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Answer 2
  1. Lisinopril. This patient has diabetic nephropathy and hypertension. His blood pressure has not yet achieved the recommended blood pressure target (125/75 mm Hg). Diabetic nephropathy typically follows an inexorable course of progression to end-stage renal disease. As shown in multiple studies, ACE inhibitors are the best class of agents to control blood pressure, reduce proteinuria, and slow progression of diabetic kidney. Following initiation of lisinopril, serum potassium and renal function should be monitored to identify the development of either hyperkalemia or acute renal failure. A 30% reduction in glomerular filtration rate is acceptable as long as renal function stabilizes at the new level within the next 60 days. Proteinuria should be reassessed intermittently to document efficacy and allow titration of the ACE inhibitor. An optimal level of proteinuria is less than 1 g/day and is associated with renoprotection. The other agents listed may control blood pressure but do not have the same renoprotective effect of lisinopril; in fact, some of these agents may worsen proteinuria.

     Brewster UC, Setaro JF, Perazella MA. The renin-angiotensin-aldosterone system: cardiorenal effects and implications of renal and cardiovascular disease states. Am J Med Sci 2003;326:15–24.

    2. Cruz DN, Perazella MA. Hypertension and hypokalemia: unusual syndromes. Connecticut Med 1997;61:67–75.

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