Here is a comprehensive management plan for a patient with diabetes and renal failure, incorporating the latest American Diabetes Association (ADA) standards and medications available in Saudi Arabia:

Patient Overview

• Age: 60 years

• Gender: Male

• Medical History: Type 2 Diabetes Mellitus (diagnosed 10 years ago), Chronic Kidney Disease (CKD) stage 3, Hypertension, and Dyslipidemia.

• Current Symptoms: Increased fatigue, controlled blood glucose levels, and episodes of edema in lower extremities.

Diagnostic Summary

• Diagnosis Criteria:

• HbA1c: 6.8% (controlled)

• eGFR: 45 mL/min/1.73m² (indicative of stage 3 CKD)

• Urine Albumin-To-Creatinine Ratio (UACR): 320 mg/g (indicative of diabetic nephropathy)

Recommended Management Plan

1. Lifestyle Modifications:

• Diet: Implement a kidney-friendly diet rich in fruits, vegetables, and whole grains while limiting sodium, phosphorus, and potassium.

• Exercise: Encourage at least 150 minutes of moderate-intensity aerobic activity per week, with adjustments for renal symptoms.

• Weight Management: Aim for a body weight goal that is achievable and sustainable; consider supervised weight management if needed.

2. Pharmacological Interventions:

• Blood Pressure Control: Start on an ACE inhibitor (e.g., Enalapril) to manage hypertension and provide renal protection.

• Glycemic Control:

• Prescribe Metformin if eGFR > 45 mL/min. If already on Metformin and eGFR drops below 45 mL/min, consider a dose adjustment to maintain renal safety.

• Initiate SGLT2 Inhibitors (e.g., Dapagliflozin) for renal protection and glycemic control, considering recent studies showing kidney outcome benefits down to eGFR of 20 mL/min^[1].

• Optionally, consider GLP-1 receptor agonists like Liraglutide or Semaglutide for both cardiovascular and kidney benefits in patients with high cardiovascular risk^[2][1].

• Dyslipidemia Management: Start a statin, such as Atorvastatin, to manage cholesterol levels.

3. Monitoring and Follow-Up:

• Schedule follow-up appointments every 3 months for:

• Monitoring HbA1c levels.

• Assessing renal function (serum creatinine and eGFR).

• Checking for any electrolyte imbalances, particularly potassium levels due to the use of ACE inhibitors and SGLT2 inhibitors.

• Evaluate blood pressure control at each visit.

Medication List with Justification

1. Metformin: First-line medication for type 2 diabetes, effective in controlling blood glucose with a good safety profile when used in patients with controlled renal function.
2. Dapagliflozin: Shown to protect kidney function and improve cardiovascular outcomes in patients with type 2 diabetes and CKD^[1].
3. Enalapril: Recommended as first-line therapy for hypertension and beneficial for kidney protection in individuals with diabetes^[3].
4. Statin (Atorvastatin): To manage dyslipidemia, reducing overall cardiovascular risk.

Follow-up and Monitoring Plan

• Routine Checkups: Every three months for:

• HbA1c level monitoring.

• eGFR and UACR assessments.

• Serum electrolytes, especially potassium.

• Adjust medications based on eGFR levels and blood pressure targets.

• Educate the patient on signs of worsening kidney function and symptoms of hypoglycemia.

This management plan aligns with the ADA's standards and utilizes medications that are available and approved in Saudi Arabia to ensure optimal care of the patient with diabetes and renal failure.

References

1. Source: 4:9
2. Source: 4:1
3. Source: 4:4