Introduction
The article Hypertension management in patients with chronic kidney disease by Liddell, Bassett, and Link (2019) summarize the overall picture concerning hypertension in patients with kidney diseases. It describes the statistics regarding these diseases, their pathophysiology, and pharmacological treatment. Hypertension affects 46% of adults in the US, which makes it a large-scale problem. Together with kidney disease, it becomes large and complex and demands to be researched well.
Pathophysiology
Pathophysiology of kidney disease includes a wide number of factors. For example, it involves the increase in sodium retention and expansion of extracellular volume, reduction of nephron mass, endothelial disfunction, overactivity of the sympathetic nervous system, and activation of hormones involved in the renin-angiotensin-aldosterone system (Ku, Lee, Wei, & Weir, 2019). This system regulates potassium, sodium, and blood volume, which regulates arterial BP. The renin-angiotensin-aldosterone system involves two main hormones: aldosterone and angiotensin. Angiotensin II stimulates aldosterone, which is an adrenal hormone increasing water and sodium retention. Thus, angiotensin contributes to the increase in the circulation of the blood volume and, consequently, BP. Kidney damage leads to a decline in the ability of sodium excretion. Thus, intracellular sodium builds up and leads to the elevation of BP and to fluid retention.
Patient-Centered Medical and Nursing Management
The most important part of the nursing management of hypertension in patients with chronic renal failure is to combine pharmacological and non-pharmacological treatment. In patients with renal diseases, non-pharmacological treatment includes a proper diet and restricting sodium consumption. It is necessary for the patients receiving diuretics, ARBS, or ACEIs, as they are blunted if the kidneys filter a large amount of sodium. Early and aggressive medical management of hypertension in patients with chronic renal failure allows for minimizing the long-term complications (Bassett, Liddell, Link, 2019). A decrease in the sodium level decreases hypertension, as it has a direct relationship with it. Besides, potassium restrictions are also necessary, as, in patients with ACEI or ARBS, the excretion of potassium is altered due to a decline in kidney function, and serum concentration can be elevated. Among the products rich in potassium there are potatoes, bananas, chocolate, avocados, pineapples, tomatoes, and oranges. Smoking also increases the risk of cardiovascular and kidney diseases, so it is necessary that the patients quit smoking. Besides, hypertension treatment should include exercises for blood pressure control and weight loss (CKD Work Group, 2012). It is recommended to exercise from 90 to 150 minutes per week.
Pharmacological treatment involves the usage of ACEIs and ARBs, probably in combination with other classes of medications. It diminishes the binding of angiotensin I receptors to a potent vasoconstrictor elevating blood pressure, angiotensin II. Besides, ACEIs dilate arterioles in the kidney glomeruli, which leads to a reduction in the intraglomerular pressure (Gilbert, Weiner, 2017). Among the effects of ARBs and ACEIs, there is a decrease of albuminuria. In patients who do not suffer from albuminuria, these medicaments do not outperform other antihypertensive classes (Ku et al., 2019). Diuretics can also be applied among other medicaments.
The risk for ineffective treatment includes using the combinations of ACEI and ARBs, as they increase hyperkalemia and AKI incidents. In general, kidney damage risks include weight gain, breath shortness, cough, facial swelling, distended abdomen, and lower extremity edema.
Application to Nursing Practice
In my clinical practice, I will use the knowledge about the medications that can cause hypertension. These are nicotine, cocaine, caffeine, ethanol, anabolic steroids, estrogen, and its analogs, metoclopramide, cyclosporin, NSAIDs, sympathomimetics (pseudoephedrine), and methylxanthines. Besides, I will remember the fact that the combination of an ARB and ACEI can lead to increase hyperkalemia and AKI incidents. I will also remember that CKD is diagnosed using both albuminuria measurements and glomerular filtration rate.
Assessment
Mrs. J, 34 years old, is a Black female with 12-year diabetes and kidney disease in her history (the causes and stage are unknown). In her family history, hypertension has been diagnosed in her mother, maternal sister, father, and parental grandmother. Previously Mrs. J has taken ER 90 mg daily, but lately, she has relocated and stopped taking blood pressure medication. The examination showed that the lungs are clear, and she is alert and oriented. A cardiovascular exam revealed 3+/0-4+ bilateral pitting edema of lower extremities and an auscultated S3. The patient’s blood pressure was 160/190, her weight is 170 lb (77.1 kg), and her height is 63 in (160 cm).
The first step of the nurse during the diagnostics is to determine why the patient ceased taking antihypertensives. Lab tests have to be taken to evaluate the stage of the kidney disease, for the presence of albuminuria and diabetes, and check electrolytes. In the case of albuminuria, ACEI or ARB can be offered. The patient should restart nifedipine and/or hydralazine in combination with a diuretic. Sodium dietary restriction is recommended, as well as weight loss and exercises. A follow-up in four weeks is also needed in order to check the treatment outcomes.
Conclusion
Thus, in patients with renal diseases, the treatment of hypertension can be treated in a combination of pharmacological and non-pharmacological ways. Non-pharmacological treatment includes consulting with a renal dietologist who will choose a proper diet, and regularly do aerobic exercises. Pharmacological treatment includes the application of diuretics, ARBs, and ACEIs. It is also important to decrease the level of sodium in the organism, as it increases blood pressure.
References
Bassett R., Liddell T.S., Link D.K. (2019). Hypertension management in chronic kidney disease. The Nurse Practitioner. 44(12),34-40.
CKD Work Group. Kidney disease: Improving global outcomes (KDIGO) (2012). 2012 Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International Supplements. 3(1) 31-150.
Gilbert S.J., Weiner D. (2017). Primer on kidney disease. (7th ed). Philadelphia, PA: Elsevier.
Ku E., Lee B.J., Wei J., Weir M.R. (2019). Hypertension in CKD: Core Curriculum 2019. Am J Kidney Diseases.74(1), 120-131.