Help me with My father

My father is 66 year old, was a chronic smoker,, diabetic diagnosed since 2006 has resitant hypertension and diabetic nephropathy and diabetic retinopathy (NPDR) for which intravitreal VEGF has been prescribed but has not been done due to lockdown His recent creatinine is 3.51 mg/dl and urea is 44. His HbA1C is 8.1 I calculated his creatinine clearance which has come around 15.2 ml/minute. We have consulted 3 cardiologists, 2 nephorologists and 1 endocrinolgist. Yet here we are His BP remains around 190/100. Even on three drugs prescribed by a cardiologist, none of it is a diuretic though. Pulse rate usually around 100. He is on glargine and gets hypoglycemic in the morning usually. He is on MNT and drugs are here below: Before breakfast he takes a)Gliclzaide 80 mg and telmesartan 80 mg After breakfast: A)clinidipine 10 mg + nebivolol 2.5 mg At night he takes A)Alpha ketoanalogue tablets, aplazar B) Tabelt calcitriol 0.25mcg and calcium 200 mg C) clinidipine 10 mg + nebivolol 2.5 mg 4) insuline galargine 18 IU Kindly help me in this regard and help me lower his BP and control his diabetes and limit progression of kidney damage as much as I can.

(Edited)
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Dear Majaz Ahmed, Thank you for tagging me. Your father is a chronic smoker suffering from Type 2 Diabetes mellitus, Uncontrolled Hypertension , stage 4 DKD ,and NPDR since 14years. Rule out CAD and diabetic neuropathy. Target organ of Diabetic kidney disease is heart. Do lipid profile ECG 2D Echo Serum electrolytes should be monitored. USG abdomen and pelvis to rule out renal parenchymal disease. Coming to the treatment part, 1.Ask him to stop smoking. 2.Stop Gliclazide because he is in stage 4 DKD ,this is not recommended. 3.Start short acting or rapid acting insulin analogues like Novorapid or Fiasp 10units 5minutes before breakfast,lunch and dinner and adjust the dose according to the blood sugars. 4.Maintain fasting blood sugar around 100to 130mg/dL and post prandial less than 180mg/dL. 5.Meticulous control of blood sugars may lead to frequent hypoglycemia. HbA1C can be relaxed up to 8%in severely ill and critical patients and it is individualised depending on hypoglycemic incidence. 6. Salt restricted diet less than 2gms per day. Avoid added salt in diet. Avoid frozen foods,processed foods meat , chicken and fish etc. Only 2egg whites can be given daily. Plant proteins are recommended. Avoid pickles,papads,fryums, and chips etc. Only two fruits are allowed Apple and Papaya. 7.No NSAIDS. 8 .Reduce the dose of Telmisartan to 40mg as serum creatinine is raised 3.51mg/dL and always monitor serum potassium . 9. Change Nebivolol to Metoprolol 50mg bd. 10.Cilinidipine 10mgbd can be continued. 11. Add a loop diuretic like Frusemide 40mg or Torsemide 10mg. 12. Add a Alpha receptor blocker like Prazosin 5mg . 13. If Hypertension is not controlled add centally acting Clonidine. 14. Add Sodium bicarbonate tablet like Sobosis Forte tid. 15. Continue Calcitriol and calcium. 16.Add Vitamin D 3 60 k 8 tablets once in a week for 8 weeks. 17. Restrict total daily fluids to 1 to 2litres per day. 18. Monitor serum creatinine and serum electrolytes frequently. 19.Add antiplatelets like tablet clopidogrel 75mg to protect the heart. 20. Advice him small frequent meals as a child. Bed time snacking like milk and fruit after dinner prevents early morning hypoglycemia. 21. Strict control of blood sugars, blood pressure and cholesterol may help in slowing down the progression of kidney disease. 22. NPDR can be treated by opthalmologist by giving intravitreal injection of Avastin. 23. Look for neuropathy. Advice him to wear proper foot wear and not to walk on bare foot. As far as urine output is normal there is no need of dialysis or renal transplant. If there is oliguria or anuria , dialysis followed by kidney transplant is recommended.
Respected mam. I am extremely thankful and honoured by your prescription and advices. You have given a complete overview for me to work on. I will do as you have asked. I will follow each and every step for my father. Mam, I want to become a doctor like you. One who helps people in need and to the extent of completeness. Thank you for inspiring me mam. I have joined as JR1 in medicine at AMU just now from NEET PG. My session is going to start now. And you have motivated me for it to an extent I cant even explain. Thanking you again Dr Majaz Ahmad
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Dear dr Majaz Ahmed With respect to your father i submit my opinion eGFR 15ml Per minute is suggestive of ESRD and hence bul and sr creatinine are raised DKD/ESRD are responsible for uncontrolled hypertension Similarly morning hypoglycemia is more troublesome than hyperglycemia Since he is taking 18unit of glarzine should be lowered to keep better glucose levels Yes he needs to be added diuretics like dytor 20mg 1od And look how the output increases This should help otherwise total regime is to be reviewed With a note he may require renal dialysis
I am so thankful and honoured by your advice sir. I really needed it.
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Hello.. Kindly stop gliclazide as he having hypoglycemia in the morning .. U can add tablet Trajenta 5 mg once daily after breakfast ... Better to use basal plus bolus regime for insulin.. For BP make Telma CT 80/ 12.5 mg once in the morning Tab Cilacar 20 mg twice daily If not controlled tab Minipress XL 2.5 mg bd He may need dialysis .
Thank you very much mam.
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Hello doctor In my opinion for Hypertension Add CTD 12.5 and Dytor Plus 10 mg morning And what about cardiac status Do 2 D echo and renal Doppler for renal artery stenosis ....
Sir ejecrion fraction was around 60% but it's almost a year back thing. Will get it done again.
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Most welcome Dr Majaz Ahmed

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