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Case History

It is generally accepted that chronic kidney disease (CKD) is a major public health issue. More than 4.902 million people worldwide are projected to have end-stage kidney disease (ESKD) and require renal replacement treatment, according to the World Health Organization (WHO). Chronic kidney disease occurs when your kidneys are damaged and unable to remove wastes from your blood as effectively as they once did, you have. People with CKD have a considerably worse quality of life compared to the general population due to a wide range of health issues. Wastes can build up in your blood and cause you to feel ill if your kidney disease progresses. As a result, you might develop health issues such as hypertension, anemia (low red blood cell count), brittle bones, poor nutrition, neurological damage, and more (Jankowski et al, 2021). As a result of kidney illness, you're more likely to get heart and blood vessel disease as well. These issues may take a long time to develop. It is possible to slow the progression of chronic kidney disease with early identification and therapy. Dialysis or a transplant may be necessary if the condition advances to the point of renal failure. This essay will focus on a case history of Mrs. Doe with chronic kidney disease. She has the complications of anaemia, cardiovascular risk, CKD-related mineral bone disorder, and hypertension. I will review the pathophysiology, treatments and management of these.

Mrs. Doe is a 56-year-old patient with stage five chronic kidney failure. Following past clinical examinations, it was established that she had a long-standing history of hypertension and diabetes. Her GFR result was at 13 mL/min per 1.73 m2, indicating kidney failure. A urine albumin result of 35 mg/g was established from the test, indicating a sign of kidney disease. Over the past two years, Mrs. Doe has had several complications that were established to be mainly associated to the chronic kidney disease. She has a major decline in her total hemoglobin concentration which resulted to anemia. Her hemoglobin level was at 10 12.0 g/dL. In some instances, she experiences gastrointestinal bleeding, which is a mechanism caused by anemia in CKD. Another complication that Mrs. Doe has experienced is the CKD-related mineral and bone disorder, that involves anomalies in mineral and bone metabolism. During the same period, she was diagnosed of Osteomalacia, which is attributed to reduced bone turnover and insufficient mineralization, largely associated to reduced synthesis of vitamin D (Cruz et al, 2011). Mrs. Doe is also diagnosed of Hypertension, which is the customary cardiovascular risk factor that enhances the cardiovascular risk related to CKD. She often has a blood pressure of 150/100 mm Hg. Being a stage five CKD patient, she is probably at increased risk for recurrent or new cardiovascular occurrences. The complications will be discussed in detail below, including their pathophysiology and possible care or treatment plans.

Discussions

Detecting the disease early can enhance treatment outcomes and reduce the risk of long-term problems for the patient. It is possible for people who have not been properly diagnosed to unintentionally spread the disease to others. (Wright & Hutchison, 2019). Many patients with end-stage renal illness visit their nephrologist only once before starting dialysis, despite the fact that the diagnosis is now quite straightforward (Drüeke et al, 2016). CKD patients need to be diagnosed as soon as possible so that preventative procedures may be set up to slow or probably stop the course of the illness. Complexity and variety of interventions in secondary prevention, as well as diverse methods of healthcare delivery, need to be examined in multidisciplinary care clinics to better understand CKD's secondary prevention (Cruz et al, 2011). In the latter stages of CKD, numerous problems develop more often and with greater severity (Hsu et al, 2018). Morbidity, mortality, and a poor quality of life are all exacerbated by these consequences. In order to better understand Mrs. Doe's CKD symptoms, we will identify and investigate her many systemic problems.

Hypertension

One of the most dangerous side effects of chronic kidney disease (CKD) is high blood pressure, which has been linked to an increased risk of cardiovascular disease (CVD) and death. Patients who suffer from hypertension might benefit from better methods of early identification and treatment. While this research did not include patients with CKD, proteinuria, or diabetes, it offered crucial information on the impacts of a more rigorous reduction of systolic blood pressure to a target of 120 mm Hg which could be appropriate to CKD victims (Hage et al, 2019). Lifestyle changes, such as losing weight and cutting back on salt intake, can also help regulate blood pressure. Such treatments are less expensive than pharmaceutical therapy and possess the ability to improve results, such as stroke and heart failure, in both established and developing health care systems (LMICs). One possible goal in LMICs would be to enhance the control of hypertension problems in CKD patients, targeting to attain objective series in a percentage of patients. This is an objective that can be achieved throughout the world, and its impact may be measured (Stevens et al, 2016).

