1. 77-year-old woman with long-standing osteoarthritis, a 20-year history of hypertension and a 3-year history of type 2 diabetes presents for a routine office visit. She admits frustration at not being able to meet A1c goals in the past. She admits to being generally weaker during the past year, during which time she has suffered 2 falling episodes without true syncope or vertigo. The patient denies chest pain, palpitations or dyspnea but admits to occasional ankle swelling. Prior glycated hemoglobin (A1c) levels have been in the 7.0-8.1% range.

2. Medications: metformin 1,000 mg twice daily, naproxen 440 mg twice daily and lisinopril 5 mg once daily. Review of systems: significant for chronic hip and knee pains but is otherwise negative except as above.

3. Somewhat frail-appearing elderly woman in no acute distress. PERRLA: fundi benign Neck: thyroid nonenlarged; no masses, lymphadenopathy, abnormal pulses or bruits Lungs: clear

4. Cardiovascular: regular rate and rhythm; no murmurs or S3 gallop Abdomen: soft; nontender; no masses or organomegaly Extremities: no cyanosis or clubbing; there is trace to 1+ ankle edema bilaterally Neurological: intact, including cranial nerves and reflexes Skin: no lesions or rash; resolving bruise over her Psychiatric: oriented x4 and fluent; MMSE not performed

5. Family History: Father died with a stroke at age 71 and her mother died at age 75 with long-standing heart failure; sister has diabetes. Social History: Widow, retired bookkeeper with 5 grown children; nonsmoker and nondrinker. Lives alone and administers her own medications.

18. Abboud H and Henrich W. N Engl J Med 2010;362:56-65 Stages of Chronic Kidney Disease and Prevalence in Adults

19. Chronic kidney disease has recently been recognized as a public health problem; it is estimated that by 2030, more than 2 million people in the United States will need dialysis or transplantation for kidney failure. Currently, approximately 19 million adults in the United States are in the early stages of the disease, defined by either a GFR of less than 60 ml per minute per 1.73 m2 of body- surface area or the presence of kidney damage, regardless of the cause, for three or more months.

22. Mitch W. N Engl J Med 2004;351:1934-1936 ACE Inhibition versus Angiotensin-Receptor Blockade in Progressive Nephropathy Associated with Type 2 Diabetes

23. A 54-year-old woman with an 11-year history of type 2 diabetes presents for care. She was first noted to have proteinuria 4 years earlier; her serum creatinine level then was 1.1 mg per deciliter (97 µmol per liter). Her urinary protein excretion has progressively increased to 2.8 g per 24 hours, and her serum creatinine level to 3.1 mg per deciliter (274 µmol per liter). The estimated glomerular filtration rate (GFR) is 26 ml per minute per 1.73 m2 of body-surface area. Her blood pressure is 155/90 mm Hg, and the glycated hemoglobin level is 7.6 mg per deciliter. The medications she is currently taking include an oral hypoglycemic agent, an angiotensin- converting–enzyme (ACE) inhibitor, a statin, and a thiazide diuretic. How should her case be managed?

24. Abboud H and Henrich W. N Engl J Med 2010;362:56-65 Major Causes of Severe Chronic Kidney Disease

25. Abboud H and Henrich W. N Engl J Med 2010;362:56-65 Cardiovascular Disease in Patients with Chronic Kidney Disease

34. Diagnosis 1.Hypertension 2.Diabetes Mellitus Type 2 3. Osteoarthritis