Posttest

Instructions

Read the supplement and complete the examination.
Use a blue or black BALLPOINT pen to complete the CME and evaluation form.
Sign and date the form.
Mail to: ASN-CME 1725 I Street, NW, Suite 500, Washington, DC, 20006-2425.
Answer ≥80% and receive the answers to the questions and CME credit.
E-mail aworkman@asn-online.org with any questions.

Case 1

T.I. is a 57-yr-old, obese Hispanic woman who is referred by her primary care physician for worsening kidney function and albuminuria (>300 mg/d). She has no complaints except for swelling in her legs. Medical history is relevant for osteopenia, dyslipidemia, hypertension, and type 2 diabetes. She had a hysterectomy 5 yrs ago. She denies smoking and reports occasional drinking. She reports frequently adding salt to her food. Her vital signs are as follows: BP 162/100 mmHg (during the previous two visits, BP readings were 158/94 and 152/98), pulse 76 bpm, body mass index 34 kg/m², and waist circumference 39 inches. Pertinent laboratory results are as follows: creatinine 1.5 mg/dl (estimated GFR [eGFR] 42 ml/min), glycosylated hemoglobin 8.6%, total cholesterol 240 mg/dl, LDL cholesterol 124 mg/dl, HDL cholesterol 28 mg/dl, and triglycerides 481 mg/dl. There is trace albumin in urine dipstick and 452 mg albumin/g creatinine in spot urine. All other laboratory values are within normal limits, including K⁺ at 4.1 mEq/L. Current medications include calcium carbonate 600 mg twice daily, atorvastatin 10 mg/d, Glucovance (glyburide and metformin) 2.5 mg/500 mg twice daily with meals, hydrochlorothiazide 25 mg orally every morning, and ramipril 10 mg/d orally.

Which of the following statements is/are TRUE regarding T.I.'s risk for chronic kidney disease (CKD) and cardiovascular disease?
1. Diabetes accounts for almost half (45%) of CKD.
2. People with both diabetes and CKD have a very high risk for death.
3. People with diabetes and microalbuminuria have twice the cardiovascular disease risk of those with normoalbuminuria.
4. A and B.
5. A, B, and C.
Which of the following statements is/are TRUE regarding the control of hypertension in patients with diabetes?
1. Hypertension is more difficult to control in patients with diabetes compared with individuals without diabetes.
2. More than one half of patients with diabetes and hypertension achieve goal BP.
3. Fewer than one third of patients with diabetes and hypertension achieve goal BP.
4. A and B.
5. A and C.
Which of the following statements is/are TRUE regarding recommendations for treatment of hypertension in patients with diabetes?
1. A multidrug regimen is usually necessary to achieve BP control.
2. In patients who are at high risk for kidney disease because of diabetes or other risk factors, there is a clear indication for the use of renin-angiotensin system blockers such as angiotensin receptor blockers (ARBs).
3. Moderate to high dosages of renin-angiotensin system blockers and diuretics are usually needed to achieve BP control.
4. A and B.
5. A, B, and C.
Which of the following statements is/are TRUE regarding monitoring and follow-up in patients with hypertension?
1. In most patients, BP should be monitored every week until goal BP is reached.
2. In most patients, BP should be monitored every month until goal BP is reached.
3. After BP is at goal and stable, it can be monitored every 3 to 6 mo.
4. A and C.
5. B and C.
What is an acceptable increase in serum creatinine in a patient with more advanced kidney disease (GFR <60 ml/min) after starting treatment with an angiotensin-converting enzyme inhibitor (ACEI) or ARB?
1. 10%
2. 20%
3. 30%
4. 40%
5. 50%

Case 2

A 62-yr-old white woman presents with a history of stroke, 2 yrs ago, and modest residual gait impairment. Her current BP regimen includes a diuretic and a β blocker. Her creatinine in a recent laboratory evaluation was 1.1 mg/dl (yielding an eGFR of 53 ml/min per 1.73 m²). Her BP recorded today averaged 136/82 mmHg. She is a nonsmoker, and her lipid profile shows an LDL of 78 mg/dl.

6. The PROGRESS study and JNC7 both suggest which combination drug approach has a proven benefit to reduce stroke recurrence?

Diuretic and α blocker
Diuretic and β blocker
Diuretic and calcium channel blocker
Diuretic and ACEI
Diuretic and vasodilator

7. In light of her eGFR value of 53 ml/min per 1.73 m² which ONE of the following statements best reflects her circumstances?

There is no increase in stroke risk when compared with patients whose eGFR is >60 ml/min per 1.73 m².
The consequences of antiplatelet therapy, if administered, show a greater risk than benefit at this level of eGFR.
Her eGFR level is not a contraindication to any particular drug therapy listed in the previous question.
A 24-h urine collection for albumin would help to define the best therapy for her in view of her reduced eGFR.

Case 3

A 45-yr-old woman presents with type 2 diabetes, obesity, hypertension, proteinuria, and chronic kidney disease. Her current medications include an ACEI (40 mg/d) and a dihydropyridine calcium channel blocker (10 mg/d). A physical examination yields that she is obese (30% above ideal body weight); her BP is 148 to 162/96 to 102; the remainder of the physical examination is unremarkable save for trace peripheral edema. Pertinent laboratory results are as follows: Serum: Na 140 mEq/L, K 4.1 mEq/L, Cl 106 mEq/L, HCO₃ 22 mEq/L, glucose 95 mg/dl, glycosylated hemoglobin 7.2%, creatinine 1.5 mg/dl, and blood urea nitrogen 18 mg/dl; urine: 24-h protein 6.6/g and 24-h Na 165/mEq.

8. What would be the next agent you would use to treat this patient?