This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
Case summary
J.T., a 61-year-old with a 12-year history of type 2 diabetes and hypertension, attends a routine visit. Current medications are metformin 1,000 mg twice daily and lisinopril 20 mg daily. Results: A1C 7.8%, eGFR 52 mL/min/1.73 m² (stable over six months), urine albumin-to-creatinine ratio (UACR) 180 mg/g, potassium 4.6 mEq/L, blood pressure 134/82 mm Hg and BMI 31.
Problem identification
J.T. has type 2 diabetes above the individual A1C goal and chronic kidney disease (CKD) stage G3a with moderately increased albuminuria (A2). Beyond glucose control, the priorities are slowing kidney disease and lowering cardiovascular risk.
Drug selection and rationale
For people with type 2 diabetes, CKD and an eGFR of 20 mL/min/1.73 m² or more, an SGLT2 inhibitor with proven kidney or cardiovascular benefit is recommended, alongside metformin when eGFR allows (de Boer et al., 2022; Kidney Disease: Improving Global Outcomes Diabetes Work Group, 2022). Empagliflozin 10 mg daily is added.
SGLT2 inhibitors block glucose and sodium reabsorption in the proximal tubule. More sodium reaches the macula densa, which restores tubuloglomerular feedback, constricts the afferent arteriole and lowers pressure inside the glomerulus; this is thought to underlie their kidney protection. Because their glucose-lowering effect falls as eGFR declines, further A1C lowering may later need a GLP-1 receptor agonist, which would also support weight loss.
Adjusting current therapy
Metformin continues at the current dose while eGFR is 45 or above. The dose is reduced if eGFR falls below 45, and metformin is stopped below 30 (de Boer et al., 2022). Lisinopril is titrated to the highest tolerated dose because of albuminuria (Kidney Disease: Improving Global Outcomes Diabetes Work Group, 2022).
Monitoring and patient education
- A small, reversible fall in eGFR is expected after starting an SGLT2 inhibitor and generally isn't a reason to stop it (de Boer et al., 2022). Kidney function and potassium are rechecked in 2 to 4 weeks.
- In trials, genital mycotic infections occurred in 6% of people taking an SGLT2 inhibitor compared with 1% taking placebo, so daily hygiene is taught.
- Sick-day rules: pause the SGLT2 inhibitor and metformin during acute illness with vomiting or poor intake, and before surgery. Ketoacidosis can occur with near-normal glucose levels.
- A1C is rechecked in 3 months and UACR within 6 months.
References
de Boer, I. H., Khunti, K., Sadusky, T., Tuttle, K. R., Neumiller, J. J., Rhee, C. M., Rosas, S. E., Rossing, P., & Bakris, G. (2022). Diabetes management in chronic kidney disease: A consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care, 45(12), 3075–3090. https://doi.org/10.2337/dci22-0027
Kidney Disease: Improving Global Outcomes Diabetes Work Group. (2022). KDIGO 2022 clinical practice guideline for diabetes management in chronic kidney disease. Kidney International, 102(5S), S1–S127. https://doi.org/10.1016/j.kint.2022.06.008