When it comes to treating high blood pressure in patients with chronic kidney disease (CKD), Mrs. Doe has relied on angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors (ACEis). They are able to reduce both the systolic and diastolic blood pressures at the same time. Because of this, RAS blockers may help Mrs. Doe minimize the risk of cardiovascular and renal problems. Most worldwide renal disease recommendations advocate RAS blockers as the first line of treatment (Al-Khoury et al, 2016). An increased use of ambulatory blood pressure monitoring in Mrs. Doe's treatment of hypertension in advanced kidney disease has assured that BP control is maintained around the clock using only validated equipment and that blood pressure is controlled at least to a level of 140/90 mmHg or below. A successful technique to decrease her blood pressure and albuminuria was limiting her salt intake to 5–6 grams of NaCl per day.

CKD-Related Complications

Hypertension- her current blood pressure level is 150/100 mm Hg. The objective was to control Mrs. Doe’s blood pressure and get it to below 140/90 mmHg. She normally uses ramipril, which is an angiotensin converting enzyme (ACE) inhibitor.

High cholesterol- She has a cholesterol level of 230 mg/dl, which is quite high and presents a risk cardiovascular disease. She was prescribed with atorvastatin, which is a statin used to lower the risk of acquiring cardiovascular disease.

To prevent hypervolemia, she is also subjected to diuretic medications, which focuses on removing excess fluid from the body. It operates by enhancing the generation of urine.

Anemia

Iron and erythropoiesis-stimulating medications are used to treat Mrs. Doe's anemia problems (ESAs). Parenteral iron and ESAs are still lacking in research in terms of appropriate dosage. ESAs may help alleviate symptoms, but their long-term effects on survival are unknown and may raise the risk of cardiovascular and cancer disease. High hepcidin may have a role in CKD, but the entire extent of the drug's negative effects and how it interacts with the body are still understood (Cai, Mukku & Ahmad, 2013). Patients may be more vulnerable to the adverse effects of ESAs because of geographical disparities in their ability to resist treatment. Many LMICs, where ESAs are hard to come by and prohibitively costly, have a different approach to treating anemia in CKD patients than wealthy nations. ESAs and i.v. iron are currently under investigation, but attempts to make these medicines (and blood transfusions) more widely available in low- and middle-income countries (LMICs) may help alleviate the symptoms of anemia in CKD.

Anemia- She is always given injections of erythropoietin medicine. It is a hormone that assists her body in generating higher red blood cells. Mrs. Doe has received recombinant human erythropoietin to address her anemia as a result of her CKD (epo). Patients with CKD who are anemic have seen their survival rates improve as a result of this medication. As additional research have been published, the target level of Hgb for individuals with CKD has altered. Since these target levels have been linked to greater mortality, achieving hemoglobin normalization is no longer seen as the primary aim of therapeutic intervention. While treating anemia has been shown to reduce morbidity and improve quality of life for people with kidney disease, this patient does not receive appropriate therapy prior to dialysis to meet current FDA suggested objectives and does not always receive erythropoietin treatment. The therapy has been mainly successful.

