Discussion w9 650

DQ-1

Hypertension and Renal Failure tend to be associated with one another, as an increased in blood pressure Is sustained, the arteries in the kidneys either narrow, weaken, or harden (Higashioka et al., 2016). Once this occurs, there is a decrease in adequate blood flow to the kidneys due to the damages of the arteries (Higashioka et al., 2016). Once there is a decrease in blood flow to the kidneys, the kidneys can no longer function properly, leading to renal failure or renal insufficiency (Higashioka et al., 2016). A classic sign of a decrease in functionality in the renal system is hyperkalemia due to decrease in renal functionality (Higashioka et al., 2016).

Another possible differential diagnosis for hyperkalemia is Renal Artery Stenosis with an etiology of Hypertension (Manaktala, Tafur-Soto & White, 2020). Hypertension as the etiology leads to atherosclerosis, and if atherosclerosis occurs at the renal arteries (amongst other arteries) the damage can be so immense that it can lead to renal failure by an upregulation of the renin-angiotensis-aldosterone system, which in turn creates a cumulative effect of continuously increasing hypertension (Manaktala, Tafur-Soto & White, 2020). The increase in hypertension can lead to a decrease in renal efficiency as described above, which can lead to renal failure and subsequently hyperkalemia (Manaktala, Tafur-Soto & White, 2020). 

These two differential diagnosis and the patient's history of renal failure can make him a candidate for dialysis but only if he reaches a certain stage of kidney failure (Chronic Kidney Disease, 2018). This point happens over a long time of renal failure in a chronic condition, or quickly if there is an acute kidney failure (Chronic Kidney Disease, 2018). Usually there are two parameters; a GFR of <15, and in conjunction with symptoms of Uremia, itchy skin, peripheral edema, nausea, vomiting, loss of appetite, and a progressive loss of renal function (Chronic Kidney Disease, 2018). 

A diet that would help slow the progression of kidney disease or even help prevent dialysis would be a conscious diet that limits nutrients that are filtered by the kidneys (Chronic Kidney Disease, 2018). A diet that is low in salt, potassium, phosphorus, and protein would help decrease the rent to dialysis (Chronic Kidney Disease, 2018). Some common foods to avoid would be dark colored soda, avocados, canned foods, whole wheat bread, brown rice, and many others (Chronic Kidney Disease, 2018). 

References:

CHronic Kidney Disease (2018). Chronic Kidney Disease: When is the best time to start dialysis? Institute for Quality and Efficiency in Health Care: NCBI.NLM.NIH.GOV. https://www.ncbi.nlm.nih.gov/books/NBK492982/

Higashioka, K., Niiro, H., Yoshida, K., Oryoji, K., Kamada, K., Mizuki, S., & Yokota, E. (2016). Renal Insufficiency in Concert with Renin-angiotensin-aldosterone Inhibition Is a Major Risk Factor for Hyperkalemia Associated with Low-dose Trimethoprim-sulfamethoxazole in Adults. Internal Medicine (Tokyo, Japan), 55(5), 467–471. https://doi-org.lopes.idm.oclc.org/10.2169/internalmedicine.55.5697

Manaktala, R., Tafur-Soto, J. D., & White, C. J. (2020). Renal Artery Stenosis in the Patient with Hypertension: Prevalence, Impact and Management. Integrated Blood Pressure Control, 71. https://doi-org.lopes.idm.oclc.org/10.2147/IBPC.S248579

DQ-2

Hyperkalemia is a condition of electrolyte imbalance where the serum potassium level exceeds 5.5 meq/L. usually seen in chronic kidney failure patients, diabetes, heart failure, and use of certain medications such as renin-angiotensin-aldosterone system inhibitors and non-steroidal anti-inflammatory drugs (Montford, & Linas, 2017). The reason is due to a high level of extracellular potassium concentration, an additive, or a defect in elimination due to kidney failure, hyperglycemia, insulin deficiency, diminished adrenergic signaling.

The differential diagnosis in this condition will be: -

1. Hyperkalemia of renal failure-due to failure to augment distal tubular potassium secretion and excretion of potassium through renal tubules.

2. Drug-induced hyperkalemia- Use of ACEi/ARBSs or beta-adrenergic blockers for hypertension may cause hyperkalemia due to kidney impairment.

