Ankle Swelling and Hypertension

🗒️ Question

A 72 year old woman presents to her GP with a 4 month history of fatigue, decreased appetite and ankle swelling. She has a background of type 2 diabetes and hypertension which are currently managed with metformin and amlodipine. She denies any recent infections or changes in her medication.

On examination, her blood pressure is 155/95 mmHg and there is bilateral pitting oedema up to the mid-calf. Heart sounds are normal and there are no added sounds on lung auscultation.

Investigations

• Serum creatinine: 145 µmol/L (60–110)

• eGFR: 52 mL/min/1.73 m² (>90)

• Urine albumin-creatinine ratio: 35 mg/mmol (<3)

• HbA1c: 7.5% (6.5% target for diabetes)

• Serum potassium: 4.6 mmol/L (3.5–5.3)

What is the most appropriate initial management?

(A) Increase the dose of metformin

(B) Prescribe atorvastatin

(C) Add an ACE inhibitor

(D) Refer for renal biopsy

(E) Start oral furosemide