Hypertensive Nephrosclerosis

Hypertensive Nephrosclerosis is the second leading cause of Chronic Renal Disease in Adults worldwide

1. Nephrology CASE PRESENTATION

2. CHIEF COMPLIANTS Vomiting x 1/12 Fever x 1/12 Muscle Cramps x 1/12 SOB x 1/52 37 year old Male referred to GPHC from Private Institution two days old

3. History of Presenting Illness COMPLAINTS DETAILS VOMITING Gradual Onset, 20 episodes/24hr, Bitter yellow fluid to meals, no associated GI Symptoms FEVER Intermittent, Associated with Productive Cough, Rx ASA CRAMPS Hands and Legs would contract, no fasciculation, paraesthesia SOB Lying down, ease with sitting, chest pains on inspiration, 2 pillow orthopnoea, PND once weekly

4. Past Medical History Uncontrolled HTN x 7/12 PSHx – nil Family Hx – DM, HTN SHx – Alcohol 0, Smoking 0, Driver Drug Hx – ASA for Fever Allergies – nil Blood Transfusions – nil Trauma - nil

5. Review of Systems Neuro – Blurred Vision CVS – Palpitation, Angina on exertion GU – Frequency, dysuria MS – Joint Pains Derm - Itching on Hands and Abdomen

6. Physical Examination VITALS HR=74, RR= 20, BP= 210/120 , SPO2 = 97% RA HEENT MM – Pale and Moist RESP BAE, decreased BS to base, Creps to Base CVS S1, S2, M0 ABD Globous, depressible, non tender, no organomegaly , BS+ EXT Nx4, no pretibial oedema CNS GCS 15/15

7. Impressions 37 year old Male with PMHx of Uncontrolled Hypertension presents with symptoms of Uraemia, possible diagnosis of Chronic Renal Disease secondary to HTN

8. Hypertensive Nephrosclerosis

9. Background The term hypertensive nephrosclerosis has traditionally been used to describe a clinical syndrome characterized by long-term essential hypertension, hypertensive retinopathy, left ventricular hypertrophy, minimal proteinuria, and progressive renal insufficiency. In 2009, hypertensive nephrosclerosis (HN) accounted for 28% of patients reaching end-stage renal disease (ESRD). HN is the leading cause of ESRD in Africans (46%) and the second leading cause of ESRD worldwide.

10. Pathophysiology Two pathophysiologic mechanisms have been proposed for the development of hypertensive nephrosclerosis . (1) Glomerular Ischemia- chronic hypertension results in narrowing of preglomerular arteries and arterioles, with a consequent reduction in glomerular blood flow. (2) glomerular hypertension and glomerular hyperfiltration - Initial Hypertension leads to glomerular endothelial damage and sclerosis, subsequently in an attempt to compensate for the loss of renal function, the remaining nephrons undergo vasodilation of the preglomerular arterioles and experience an increase in renal blood flow and glomerular filtration. The result is glomerular hypertension, glomerular hyperfiltration, and progressive glomerular sclerosis.

11. Clinical Presentation HISTORY In most patients, hypertension is present for many years (usually >10 y), with evidence of periods of accelerated or poorly controlled BP. Patients may present with symptoms of Uremia Nausea Vomiting Fatigue Anorexia Weight loss Muscle cramps Pruritus Mental status changes Visual disturbances Increased thirst

12. Clinical Presentation PHYSICAL evidence of hypertension-related target organ damage includes hypertensive changes in the retinal vessels and signs of left ventricular hypertrophy.

13. Diagnostic Steps Blood Tests CBC, BUN, Cr, Electrolytes, Glucose Urine Analysis Microalbuminuria ( 0.5 to 1g / 24hr) Ultrasound of Kidneys kidney size is usually symmetric and may be normal or modestly reduced. ECG LVH RENAL BIOPSY Diagnsotic , Myointimal hypertrophy of the interlobular arteries, hyaline degeneration, and sclerosis of afferent arterioles are the most characteristic findings of hypertensive nephrosclerosis .

14. Management Blood Pressure Control ideal BP of <130/80 mmHg for patients with hypertensive nephropathy Several antihypertensive medications, including thiazide diuretics, beta-blockers, ACE inhibitors, ARBs, and calcium channel blockers, in principle, can be used as initial monotherapy in patients with hypertension. Uremia and CRD PD or Hemodialysis Fluid restriction Epo and iron supplements for anemia

15. Prognosis The optimal BP goal to slow the progression of renal failure in patients with hypertensive nephrosclerosis currently is unknown. Evidence for the beneficial effect of hypertension treatment on patients with hypertensive nephrosclerosis is lacking, and many questions regarding the ability of these drugs to protect renal function in the long term remain unanswered. hypertensive nephropathy accounts for more than one-third of patients on hemodialysis and the annual mortality rate for patients on hemodialysis is 23.3%. Haemodialysis is recommended for patients who progress to end-stage kidney disease (ESKD) and hypertensive nephropathy is the second most common cause of ESKD after diabetes.  

16. References http://emedicine.medscape.com/article/244342-overview Harrisons Principles of Internal Medicine