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Question:

Please Explain why Hypertension causing Kidney Disease. Compare two Options for treatment.
 
 

Answer:

This essay focuses on the pathophysiology, clinical symptoms and treatment procedures of end stage renal disease with respect to the medical reports of a patient.

Relationship between pathophysiology and clinical symptoms- The patient is suffering from end stage kidney disease in which the kidneys barely function. In case of end stage renal failure, the rennin-angiotensisn-aldosterone-system (RAAS) gets abnormally upregulated. The enzyme rennin cleaves angiotensinogen to angiotensin I, which is converted to angiotensin II. Upregualtion of RAAS leads to increase in the production of angiotemsin II.  There is an increase in intra-glomerular pressure. Hypertension, glomerulonephritis and diabetes are the most common cause of this condition (Jha et al., 2013). Increase in blood pressure leads to thickening of the vasculature (Coresh et al., 2014). The protein metabolism products begin to accumulate in the blood when the kidney stops functioning. This leads to waste buildup. With decline in kidney function, urea begins to accumulate and leads to a condition uremia. Accumulation of fluids in the body leads to edema (swelling of tissues) (Tomino, 2014). The other most common symptoms are increase in blood pressure (more than 120/80 mmHg), elevation of potassium levels in blood (greater than 5.0 mmol/L), hyperphosphatemia (reduction in phosphate excretion), hypocalcemia, higher creatinine volume due to low glomerular filtrate, calcification of vascular tissues. Failure to excrete excess amounts of potassium leads to an increase in its levels. This condition is called hyperkalemia. This increased level manifests itself in the form of numbness, weakness, nausea and slow pulse. Excess potassium levels make a patient more prone to cardiac arrest. Decrease in urine output (720 mL/ day compared to 800-2000 mL/day) is another major symptom. Abnormally elevated levels of serum creatinine (825 compared to 135  micromol/L) is a direct consequence of low glomerular filtration rate. Obesity is a major risk factor in case of chronic kidney disease. It is also associated with a high heart rate (HR- more than 80 bpm), crackels in the lungs (Gansevoort et al., 2013). Chronic kidney disease also causes muscle fatigue and makes a patient feel exhausted. This is due to failure in proper oxygen circulation in the body. Signs of depression are extremely common in such patients. Several studies have established links between depression and uremia. The patient has normal sodium levels in the blood. However, a sodium rich diet will increase complications in the body. This disease is also associated with uremic pruritus. The patients suffer from itching syndrome. The normal hemoglobin count ranges from 130-180 g/L. However, a renal patient suffers from anemia (low red blood cell count). Certain psychiatric issues like agitation, palpitation, malaise and somnolence may also develop in case of extreme renal failure. Therefore, the symptoms and biochemical test reports of the patient in this case study are manifestations of kidney failure.

Relationship between medical history and renal condition- The patient has a medical history of hypertension, depression and seasonal rhinitis. Hypertension is a leading cause of end stage renal failure. The blood vessels in the body are damaged due to high blood pressure (Hall et al., 2014). The arteries become narrow and hard. Therefore, there occurs a reduction in blood supply to the kidneys. The nephrons do not get nutrients and oxygen in adequate amounts and the balance of salts, acids and hormones in the blood gets disturbed. Kidney failure often leads to development of allergic symptoms like runny nose, which resemble rhinitis conditions. Seasonal rhinitis is a nasal tract inflammation that occurs during specific periods of the year. It is caused due to hypersensitive reactions to pollens, weeds, spores or grasses. There is a close relationship between chronic kidney failure and symptoms of depression. The possible cause for this association might lie in the fact that depression leads to inflammation in the body and such inflammations accelerate the progress of kidney failure (Tomino, 2014). A study suggests that depression is more prevalent in patients who are on the fifth stage of chronic kidney failure (end stage kidney disease). The patient also shows a history of alcoholism and smoking. Prolonged smoking reacts with drugs used to treat hypertension and reduces the flow of blood to the kidneys. It also increases the risks of cardiac attacks in people suffering from hypertension. This worsens their condition. The patient also reports consuming 6 stubbies of heavy beer every week. Excess consumption of alcohol interferes with the kidney’s ability to filter blood. It also disturbs the balance of fluids and electrolytes in the body. It leads to hepatorenal failure and liver cirrhosis. It also increases blood pressure, which is again associated with chronic kidney damage. Therefore, it can be stated that the patient’s medical and social history have aggravated his renal failure.