Cardiovascular Complications

Chronic kidney disease (CKD) patients are highly likely to die from cardiovascular disease (CVD) as their renal function declines. Considering that Mrs. Doe is a stage five patient, she has a larger chance of death. Patients with CKD stage G5 are at a higher risk of dying from cardiovascular disease by about 8.1 times than a group without kidney disease (Davison, 2010). For patients with CKD stages 1 to 3, therapy of traditional cardiovascular risk factors such as cholesterol and blood pressure are widely regarded to be effective, but there are extra risk factors that should be factored in, where a good number is often believed to be the consequences of the disease (McClellan et al, 2014). Cardiomyopathy and vasculopathy may be exacerbated by CKD-related mineral and endocrine abnormalities, like retention of phosphate, increased levels of fibroblast growth factor 23 and abnormalities in Klotho metabolism. CKD-related cardiovascular disease (CVD) can be reduced through better knowledge of the variables that contribute to the disease and the development of novel therapeutic targets, as well as efforts to manage blood pressure and raise the prescription of lipid-reducing medicines (Locatelli et al, 2019).

A comprehensive approach to Mrs. Doe's treatment of both classic and non-traditional cardiovascular risk factors has been necessary. Surgeons, nurses, educators, and dieticians have all played an important role in improving patient outcomes. When she has diabetes, her blood pressure is managed according to the KDOQI standards (BP target 130/85). Reducing proteinuria, lowering glycated hemoglobin and serum cholesterol (100 mg/dL) while also slowing the course of kidney failure have all been part of this treatment strategy, as have the usage of ACE inhibitors or angiotensin receptor blockers. Mrs. Doe's therapeutic goals for cardioprotective treatments need to be established through more randomized studies.

CKD-Related Mineral Bone Disorder

Conventional mineral biochemistry abnormalities, the spectrum of renal osteodystrophy and soft tissue calcification are all included in CKD-mineral and bone problem syndrome. In certain cases, these anomalies may be caused by left ventricular hypertrophy. Despite a large amount of preclinical research, very few advances have been converted into clinical applications for this diverse set of illnesses (Phrommintikul et al, 2017). The genuine advantages of correcting anomalies such as high blood phosphate levels, vitamin D insufficiency, and secondary hyperparathyroidism are yet to be demonstrated. Due to their propensity to aggravate tissue calcium deposition, low-cost calcium-based phosphate binders have become contentious. Efforts to ameliorate the symptoms of tertiary hyperparathyroidism might be made by increasing the accessibility of analogs of 1,25-dihydroxyvitamin D, nutritional vitamin D, and phosphate binders (Van Pottelbergh et al, 2012).

Bone problems- She is generally low in vitamin D thus often given the cholecalciferol supplement to boost her vitamin D level.

Phosphorus level decrease is the primary focus of Mrs. Doe's therapy for CKD-associated bone and mineral problems. When phosphate or parathyroid hormone levels start to rise, the first therapy is to decrease dietary phosphorus consumption. Stage 5 CKD patients had phosphorus levels between 3.5 and 5.5 mg/dL in their blood. A variety of phosphate-binding agents have been employed to achieve this end result. Vitamin D and its related chemicals have also been used to boost the blood calcium levels enough to limit parathyroid hormone output because of the kidney's inability to 1-hydroxylate vitamin D. Aside from calcimimetics, which increase the calcium sensitivity of the parathyroid-specific receptor, she is frequently administered calcimimetics in order to decrease parathyroid hormone production and reduce parathyroid gland hyperplasia.

Conclusion

Mrs. Doe, a fifth-stage CKD patient, has been suffering a number of issues. Hypertension, anemia, and cardiovascular problems are among her other health complications that occur from the chronic disease. She also has CKD-related mineral bone disease. Metabolic acidosis and electrolyte imbalances are among her other health issues. Mrs. Doe has been subjected to several treatments to help maintain her health. Most of the interventions have largely been effective mainly because they were applied as per the international health guidelines. The angiotensin converting enzyme (ACE) inhibitor that she uses has been effective in lowering her blood pressure to below 140/90 mmHg, which is the desired level. The statin she uses has also been successful in lowering her cholesterol level to below 200 mg/dL, which is the normal level. This has significantly reduced her chances of acquiring cardiovascular disease. The diuretic medications have also enhanced the production of urine, thus preventing hypervolemia. Patients with chronic renal illness should expect to live longer and better lives if primary care doctors and nephrologists work collaboratively to identify and treat issues early on. The most debilitating side effect of CKD for Mrs. Doe is high blood pressure. It can lead to heart disease, which in turn can lead to renal failure. Patients may be prescribed medication to decrease their blood pressure as well as diet and activity adjustments. Dieticians with expertise in the treatment of renal disease patients should be involved in the nutrition management of patients with chronic kidney disease and those on dialysis.

