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Examining Pathophysiological Processes: Heart Failure & Chronic Kidney Disease Case Study

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Updated: Jun 25th, 2022

Introduction

The prevalence of heart failure (HF) and chronic kidney disease (CKD) worldwide is increasing for a variety of reasons. Research conducted by Sahle (2016) concludes that the prevalence of HF in Australia is 1%-2%, which is similar to the statistics of the developed countries. HF is associated with 1%-3% of all healthcare costs in Australia, and the common risk factors are obesity, hypertension, smoking, and high cholesterol (Sahle, 2016).

Australian Institute of Health and Welfare (AIHW 2019a) reports that 1.7 million adult Australians are affected by CKD. According to Segall, Nistor, and Covic (2014), 63% of CKD patients have cardio-vascular diseases, and HF is a common complication of the condition. Therefore, the chances of a patient experiencing both of the problems are very high. Additionally, House (2018) states that due to the declining death rate from immunodeficiency virus (HIV)/AIDS, malaria, and other infectious diseases along with different kinds of cancers, CKD “has increased dramatically as a cause of both morbidity and mortality worldwide” (p. 285). In summary, HF and CKD are considerable bothers of the Australian healthcare system.

Patient case study

Mohammad, a 67-year-old Arab male, presents for his annual physical exam. He has a history of long-standing hypertension, chronic congestive HF, and myocardial infarction at the age of 64. Due to an increased risk of CKD, the patient was referred to have a blood creatinine test to determine the estimated glomerular filtration rate (eGFR), which turned out to be 46 mL/min. Urine analysis revealed a moderately increased presence of albumin of 187 mg/g in the urine. An echocardiogram showed normal systolic function, increased left ventricular mass index with concentric left ventricular hypertrophy, and diastolic dysfunction. His blood pressure (BP) is 165/105 and his body temperature is 36.7 degrees Celsius.

Mohammad is obese with a BMI of 32 kg/m2, smokes 25-30 cigarettes a day, and occasionally drinks alcohol. The patient has a family history of obesity, HF, and myocardial infarction in their parents and his son but no history of CKD. The patient reports shortness of breath, wheezing, occasional fatigue, chest pain after walking, the sensation of rapid heartbeats, and dizziness. His current medications are taken once a day and include acetylsalicylic acid (81 mg), bisoprolol, candesartan, and furosemide. In short, the patient has clear HF and CKD symptoms that are to be treated.

Problems

Identification

Mohammad presents several altered physical findings during the physical assessment. BP of the patient is high, which may lead to increased morbidity and mortality. National Heart Foundation of Australia (NHFA 2016) states that older adults with BP consistently above 140/90 can be considered to have chronic hypertension. According to the classification provided by NHFA (2016), Mohammad has moderate hypertension, since his systolic BP falls between 160 and 179 mmHg, and his diastolic BP is between 100 and 109 mmHg. Even though the matter is not a hypertensive emergency, the condition is to be attending in a due manner.

The patient has apparent lifestyle issues that may negatively affect his well-being. According to the classification of overweight and obesity, a BMI of 32 is to be considered class I obesity (AIHW 2019b). The condition is not rare in Australia since 31% of the adult population were obese in 2017-2018 (AIHW 2019b). The disease is usually caused by poor nutritional habits and a lower level of activity. Since the patient is also a heavy smoker, it may be stated that the patient’s lifestyle contributes to the development of the identified conditions.

Mohammad’s eGFR is decreased, which may be a sign of CKD. According to the classification provided by the National Kidney Association (NKA n.d.), the patient has moderately decreased GFR, which may be associated with moderate to severe risk for progression, morbidity, and mortality. House et al. (2019) state the decreased GFR may lead to sudden arrhythmic death or pump failure death. Therefore, the physical finding is crucial for further evaluation of the patient’s well-being.

