Foot Swelling in a Woman
During a routine office visit, a 64-year-old woman who has had type 2 diabetes for more than 10 years complains of increased pedal edema. The edema is minimal on awakening and worsens throughout the day.
HISTORY AND REVIEW OF SYSTEMS
The patient also has stiffness in the hands and facial puffiness on awakening. There is no history of edema or congestive heart failure symptoms. A urinalysis performed 18 months earlier showed no proteinuria; an ECG done at the same time was also normal. She takes a sulfonylurea twice daily for glycemic control and metoprolol(Drug information on metoprolol), 50 mg/d, for hypertension.
The patient is overweight at 63 kg (138.5 lb) (ideal weight for her height is 55 kg [121 lb]). Heart rate is 90 beats per minute; blood pressure is 155/92 mm Hg. Heart and lungs are normal. Neck veins are not distended, and there is no hepatojugular reflux. No abdominal distention or organomegaly. There is 2+ edema from the feet to the middle of both calves. Peripheral pulses are intact. No focal neurologic deficits; peripheral nerves are intact. A fundus examination reveals proliferative retinopathy.
LABORATORY AND IMAGING RESULTS
Hemogram is normal. Random blood glucose level is 206 mg/dL. Serum creatinine level is 1.6 mg/dL; potassium, 4.7 mEq/L; total cholesterol, 222 mg/dL; triglycerides, 299 mg/dL; glycosylated hemoglobin, 7.9%; and albumin, 3.2 g/dL. Urinalysis shows 3+ proteinuria on dipstick. ECG findings are unchanged from 18 months earlier.
Which of the following statements about this patient's diabetic
nephropathy is not true?
A. Better glycemic and lipid control are needed to slow the progression of renal disease.
B. Angiotensin-converting enzyme (ACE) inhibitors are contraindicated because of the patient's elevated creatinine level.
C. In patients such as this woman, more effective blood pressure control will reduce both the progression of renal disease and the risk of cardiovascular complications.
D. There is ample evidence that this patient has overt nephropathy.
E. Restriction of dietary protein may help slow the progression of this patient’s renal disease.