A 60-year-old man with a 1 7-year history of type 2 diabetes mellitus visits a clinic because of…

A 60-year-old man with a 1 7-year history of type 2 diabetes mellitus visits a clinic because of increasing swelling in his lower extremities. The swelling began approximately 7 months previously and has worsened over the past 6 to 8 weeks. The patient reports no recent illnesses and specifically denies any fever, chills, arthralgias, joint swelling, or skin rash. In addition, he reports no visual changes, epistaxis, hemoptysis, or cough. The patient's medical history is significant for hypertension, type 2 diabetes mellitus, and an appendectomy. His medications include glyburide 10
» A 60-year-old man with a 1 7-year history of type 2 diabetes mellitus visits a clinic because of increasing swelling in his lower extremities. The swelling began approximately 7 months previously and has worsened over the past 6 to 8 weeks. The patient reports no recent illnesses and specifically denies any fever, chills, arthralgias, joint swelling, or skin rash. In addition, he reports no visual changes, epistaxis, hemoptysis, or cough. The patient's medical history is significant for hypertension, type 2 diabetes mellitus, and an appendectomy. His medications include glyburide 10 mg daily, amlodipine 10 mg daily, and ibuprofen occasionally. He does not abuse alcohol, tobacco, or illicit drugs. No family history of kidney disease is present, although several of his family members have diabetes mellitus and heart disease. His physical examination reveals a healthy-appearing man in no acute distress. He has 3+ pitting edema up to the midcalf. His glomerular biopsy shows the lesion below (Fig. 2-5). 1. What is the most likely cause of the patient's renal disease? a. Diabetic nephropathy b. Focal and segmental glomerulonephritis c. Acute glomerulonephritis d. Membranous glomerulonephritis e. Minimal change disease 2. What is the most appropriate treatment? a. Administer more amlodipine for better control of blood pressure b. Begin insulin therapy for better glycemic control c. Initiate therapy with an angiotensin-converting enzyme inhibitor d. Restrict dietary protein to 0.6 g/kg body weight per day 3. In what stage of chronic kidney disease is this patient? a. 2 b. 3AI c. 3B d. 4 e. 5

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