References

Al-Khoury, S., Afzali, B., Shah, N., Covic, A., Thomas, S. and Goldsmith, D.J., 2016. Anaemia in diabetic patients with chronic kidney disease—prevalence and predictors. Diabetologia, 49(6), pp.1183-1189.

Cai, Q., K Mukku, V. and Ahmad, M., 2013. Coronary artery disease in patients with chronic kidney disease: a clinical update. Current cardiology reviews, 9(4), pp.331-339.

Cruz, M.C., Andrade, C., Urrutia, M., Draibe, S., Nogueira-Martins, L.A. and Sesso, R.D.C.C., 2011. Quality of life in patients with chronic kidney disease. Clinics, 66(6), pp.991-995.

Davison, S.N., 2010. End-of-life care preferences and needs: perceptions of patients with chronic kidney disease. Clinical Journal of the American Society of Nephrology, 5(2), pp.195-204.

Drüeke, T.B., Locatelli, F., Clyne, N., Eckardt, K.U., Macdougall, I.C., Tsakiris, D., Burger, H.U. and Scherhag, A., 2016. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. New England Journal of Medicine, 355(20), pp.2071-2084.

Hage, F.G., Venkataraman, R., Zoghbi, G.J., Perry, G.J., DeMattos, A.M. and Iskandrian, A.E., 2019. The scope of coronary heart disease in patients with chronic kidney disease. Journal of the American College of Cardiology, 53(23), pp.2129-2140.

Hsu, C.Y., Ordonez, J.D., Chertow, G.M., Fan, D., McCulloch, C.E. and Go, A.S., 2018. The risk of acute renal failure in patients with chronic kidney disease. Kidney international, 74(1), pp.101-107.

Jankowski, J., Floege, J., Fliser, D., Böhm, M. and Marx, N., 2021. Cardiovascular disease in chronic kidney disease: pathophysiological insights and therapeutic options. Circulation, 143(11), pp.1157-1172.

Locatelli, F., Covic, A., Eckardt, K.U., Wiecek, A., Vanholder, R. and Era-Edta Erbp Advisory Board, 2019. Anaemia management in patients with chronic kidney disease: a position statement by the Anaemia Working Group of European Renal Best Practice (ERBP). Nephrology Dialysis Transplantation, 24(2), pp.348-354.

McClellan, W., Aronoff, S.L., Bolton, W.K., Hood, S., Lorber, D.L., Tang, K.L., Tse, T.F., Wasserman, B. and Leiserowitz, M., 2014. The prevalence of anemia in patients with chronic kidney disease. Current medical research and opinion, 20(9), pp.1501-1510.

Phrommintikul, A., Haas, S.J., Elsik, M. and Krum, H., 2017. Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: a meta-analysis. The lancet, 369(9559), pp.381-388.

Schwartz, G.J. and Furth, S.L., 2017. Glomerular filtration rate measurement and estimation in chronic kidney disease. Pediatric nephrology, 22(11), pp.1839-1848.

Stevens, L.A., Coresh, J., Greene, T. and Levey, A.S., 2016. Assessing kidney function—measured and estimated glomerular filtration rate. New England Journal of Medicine, 354(23), pp.2473-2483.

Van Pottelbergh, G., Vaes, B., Jadoul, M., Matheï, C., Wallemacq, P. and Degryse, J.M., 2012. The prevalence and detection of chronic kidney disease (CKD)-related metabolic complications as a function of estimated glomerular filtration rate in the oldest old. Archives of gerontology and geriatrics, 54(3), pp.e419-e425.

Wright, J. and Hutchison, A., 2019. Cardiovascular disease in patients with chronic kidney disease. Vascular health and risk management, 5, p.713.

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