Prof G. Conte Full-professor of Nephrology at II University of Neaples and Chief of Nephrology and Dialysis “Incurabili” Hospital of Neaples Neaples, Italy	Dr P. Zamboli Senior Fellow at II University of Neaples “Incurabili” Hospital of Neaples Neaples, Italy

 

A 85 year-old white woman, affected by diabetes mellitus from 20 years and hypertension from about 14 years, underwent a visit at the ambulatory of nephrology. Her past medical history included a myocardial infarction 5 years before, followed by coronary artery bypass graft surgery.

On physical examination blood pressure (BP) was 170/100 mmHg, heart rate 85 b/min, body weight 53 kg, absence of peripheral edema. The routine laboratory and instrumental tests showed glycemia 145 mg/dl, plasma urea concentration 91 mg/dl, plasma creatinine 2.1 mg/dl, sodium 143 mEq/l, potassium 5.6 mEq/l, 24h measured creatinine clearance 26 ml/min, proteinuria 1 g/day, urinary sodium 178 mEq/day; ECG showed left ventricular hypertrophy and alterations compatible with previous myocardial infarction; renal ultrasound with doppler of renal arteries showed kidneys of preserved morphology and reduced volume (longitudinal diameters: right kidney 9.0 cm and left kidney 9.5 cm) (figure 1); renal arteries were evaluated bilaterally with no signs of stenosis (figures 2); fundus oculi was not well appraisable for the presence of cataract bilaterally.

 

Figure 1	Figure 2

 

Therapy consisted of ramipril 5 mg/day, irbesartan 300 mg/day, furosemide 50 mg/day, carvedilol 25 mg/day, transdermic nitroglycerine and insulin 30 UI/day.

Questions 1,2,3,4