M is 64-year-old Asian man who presents to the clinic for an HTN foIlow up examination after starting hydrochlorothiazide 6 months ago. He denies chest pain. shortness of breath, dizziness or Headache. His past medical history is significant for diabetes and HTN. He Is currently only receiving hydrochlorothiazide.
On examination
Vital signs are T -37.5degree C, BP 154/92 mm Hg. HR 82/ min. and RR 16 breaths/min. His 8P remains elevated above goal ( 130/85 mm Hg).
labs: K+ 4.3 mEq/l. BUN 26mg/dl,Cr 1.4 mg/dL.
UrinaIysis(UA): 3+ protein
Case Conclusion :
A 24-hour urine collection is performed, which reveals 780 mg of protein and a creatinine clearance rate of 58 mL/min. Thus. this patient has chronic renal disease. most likely diabetic nephropathy. Therefore, an ACE-Inhibitor would be a good choice for this patient
Discussion
ACE -I are particularly useful in treating patients with diabetic nephropathy. In these patients, ACE-I can decrease proteinuria and stabilize renal function independent of their antihypertensive effects. The benefits are attributed to their effects on renal hemodynamics. Angiotensin II may adversely affect the kidney by increasing the glomerular efferent arteriole resistance. Hence, the decrease in production of angiotensin II results in vasodilatation of the efferent arteriole and lowering intra-glomerular capillary pressure.
ACE-I blocks the conversion of angiotensin I to angiotensin II, which causes vasoconstriction and stimulates the production of aldosterone synthesis. Thus, ACE-I promote vasodilatation and decrease sodium retention, consequently lowering blood pressure.
