal bolus insulin and lisinopril, 20 mg/d.

On physical examination, temperature is normal, blood pressure is 145/75 mm Hg, pulse rate is 82/min, and respiration rate is 16/min. BMI is 28. There is no jugular venous distention. The lungs are clear.

Laboratory studies:

Bicarbonate Normal
Creatinine 1.9 mg/dL (168 µmol/L)
Potassium 4.0 mEq/L (4.0 mmol/L)
Estimated glomerular filtration rate 42 mL/min/1.73 m2
Urine protein-creatinine ratio 3900 mg/g

Kidney ultrasound shows mildly echogenic kidneys that are of normal size with no obstruction.

Which of the following is the most appropriate treatment?

A. Add an angiotensin receptor blocker
B. Increase lisinopril dose
C. Replace lisinopril with amlodipine
D. No change in current medications

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