 


Management of end stage renal failure- Several treatment options are available, which help in reversing the function of damaging kidneys and purifying the blood. Most patients with end stage renal disease are treated with hemodialysis and renal transplantation (Liyanage et al., 2015). In hemodialysis, an artificial kidney machine or dialyzer is used to restore the balance of electrolytes and to purify the blood. The walls of the dialyzer are made up of cellulose (semi-permeable membrane) and contain pores of different sizes. Solute diffusion across the semi-permeable membrane is its basic mechanism. This membrane separates the two compartments inside the machine (one for washing the fluids, the dialysate compartment and other for blood purification). The concentration gradient across this membrane is maintained by counter-current mechanism (Robinson et al., 2016). Alteraton of hydrostatic pressure inside the dialysate compartment leads to ultrafiltration. Blood from the patient is sent to the machine by a synthetic graft or an arteriovenous fistula in one arm. The purified blood is returned to the person through the same arm. Hemodialysis is of different types depending on the severity of the disease. Patients can opt for in-centre hemodialysis, daily home hemodialysis or nocturnal home hemodialysis. Certain complications and risks are associated with this procedure. The hand with the arteriovenous fistula can experience some numbness, which can lead to a condition called ‘steal syndrome’ (Coresh et al., 2014). Other complications like formation of aneurysm, narrowing or clotting of the vessel may also occur. Infection and bleeding are prevalent risks. It creates some adverse mental effects like fatigue, anxiety, depression and increased vulnerability to suicide on the patient as well. Renal transplantation is another effective treatment option. Its success depends on the medical conditions of the kidney donor (Liyanage et al., 2015). A functional kidney is inserted in the lower portion of the abdomen and connected with the urinary bladder and blood vessels (Muzaale et al., 2014). Several immunosuppressants are prescribed to the patient, which will prevent the immune system from rejecting the donated kidney. Transplantation is considered more effective than hemodialysis and shows better survival chances. Its major complications are abscesses in the walls of the abdomen, abdominal hernia, urinary fistulae and rejection by immune system. Cognitive behavioral changes and depression are associated with this method.

Therefore, it can be concluded from the essay that there are several factors which increase the risk of end stage renal disease. The electrolyte balance in the body gets disturbed and the person has to opt for rigorous treatment procedures.

 

References

Coresh, J., Turin, T. C., Matsushita, K., Sang, Y., Ballew, S. H., Appel, L. J., ... & Green, J. A. (2014). Decline in estimated glomerular filtration rate and subsequent risk of end-stage renal disease and mortality. Jama, 311(24), 2518-2531.

Gansevoort, R. T., Correa-Rotter, R., Hemmelgarn, B. R., Jafar, T. H., Heerspink, H. J. L., Mann, J. F., ... & Wen, C. P. (2013). Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. The Lancet, 382(9889), 339-352.

Hall, M. E., do Carmo, J. M., da Silva, A. A., Juncos, L. A., Wang, Z., & Hall, J. E. (2014). Obesity, hypertension, and chronic kidney disease. International journal of nephrology and renovascular disease, 7, 75.

Jha, V., Garcia-Garcia, G., Iseki, K., Li, Z., Naicker, S., Plattner, B., ... & Yang, C. W. (2013). Chronic kidney disease: global dimension and perspectives. The Lancet, 382(9888), 260-272.

Liyanage, T., Ninomiya, T., Jha, V., Neal, B., Patrice, H. M., Okpechi, I., ... & Rodgers, A. (2015). Worldwide access to treatment for end-stage kidney disease: a systematic review. The Lancet, 385(9981), 1975-1982.

Muzaale, A. D., Massie, A. B., Wang, M. C., Montgomery, R. A., McBride, M. A., Wainright, J. L., & Segev, D. L. (2014). Risk of end-stage renal disease following live kidney donation. Jama, 311(6), 579-586.

Robinson, B. M., Akizawa, T., Jager, K. J., Kerr, P. G., Saran, R., & Pisoni, R. L. (2016). Factors affecting outcomes in patients reaching end-stage kidney disease worldwide: differences in access to renal replacement therapy, modality use, and haemodialysis practices. The Lancet, 388(10041), 294-306.

Tomino, Y. (2014). Pathogenesis and treatment of chronic kidney disease: a review of our recent basic and clinical data. Kidney and Blood Pressure Research, 39(5), 450-489.

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