Dr G.B. Piccoli Chair of Nephrology University of Turin Turin, Italy

 

Follow-up

The patient is started on ACE-inhibitors at low doses (enalapril 2.5 mg/day), trying to up-titrate them to the maximal tolerated dose (up to 7.5 mg/day), avoiding hypotension. Proteinuria, initially found to be as high as 6 g/day, is progressively reduced to 2.5-3 grams/day. Albumin levels are in the low-normal range.

Diabetic control improves through a stepwise policy and careful self monitoring.

Renal clearances remain in the previous range (50-60 mL/min).

The patient repeatedly underlines her firm wish to undertake a pregnancy.

 

Question 4

 

Figure 3

Picasso Mother and Child (Marie-Thérèse and Maya). 1938. Oil on canvas (65 x 54 cm). Private collection.

Picasso, who was himself father of several children, painted often their mothers caring for the babies. Despite his harsh character, his motherhood paintings convey images of sweetness and care.

References

1.	American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2004; 27 (Suppl 1): S15-35.
2.	American Diabetes Association. Preconception care of women with diabetes. Diabetes Care 2004; 27 (Suppl 1):S76-8.
3.	Warren E, Weatherley-Jones E, Chilcott J, Beverley C. Systematic review and economic evaluation of a long-acting insulin analogue, insulin glargine. Health Technol Assess 2004; 45: 1-57.
4.	Loukovaara S, Immonen I, Teramo KA, Kaaja R. Progression of retinopathy during pregnancy in type 1 diabetic women treated with insulin Lispro. Diabetes Care 2003; 26: 1193-1198.
5.	Kendrick JM. Preconception care of women with diabetes. J Perinat Neonat Nurs 2004; 18: 14-25.
6.	Khoury JC, Miodovnik M, LeMasters G, Sibai B. pregnancy outcome and progression of diabetic nephropathy. What's next? J Matern Fetal Neonatol Med 2002; 11: 238-244.
7.	Leguizamon G, Reece EA. Effect of medical therapy on progressive nephropathy: influence of pregnancy, diabetes and hypertension. J Matern Fetal Med 2000; 9: 70-78.
8.	Piccoli GB, Mezza E, Grassi G, Burdese M, Todros T. Interactive case report: A 35 year old woman with diabetic nephropathy who wants a baby: Case progression. BMJ 2004; 329: 729.
9.	Rao S, Lindow SW, Masson EA. Survey of pre-conception counselling. Diabetic Med 2002; 19: 615.
10.	Lockwood GM. A case-study in IVF: paternalism and autonomy in a “high risk” pregnancy. In: Ethical Issues in Maternal-Fetal Medicine. Ed Dickenson DL. Cambridge University Press 2002; pp 161-166.