The increased presence of protein in the urine sample is also a relevant finding that is likely to be associated with kidney damage. NKA (n.d.) categorizes the albuminuria in the patient as A2. According to Kidney Health Australia (2017), the finding may be an early sign of CKD, especially if combined with decreased eGFR. According to NKA (n.d.), the combination of eGFR of 46 mL/min and albuminuria of 187 mg/g is associated with a high risk of kidney function deterioration that may lead to kidney failure and death.

The echocardiogram revealed several abnormalities with the patient’s heart condition. First, the patient demonstrates the signs of left ventricular hypertrophy associated with the increased left ventricular mass index. The condition can explain the symptoms reported by the patient, including shortness of breath, fatigue, chest pain, and dizziness. According to Mizukoshi et al. (2016), the condition may lead to adverse cardiac events, including HF.

Left ventricular hypertrophy may be caused by hypertension, aging, and excess fat (Salama, Hasan & Farag 2019) Second, the test revealed diastolic dysfunction, which is likely to have been caused by hypertension. According to Nadruz, Shah, and Solomon (2017), “hypertension is the leading etiology for diastolic dysfunction, which is ubiquitous in elderly individuals and contributes to the development of heart failure” (p. 7). In brief, an echocardiogram showed several abnormalities of the heart, which might have caused CKD.

Prioritization

There are various ways of prioritizing abnormal findings in patients. One of the most common methods is A-G prioritization, which is most commonly used in emergency departments to assess immediate threats to the patient. The ABCDEFG mnemonic stands for airway, breathing, circulation, disability, exposure, fluids, glucose (Trauma Victoria n.d.). Even though the mnemonic is usually used for trauma, it can be utilized to prioritize findings in Mohammad, which are high BP, decreased eGFR, albuminuria, left ventricular hypertrophy, left ventricular diastolic dysfunction, shortness of breath, wheezing, fatigue, chest pain, and dizziness. The signs and symptoms and prioritized below:

  1. Airway: none;
  2. Breathing: shortness of breath, wheezing;
  3. Circulation: high BP, left ventricular hypertrophy, left ventricular diastolic dysfunction, dizziness, fatigue;
  4. Disability: none;
  5. Exposure: none;
  6. Fluids: decreased eGFR, albuminuria;
  7. Glucose: none.

Discussion

Lifestyle and Obesity

Mohammad’s lifestyle and dietary habits seem to be the primary reason for all the conditions described above. The patient eats excessive amounts of high-fat sugary foods that are associated with rapid weight gain. To maintain a normal weight, people are to balance between food intake and energy expenditure. The patient is physically inactive, which prevents him from using the consumed calories. Therefore, the body stores energy in the form of fat cells, which cause excess adiposity or obesity. However, according to Gadde et al. (2018), obesity results from the interaction between lifestyle and genetics. Gadde et al. (2018) state that “common obesity is thought to be associated with a large number of genes with small effect sizes” (p. 70). Since Mohammad has a family history of the condition, he was preconditioned to obesity, and lifestyle choices contributed to the matter.

Links between Obesity and Hypertension

The relationship between obesity and hypertension is well established, and children and adults globally. Even though there are obese patients, who do not have high BP, a wide variety of studies confirms almost linear relations between BMI and BP.

According to Natsis et al. (2019), for every 5% increase in BMI hypertension risks increase by 20-30%. The problem is that increased plasma levels of free fatty acids and cytokines, liposomes, and ectopic adipose tissue depots can be the reason for hypertension and other conditions (Gadde et al. 2018). Additionally, excess adiposity causes the body to create ectopic lipid deposits s around the myocardium, kidney, and cytoplasm of cardiomyocytes (Gadde et al. 2018). These deposits are linked with pathological states, including hypertension, HF, and type 2 diabetes. In brief, Mohammad’s obesity caused by poor dietary habits, lack of physical exercise, and genetics provoked hypertension and contributed to HF.

