CASE STUDY 1

Patient A is an African American woman, 53 years of age, with a 17-year history of type 2 diabetes, hypertension, and hyperlipidemia and a 35-year history of smoking. She had been referred to a diabetes clinic for intensive diabetes self-management education and training over this period. She presents in the office with shortness of breath, pruritus, and pitting edema of bilateral extremities. Her blood pressure is 165/92 mm Hg, heart rate 94 beats per minute (regular rate and rhythm), and respiration 26 breaths per minute. She is 5 feet 3 inches tall and weighs 202 pounds (BMI: 35.8). Blood is taken and sent to the laboratory for analysis, which reveals some abnormal findings (Table 5).

Based on the serum biomarker results, Patient A is diagnosed with stage 3 chronic kidney disease, with a GFR of 49 mL/min/1.73 m² and profound microalbuminuria. This diagnosis is substantiated by the noted elevation in random blood glucose levels and HbA1c.

Patient A is also experiencing anemia, with a hemoglobin level of 8.7 g/dL, and early signs of a bone and mineral metabolism disorder. She is considered at high risk for a cardiovascular event due to her long history of diabetes, hypertension, tobacco abuse, and hyperlipidemia, all of which appear to be uncontrolled.

Patient A attends diabetes self-management classes taught by a registered nurse and a registered dietitian. A 24-hour food recall demonstrated a high-protein diet and difficulty complying with the low-carbohydrate plan necessary to control her blood glucose levels. Over a period of six months, the patient lost and regained 10 pounds. She generally does not eat breakfast, has a salad at her desk at work for lunch, and typically stops at a fast food restaurant or orders delivery for dinner due to worsening fatigue and loss of energy. Patient A lives alone and does not enjoy cooking for one person. She also admits to not sleeping well and frequently eating in the middle of the night. Goals for treatment include glucose management, regulation of blood pressure, smoking cessation education, and lowered protein intake.

A meal plan is created for Patient A geared toward weight loss; the plan is low carbohydrate without being high protein in order to prevent further damage to the kidneys. Meal planning is simplified and incorporates homemade quick-fix meals or slow cooker recipes that should reduce the fat intake associated with a predominantly fast food diet. Specific emphasis is given to the need to refrain from high-protein foods and to eat at regular intervals throughout the day, including breakfast.

The need for physical activity is vital for Patient A and should help with weight loss, stress control, and blood pressure management. The patient is encouraged to wear a pedometer and work up to walking 10,000 steps each day. She is encouraged to start slowly and increase activity gradually.

Adherence to medications is an important part of Patient A's treatment plan. She is prescribed medications for many of her existing conditions including diabetes, hypertension, anemia, and cardiovascular disease. Instructions for her diabetes medications include the rationale for maintaining adequate glucose control. Patient A's history reveals a lack of glycemic control, so medication adherence is paramount and patient education includes insulin therapy instructions. The nurse also discusses the action, dosage, side effects, and need for a newly prescribed ACE inhibitor. Patient A is instructed to monitor her blood pressure at home and to report any high or low reading to her primary care provider.

Anemia education is completed, with further explanation regarding the need for additional testing to determine if supplemental iron or an erythropoiesis-stimulating agent is necessary. To prevent damage related to cardiovascular disease, Patient A is started on a statin to help decrease her lipid levels in conjunction with a low-fat diet. A vitamin D supplement is also recommended due to the elevated parathyroid hormone level.

Lastly, Patient A is encouraged to conduct self-blood glucose monitoring, maintain regular check-ups with her healthcare team, and follow-up with a nephrologist to further impede kidney disease progression. With education and understanding, Patient A can maintain her current kidney function. However, if she continues on her current path, progression into end-stage renal disease could be inevitable.