Mr. N is a 54-year-old man with a history of hypertension, coronary disease, peripheral vascular disease, gout, dyslipidemia, and chronic kidney disease (CKD) Stage III (MDRD eGFR 35 mL/min) who presents with a 10 kg weight gain over the last 2 months. The patient reports that he has not been very compliant with his diet or exercise program. Gout attacks have been frequent. Physical exam: Height 5′9″; Weight 97 kg, 213 lb; BMI 31. The patient has 7 cm JVD at 30° and 1+ bilateral lower extremity edema. The exam is otherwise unremarkable. Significant labs: creatinine 2.3 mg/dL, triglycerides: 346 mg/dL, serum bicarbonate: 19 mEq/L, potassium: 5.7 mEq/L, phosphorus: 5.5 mg/dL, and PTH: 220 pg/dL. Despite the presence of volume overload, his blood urea nitrogen (BUN) to Cr ratio is 20:1. The patient also has proteinuria (albumin to creatinine ratio: 830 μg/mg).
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