From Hypertension to HF

Sustained high blood pressure in the older population often leads to heart failure due to left ventricular diastolic dysfunction. According to Messerli, Rimoldi, and Bangalore (2017), 91% of all patients with HF had a history of hypertension. The risk of HF doubles in patients with BP over 160/100 (Messerli, Rimoldi & Bangalore 2017); therefore, Mohammad’s hypertension might have caused his HF. Increased pressure leads to an increase in left ventricular cardiac mass at the expense of chamber volume. Left ventricular hypertrophy leads to the progress of diastolic dysfunction, which was revealed in Mohammad’s case (Messerli, Rimoldi & Bangalore 2017). Therefore, the patient’s HF is associated with left ventricular diastolic dysfunction, hypertrophy, and increased mass index.

Other Pathologies

Obesity can cause shortness of breath due to increased pressure on muscles. According to Schwartzstein (2019), excess weight in the chest and abdomen lead to increased work breathing muscles is to do. Additionally, the symptom may be caused by HF, since the heart becomes unable to pump blood with oxygen to the organs making people want to inhale more frequently (Schwartzstein. 2019). Mohammad’s wheezing or cardiac asthma also seems to be connected with HF.

According to Mankad (n.d.), HF can cause pulmonary edema and the building up of fluids around airways. Depending on the intensity of the symptom, it can be an emergency; therefore, the symptom is highly prioritized by the ABCDEFG mnemonic. At the same time, fatigue and dizziness are common symptoms of both HF and hypertension, making it unclear what exactly caused them (Williams 2017). In the case of HF, the heart cannot pump enough blood to all the organs, and the body diverts bloodstreams from less important organs, causing fatigue. In summary, the majority of the patient’s complaints are likely due to HF.

From HF to CKD

Heart and kidney work close together, and cardiovascular problems often lead to kidney disease. According to Sarnak (2014), heart conditions, including HF, are often associated with decreased supply of vital organs, such as kidneys, with blood. Blood insufficiency leads to renal function issues, and GFR starts to fall. Decreased renal function interferes with the kidneys’ ability to maintain fluid and electrolyte homeostasis. The kidneys cannot concentrate urine, and creatinine and urea begin a hyperbolic rise. Even though the condition can be easily diagnosed, it is very unlikely it can be suspected due to renal functional adaptation. While the problem is usually described as a diminished renal reserve or renal insufficiency, it may progress into renal failure (Sarnak 2014). Therefore, urgent treatment is required to decrease the chance of Mohammad’s death.

In Summary

The present discussion shows how all the abnormal findings are closely correlated with each other. While the pathological process was initiated by a lack of physical activity and poor dietary habits, the lack of appropriate treatment and patient education led to HF and CKD. The absence of physical activity, a diet high in fat and sugar, and genetics led to obesity. Excess adiposity caused high blood pressure and shortness of breath. Hypertension caused congestive HF, and HF was the reason for dizziness, fatigue, and wheezing. Moreover, the absence of adequate treatment and lifestyle alteration led to decreased renal function and CKD. An efficient intervention in any of the stages of Mohammad’s condition progression may have resulted in improved outcomes.

Conclusion

Mohammad’s case is a vivid example of a patient that has two significant health issues. Even though the situation overviewed in the present paper is difficult, it is not unique since CKD and HF are increasingly prevalent in Australia. The case study revealed that the development of the patient’s condition was predictable. Mohammad is a heavy smoker and suffers from obesity, which are common risk factors for hypertension. High BP often leads to cardiovascular conditions, including HF, and CKD can be caused by these diseases. Mohammad needs a thorough assessment of an interdisciplinary team to elaborate a new treatment plan since the medications he is currently taking do not seem to help.

References

Australian Institute of Health and Welfare 2019a, . Web.

Australian Institute of Health and Welfare 2019b, . Web.

Gadde, KM, Martin, CK, Berthoud, HR, & Heymsfield, SB 2018, ‘Obesity: Pathophysiology and management’, Journal of the American College of Cardiology, vol. 71, no. 1, pp. 69–84.

