Nephrology Q4

A 69-year-old woman is evaluated in the emergency department for new-onset dependent edema that began 3 weeks ago. She says it is difficult to walk, and she has gained 4.5 kg (10 lb) of fluid weight. History is significant for obesity and hypertension. Her only medication is lisinopril.

On physical examination, vital signs are normal. BMI is 32. There is no rash. There is 3-mm bilateral dependent edema stopping just below the abdomen; it is equal on both sides. The remainder of the examination is unremarkable.

Kidney biopsy findings are consistent with a diagnosis of minimal change glomerulopathy with superimposed acute tubular necrosis.

Laboratory studies:

Albumin 

2.1 g/dL (21 g/L)

Creatinine 

1.3 mg/dL (114.9 µmol/L)

Urine protein-creatinine ratio 

8700 mg/g

In addition to initiating diuretic therapy, which of the following is the most appropriate treatment?

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