Controlling hypertension in patients with comorbidities

Leon is a retired 62-year-old man referred for assessment of a raised serum creatinine of 145µmol/L (Normal range: 60-110).

He was diagnosed with hypertension at age 32. He is currently treated with atenolol 50mg daily, irbesartan 300mg plus hydrochlorothiazide 25mg daily (Avapro HCT), and amlodipine 10mg daily (Norvasc).

He reports occasional symptoms of postural hypotension. He adds no salt to his food. Recently, he has been experiencing 3-4 episodes of gout each year.

Leon was diagnosed with type 2 diabetes at 46. Although this is currently well controlled with sitagliptin 50mg daily (HbA1c 5.7%), he has peripheral neuropathy, suggesting this may not always have been the case.

His urine albumin:creatinine ratio is 1.4mg/mmol (normal: <2.5) suggesting he is unlikely to suffer from diabetic nephropathy.

He has no other identifiable risk factors for, or family history of, chronic kidney