House, A. (2018). ‘Management of heart failure in advancing CKD: Core curriculum 2018’, American Journal of Kidney Diseases, vol. 72, no. 2, pp.284-295.

House, A, Wanner, C, Sarnak, M, Piña, I, McIntyre, C, Komenda, P, Kasiske, B, Deswal, A, deFilippi, C, Cleland, J, Anker, S, Herzog, C, Cheung, M, Wheeler, D, Winkelmayer, W, McCullough, P, Abu-Alfa, A, Amann, K, Aonuma, K, Appel, L, Baigent, C, Bakris, G, Banerjee, D, Boletis, J, Bozkurt, B, Butler, J, Chan, C, Costanzo, M, Dubin, R, Filippatos, G, Gikonyo, B, Gikonyo, D, Hajjar, R, Iseki, K, Ishii, H, Knoll, G, Lenihan, C, Lentine, K, Lerma, E, Macedo, E, Mark, P, Noiri, E, Palazzuoli, A, Pecoits-Filho, R, Pitt, B, Rigatto, C, Rossignol, P, Setoguchi, S, Sood, M, Störk, S, Suri, R, Szummer, K, Tang, S, Tangri, N, Thompson, A, Vijayaraghavan, K, Walsh, M, Wang, A & Weir, M 2019, ‘Heart failure in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference’, Kidney International, vol. 95, no. 6, pp.1304-1317.

Kidney Health Australia 2017, . Web.

Mankad, R n.d., . Web.

Messerli, FH, Rimoldi, SF & Bangalore, S 2017, ‘The transition from hypertension to heart failure’, JACC: Heart Failure, vol. 5, no. 8, 543–551.

Mizukoshi, K, Takeuchi, M, Nagata, Y, Addetia, K, Lang, R, Akashi, Y & Otsuji, Y 2016, ‘Normal values of left ventricular mass index assessed by transthoracic three-dimensional echocardiography’, Journal of the American Society of Echocardiography, vol. 29, no. 1, pp.51-61.

Nadruz, W, Shah, AM & Solomon, SD 2017, ‘Diastolic dysfunction and hypertension’, Medical Clinics of North America, vol. 101, no.1, pp. 7–17.

National Heart Foundation of Australia 2016, Guideline for the diagnosis and management of hypertension in adults, National Heart Foundation of Australia, Melbourne, Australia.

Natsis, M, Antza, C, Doundoulakis, I, Stabouli, S & Kotsis, V 2019, ‘Hypertension in obesity: Novel insights’, Current Hypertension Reviews, vol. 15, pp. 1-7.

National Kidney Foundation n.d., . Web.

Sahle, B.W. et al. 2016, ‘Prevalence of heart failure in Australia: a systematic review’, BMC Cardiovascular Disorders, vol. 16, no. 32, pp. 1-6.

Salama, M, Hasan, Y & Farag, M 2019, ‘The relation of left ventricular diastolic dysfunction and increased left ventricular mass with blood pressure variability in non-established hypertensive patients’, The Egyptian Journal of Hospital Medicine, vol. 75, no. 6, pp. 3013-3017.

Sarnak, M 2014, ‘A patient with heart failure and worsening kidney function’, Clinical Journal of the American Society of Nephrology, vol. 9, no. 10, pp.1790-1798.

Segall, L, Nistor, I & Covic, A 2014, ‘Heart failure in patients with chronic kidney disease: A systematic integrative review’, BioMed Research International, vol. 2014, pp.1-21.

Schwartzstein, R 2019, . Web.

Trauma Victoria n.d., ABCDEFG for deteriorating patients. Web.

Williams, B 2017, ‘The clinical epidemiology of fatigue in newly diagnosed heart failure’, BMC Cardiovascular Disorders, vol. 17, no. 1, pp. 1-10.

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