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, 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
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
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.
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of renal disease: a meta-analysis. Kidney Int. 2001;59:260-269.
4. Lewis EJ, Hunsicker LG, Bain RP, Rhode RD. The effect of angiotensin-converting
enzyme inhibition on diabetic nephropathy. N Engl J Med. 1993;329:1456-1462.