Criteria for beginning hemodialysis were symptomatic lethal hyperkalemia which is resistant to other medical therapy with elevated creatinine levels due to kidney failure and life-threatening cardiac arrhythmia due to hyperkalemia which may lead to cardiac arrest. The acute treatment of life-threatening hyperkalemia necessitates infusion of intravenous calcium to protect against malignant cardiac hyperexcitability followed by agents such as intravenous insulin along with iv dextrose to prevent hypoglycemia to rapidly shift potassium into the intracellular space (Montford, & Linas, 2017). Sodium bicarbonate also may be used in acidosis correction which will correct hyperkalemia and oral agents such as sodium polystyrene sulfate or oral kayexalate to potentiate the GI excretion of potassium may be used. If any of these therapies are not able to bring down the potassium level and patiently continue to have tachy or Brady arrhythmia, an urgent referral to a nephrologist needed for emergent hemodialysis. Since the patient is worried about “being tied to the machine”, I would discuss in detail the need for emergent hemodialysis as a life-saving measure and if recovered, in the future other medical and nutritional management can be adopted. Another form of dialysis such as peritoneal dialysis is done for the non-emergent situation and in chronic stages for patients who are asymptomatic and more controlled lab values who meet the criteria.

Nutritional interventions that I discuss with my patient are avoidance of fruits and fruit juices that contain a high level of potassium and avoid other potassium-rich food supplements in the markets when taking medical therapy for hypertension and renal failure. Avoidance of drugs causing hyperkalemia such as ACEis and ARBs until instructed by the provider. I would refer to a dietician/nutritionist who may be helpful to teach and counsel patients on nutritional restrictions to prevent future incidences. 

Reference.

Montford, J. R., & Linas, S. (2017). How dangerous is hyperkalemia?. Journal of the American society of nephrology, 28(11), 3155-3165. Retrieved from https://jasn.asnjournals.org/content/28/11/3155?utm_source=TrendMD&utm_medium=cpc&utm_campaign=TMDPJ&WT.MC_ID=TMDPJ

Q-3

Do you have any pain or discomfort when urinating? , Are you able to void at all, location of pain, provocation and alleviating factors, type and nature of pain, quality of pain whether is it an acute, chronic, continuous or intermittent and previous incident, and any radiation, intensity or severity, and associated symptoms such as hematuria, anuria, oliguria, passing of stones and spasm, fever, chills, nausea, vomiting, any swelling of body parts. An initial detailed history which includes current prescription and non-prescription medications such as anticholinergics, antiarrhythmics, antidepressants, antihistamines, antihypertensives, antiparkinsonian agents, antipsychotics, hormonal agents and muscle relaxants and Herbal supplements and medical history, sexual history, and previous instrumentation (Serlin, Heidelbaugh, & Stoffel, 2018). Depends on the patient’s acuity of symptoms for not voiding more than 8 hours with severe pain/discomfort with distension of the urinary bladder (lower abdomen), unable to urinate with a full bladder is a bladder outlet obstruction emergency that needs immediate intervention.

The diagnostic tools I would use is a focused physical exam of the abdomen with neurologic evaluation, starting with inspection for bladder distension, palpation of the lower abdomen and pelvis, and percussion. A bladder scanning for post-void residual will determine the volume of urine in the bladder (Serlin, Heidelbaugh, & Stoffel, 2018). Initial management of urinary retention involves assessment of urethral patency with complete bladder decompression by catheterization. If unsuccessful a CT or US of the abdomen, pelvis for any mass or malignancy causing bladder obstruction. An MRI scan may be warranted for lumbosacral spinal causes and other neurological causes and urologist/ and neurology needs to be consulted for management. Other lab tests indicated were PSA antigen to screen for BPH, prostate cancer, acute prostatitis in the setting of acute urinary retention. A serum blood glucose to evaluate uncontrolled diabetes with neurogenic bladder, serum blood urea nitrogen, creatinine, electrolytes to evaluate for renal failure from lower urinary tract obstruction, urine analysis for infection, hematuria, proteinuria, and glucosuria.

Education of patient on environmental and nutritional interventions

Have a bladder graining program instructions such as empty the bladder as soon as the patient gets up in the morning, have a schedule for bladder emptying and void only at the scheduled time during day time even if the urge to go before the time or no urge to go at the scheduled time. Use urge suppression techniques and deep breathing exercises until the sensation passes. Practice pelvic exercises (Kegel’s) to strengthen the bladder muscles. Take 2-3 liters of fluids per day and drink most of it in the daytime and reduce fluid intake towards evening and night hours and empty bladder prior to going to bed.

Reference.

Serlin, D. C., Heidelbaugh, J. J., & Stoffel, J. T. (2018). Urinary retention in adults: evaluation and initial management. American family physician, 98(8), 496-503.Retrieved from https://www.aafp.org/afp/2018/1015/p496.html